NQF

Version Number: 2.5
Meeting Date: December 9-10, 2015

Measure Applications Partnership
Clinician Workgroup Discussion Guide

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Agenda

Agenda Synopsis

Day 1-December 9, 2015  
8:30 am   Breakfast
9:00 am   Welcome, Disclosures of Interest, Review Meeting Objectives
9:20 am   Pre-Rulemaking Opening Remarks
9:40am   Overview of Pre-Rulemaking Approach
10:00 am   Overview of the Medicare Shared Savings Program (MSSP)
10:30 am   Break
10:45 pm   Opportunity for Public Comment on Medicare Shared Savings Program Consent Calendar
11:00 am   Consent Calendar: Medicare Shared Savings Program
12:00 pm   Lunch
12:30 pm   Overview of the Merit-Based Incentive Payment System (MIPS) and Physician Compare Programs
1:15 pm   Opportunity for Public Comment on Dermatology Consent Calendar
1:30 pm   Consent Calendar- Dermatology
2:15 pm   Break
2:30 pm   Opportunity for Public Comment on Eye Care Consent Calendar
2:45 pm   Consent Calendar- Eye Care
3:45 pm   Opportunity for Public Comment on Cancer Consent Calendar
4:00 pm   Consent Calendar- Cancer
4:45 pm   Opportunity for Public Comment
5:00 pm   Adjourn


Day 2-December 10, 2015  
8:00 am   Breakfast
8:30 am   Welcome and Recap of Day 1
8:45 am   Opportunity for Public Comment on Interventional Radiology Consent Calendar
9:00 am   Consent Calendar- Interventional Radiology
10:00 am   Break
10:15 pm   Opportunity for Public Comment on Urogynecology Consent Calendar
10:30 pm   Consent Calendar- Urogynecology
11:30 pm   Opportunity for Public Comment on Gastroenterology Consent Calendar
11:45 pm   Consent Calendar- Gastroenterology
12:30 pm   Lunch
1:45 pm   Opportunity for Public Comment on Miscellaneous Consent Calendar
1:00 pm   Consent Calendar-Miscellaneous
2:00 pm   Workgroup Discussion – Gaps in the Clinician program measure sets
2:30 pm   Workgroup Discussion – Alignment
3:00 pm    Workgroup discussion – Public reporting of clinician measures
3:30 pm   Opportunity for Public Comment
3:45 pm   Summary of the MAP Clinician Workgroup pre-rulemaking input
4:00 pm   Adjourn


Full Agenda

Day 1-December 9, 2015  
8:30 am   Breakfast
9:00 am   Welcome, Disclosures of Interest, Review Meeting Objectives
Bruce Bagley, Workgroup Chair; Eric Whitacre, Workgroup Chair; Chris Cassel, CEO, NQF; Reva Winkler, Senior Director, NQF; Ann Hammersmith, General Counsel, NQF

9:20 am   Pre-Rulemaking Opening Remarks
Kate Goodrich, CMS

9:40am   Overview of Pre-Rulemaking Approach
Andrew Lyzenga, Senior Project Manager, NQF; Poonam Bal, Project Manager, NQF

10:00 am   Overview of the Medicare Shared Savings Program (MSSP)
Rabia Khan, CMS (MSSP); Dr. Winkler

10:30 am   Break
10:45 pm   Opportunity for Public Comment on Medicare Shared Savings Program Consent Calendar
11:00 am   Consent Calendar: Medicare Shared Savings Program
Provide recommendations on measures under consideration; Identify high-priority measure gaps for the program
Reactors: Marci Nielsen ; Kate Koplan
  1. Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls (MUC ID: MUC15-579)
    • Description: This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates: A) Screening for Future Fall Risk: Percentage of patients aged 65 years of age and older who were screened for future fall risk at least once within 12 months; B) Falls: Risk Assessment: Percentage of patients aged 65 years of age and older with a history of falls who had a risk assessment for falls completed within 12 months; C) Plan of Care for Falls: Percentage of patients aged 65 years of age and older with a history of falls who had a plan of care for falls documented within 12 months. (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention of falls is a cross-cutting, patient safety measure applicable to all Medicare patients. This NQF-endorsed measure is aligned with PQRS.
      • Impact on quality of care for patients:According to the CDC, one out of three adults aged 65 or older falls each year, but less than half talk to their healthcare providers about it, suggesting an opportunity for improvement that would be addressed by this measure. The CDC reports that falls are the leading cause of both fatal and nonfatal injuries in older adults, and that in 2013, the direct medical costs of falls, adjusted for inflation, were $34 billion.
    • Preliminary analysis result: Support


  2. Advance Care Plan (MUC ID: MUC15-578)
    • Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 5
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is aligned with PQRS/MIPS, addresses an important need for patients and caregivers and is a cross-cutting communication and care coordination measure applicable to all Medicare patients..
      • Impact on quality of care for patients:In 2010, there were 40.3 million people aged 65 and older, a 13% share of the US population, that is projected to reach 20.9% by 2050. As people age, consideration should be given to their treatment wishes in the event that they lose the ability to manage their care. A large discrepancy exists between the wishes of dying patients and their actual end-of-life care. Advance Care Plan is recommended as a strategy to improve compliance with patient wishes, and thereby ensure appropriate use of health care resources at the end of life.
    • Preliminary analysis result: Support


  3. PQI 91 Prevention Quality Acute Composite (MUC ID: MUC15-577)
    • Description: PQI composite of acute conditions per 100,000 population, ages 18 years and older. Includes admissions with a principal diagnosis of one of the following conditions: dehydration, bacterial pneumonia, or urinary tract infection. (Includes PQIs 10, 11, and 12) (Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services. This measure is sensitive to dual eligible patients. A risk-model that includes co-morbidities is being devloped.
      • Impact on quality of care for patients:This measure encourages appropriate care of acute conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families.
    • Preliminary analysis result: Encourage continued development


  4. Prevention Quality Indicators 92 Prevention Quality Chronic Composite (MUC ID: MUC15-576)
    • Description: PQI composite of chronic conditions 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, or angina without a cardiac procedure. (Includes PQIs 1, 3, 5, 7, 8, 13, 14, 15, and 16) (Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. However, the measure should reconsider some of the components and must be fully developed and tested with appropriate risk-adjustment at the ACO level of analysis and submitted to NQF.
      • Impact on quality of care for patients:This measure encourages appropriate care of chronic conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families and reduces costs.
    • Preliminary analysis result: Encourage continued development


  5. Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (MUC ID: MUC15-275)
    • Description: The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use (Measure Specifications)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is duplicative of PQRS #349 (NQF#0076) – both are all-or-none composite measures for ischemic vascular disease . CMS recently removed PQRS #349 because it is duplicative of the Millions Hearts measures. The approach for cardiovascular measures should be aligned in both PQRS/MIPS and MSSP.
      • Impact on quality of care for patients:Composite measures of evidence-based processes and intermediate clinical outcomes combine multiple factors important to care and address whether a patients is receiving all the evidence-based care they receive. Most of the atherosclerotic disease measures enjoy high performance individually, but the composite reveals that the results are not uniformly high for individual patients – further opportunity for improvement exists which can further reduce the risks of poor outcomes for patients. and represents measure that promote high performance.
    • Preliminary analysis result: Do not support


12:00 pm   Lunch
12:30 pm   Overview of the Merit-Based Incentive Payment System (MIPS) and Physician Compare Programs
Molly A. MacHarris, CMS (MIPS); Alesia D. Hovatter, CMS (Physician Compare); Dr. Winkler

1:15 pm   Opportunity for Public Comment on Dermatology Consent Calendar
1:30 pm   Consent Calendar- Dermatology
Reactors: Scott Furney (MIPS); Stephen Friedhoff (MIPS); Bruce W. Sherman (Physician Compare)
  1. Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (MUC ID: MUC15-215)
    • Description: Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure adds a communication measure. Data on current performance would provide a better understanding of the gap in care. . This patient centered-communication measure should be expanded to include all biopsies performed by any clinician for any condition. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
      • Impact on quality of care for patients:Patients should expect a timely report on the results of any biopsy. There are more new cases of skin cancer reported each year than cancers of the breast, prostate, lung and colon combined (http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf).The most common types of skin cancer are basal cell and squamous cell skin cancer, most commonly referred to as non-melanoma skin cancer or NMSC. The most recent study from 2006 estimated 3.5 million cases of NMSC were diagnosed from 2.2 million people. Currently, pathology reports are received by the biopsying clinician within 10 days after the biopsy is performed (cancer.org) and even longer for the clinician to share the results with the patient. Effective and timely communication between the clinician and patient is essential to ensuring safe and effective patient care along with reducing cost.
    • Preliminary analysis result: Encourage continued development


  2. Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (MUC ID: MUC15-215)
    • Description: Length of time taken from when a biopsy is performed to when a patient is notified by the biopsying physician that he or she has cutaneous basal or squamous cell carcinoma (including in situ disease). This measure evaluates the reporting time between the biopsying clinician and patient. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an important communications measure
    • Preliminary analysis result: Clinician web page


  3. NMSC: Biopsy Reporting Time - Pathologist (MUC ID: MUC15-216)
    • Description: Length of time taken from when the pathologist completes the final biopsy report to when s/he sends the final report to the biopsying physician. This measure evaluates the reporting time between pathologist and biopsying clinician. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:A measure that evaluates the reporting time between pathologist and biopsying clinician should not be restricted to dermatology biopsies. Strong consideration should be given to expanding this communication measure to all biopsies. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016. Data on current performance is needed to understand the gap in care.
      • Impact on quality of care for patients:Timely pathology reports are essential to inform the patient and plan treatment. Patients should expect a timely report on the results of any biopsy. Delays or lost reports are potentially quite costly. Effective and timely communication between the two practitioners is essential to ensuring timely and effective patient care.
    • Preliminary analysis result: Encourage continued development


  4. NMSC: Biopsy Reporting Time - Pathologist (MUC ID: MUC15-216)
    • Description: Length of time taken from when the pathologist completes the final biopsy report to when s/he sends the final report to the biopsying physician. This measure evaluates the reporting time between pathologist and biopsying clinician. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  5. Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (MUC ID: MUC15-178)
    • Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with appropriate use criteria (AUC) and should result in healthcare savings. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an appropriate use measure for dermatology. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk cancers on the trunk which should result in savings for the healthcare system. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
      • Impact on quality of care for patients:Skin cancer is the most common form of cancer in the United States. Basal cell carcinoma (BCC) is one of the three major types of skin cancer, along with squamous cell carcinoma (SCC) and melanoma. There are about 4 million new cases of nonmelanoma skin cancer in the United States annually. Almost all of these are treated surgically, and some are treated with radiation. Mohs surgery is accepted as the most effective technique for removing BCC and SCC, boasting a cure rate of 98% or higher. Currently, 1 in 4 skin cancers is being treated with Mohs surgery. The average cost for Mohs surgery may range between $1000-$3000. Currently, Medicare covers 80% of the cost.Mohs surgery appropriate use criteria detail a guideline for clinical decision making on the use of Mohs surgery in the practice setting. This document was supported by an evidence review of 69 BCC cases, where 14.5% was found to be an inappropriate use of this technique.
    • Preliminary analysis result: Encourage continued development


  6. Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (MUC ID: MUC15-178)
    • Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary superficial basal cell carcinomas (BCCs) on the trunk in immune-competent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with appropriate use criteria (AUC) and should result in healthcare savings. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This appropriate use measure will provide patients and other stakeholders information on clinicians that inappropriately use Mohs surgery. Performing Mohs surgery is often advertised by clinicians to encourage consultation with their practice.
    • Preliminary analysis result: Clinician web page


  7. Use of Mohs Surgery For Squamous Cell Carcinoma In Situ And Keratoacanthoma Type - Squamous Cell Carcinoma on The Trunk that are 1 cm or smaller (MUC ID: MUC15-179)
    • Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary squamous cell carcinomas in situ (SCCis) and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is another appropriate use measure for dermatology. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk cancers on the trunk which should result in savings for the healthcare system. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
      • Impact on quality of care for patients:Skin cancer is the most common form of cancer in the United States. Basal cell carcinoma (BCC) is one of the three major types of skin cancer, along with squamous cell carcinoma (SCC) and melanoma. There are about 4 million new cases of nonmelanoma skin cancer in the United States annually. Almost all of these are treated surgically, and some are treated with radiation. Mohs surgery is accepted as the most effective technique for removing BCC and SCC, boasting a cure rate of 98% or higher. Currently, 1 in 4 skin cancers is being treated with Mohs surgery. The average cost for Mohs surgery may range between $1000-$3000. Currently, Medicare covers 80% of the cost.Mohs surgery appropriate use criteria detail a guideline for clinical decision making on the use of Mohs surgery in the practice setting. This document was supported by an evidence review of 69 BCC cases, where 14.5% was found to be an inappropriate use of this technique.
    • Preliminary analysis result: Encourage continued development


  8. Use of Mohs Surgery For Squamous Cell Carcinoma In Situ And Keratoacanthoma Type - Squamous Cell Carcinoma on The Trunk that are 1 cm or smaller (MUC ID: MUC15-179)
    • Description: This measure evaluates the number of inappropriately utilized Mohs surgeries to treat primary squamous cell carcinomas in situ (SCCis) and keratoacanthoma (SCC-KA) on the trunk that are 1 cm or smaller in immunocompetent patients. The assessment of inappropriate use of Mohs surgery will help to improve compliance with AUC and should result in healthcare savings. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This appropriate use measure will provide patients and other stakeholders information on clinicians that inappropriately use Mohs surgery. Doing Mohs surgery is often advertised by clinicians to encourage consultation with their practice.
    • Preliminary analysis result: Clinician web page


  9. Use Of Preventive Screening Protocol For Transplant Patients (MUC ID: MUC15-177)
    • Description: This measure evaluates the number of organ transplant recipients (OTRs) that receive sun protection education and a full skin exam annually by their provider. Preventative screenings and education for OTRs is critical in order to lower incidence and/or severity of skin cancers in these increased risk individuals. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is a process measure assessing whether screening and education activities have been performed. This measure addresses population health and prevention. The measure adds to the measures specific to dermatology, and addresses the new area of organ transplant recipients. No data is provided to understand current performance or gap in care. The registry is the AAD’s clinical data registry called DataDerm that will be launched January 2016.
      • Impact on quality of care for patients:29,532 people received organ transplants in 2014. Due to the effects of immunosuppressive medications and other risk factors, these recipients are at significantly higher risk for skin cancer. If patients are already receiving screening and education, the impact on patients will be limited.
    • Preliminary analysis result: Encourage continued development


  10. Use Of Preventive Screening Protocol For Transplant Patients (MUC ID: MUC15-177)
    • Description: This measure evaluates the number of organ transplant recipients (OTRs) that receive sun protection education and a full skin exam annually by their provider. Preventative screenings and education for OTRs is critical in order to lower incidence and/or severity of skin cancers in these increased risk individuals. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


2:15 pm   Break
2:30 pm   Opportunity for Public Comment on Eye Care Consent Calendar
2:45 pm   Consent Calendar- Eye Care
Reactors: Scott Friedman (MIPS); Beth Averbeck (MIPS); Robert Krughoff (Physician Compare)
  1. Glaucoma - Intraocular Pressure (IOP) Reduction (MUC ID: MUC15-372)
    • Description: Percentage of glaucoma patients where their intraocular pressure (IOP) was below a threshold level based on the severity of their condition (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This intermediate outcome measure is very similar to PQRS # 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care. This new MUC might be an improvement on PQRS #141.This MUC differentiates the outcome threshold based on severity of disease and does not have the plan of care component. No information regarding the targets specified in this measure could be identified nor evidence that these targets are related to specific outcomes.
      • Impact on quality of care for patients:There are approximately 4 million Americans with glaucoma – 200,000 are severely visually impaired. Reduction of intraocular pressure (IOP) has been shown to effectively reduce the risk of glaucoma progression. American Association of Ophthalmology guidelines recommend “The goal of glaucoma treatment is to maintain the IOP in a range at which a patient is likely to remain stable or at which worsening of glaucoma will be slow enough that the risk of additional intervention is not justified. The target pressure should be individualized and may need adjustment during the course of the disease.” Evidence level A:III.
    • Preliminary analysis result: Encourage continued development


  2. Glaucoma - Intraocular Pressure (IOP) Reduction (MUC ID: MUC15-372)
    • Description: Percentage of glaucoma patients where their intraocular pressure (IOP) was below a threshold level based on the severity of their condition (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  3. Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (MUC ID: MUC15-374)
    • Description: Percentage of who underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an additional outcome measure for patients undergoing laser surgery for glaucoma. Clarification of the timing of the post-operative pressure measurement is needed.
      • Impact on quality of care for patients:Surgery is used when medications fail to control vision loss caused by glaucoma. Laser surgery is done more often than conventional surgery. The most common complication from laser surgery for glaucoma is increased pressure within the eye that may rise sharply 1-4 months after surgery. The measure does not specify a timeframe for measuring the IOP after surgery– if performed too soon the measure may not capture increased pressures that occur several months after surgery and would over estimate good outcomes.
    • Preliminary analysis result: Encourage continued development


  4. Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (MUC ID: MUC15-374)
    • Description: Percentage of who underwent laser trabeculoplasty who had IOP reduced by 20% from their pretreatment level. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  5. Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-379)
    • Description: Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an outcome measures for a topic with only process measures currently. Since AMD is a slowly progressive condition, it is unclear whether this outcome measure is a function of the natural progression of the disease and to what extent clinical management will influence the outcome.
      • Impact on quality of care for patients:There is an estimated 1.75 million cases of advanced AMD in the US. AMD is the leading cause of irreversible visual loss in the United States, with variable degrees of age-related macular changes occurring in more than 10% of the population aged 65-74 years and 25% of the population older than 74 years. Therapy with anti-VEGF agents is the gold standard with promising results, many intravitreal injections are often required, and they do not cure all cases of wet (neovascular) AMD. A Mayo Clinic study reported that “the anti-VEGF therapy yielded improved best-corrected visual acuity. “
    • Preliminary analysis result: Encourage continued development


  6. Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-379)
    • Description: Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  7. Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-392)
    • Description: Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with a visual acuity loss of less than 0.3 logMar within the past 12 months (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This MUC is an outcome measure for a condition that only has process measures. It is unclear whether the degree of vision change quantified in this measure will reflect the natural slow progression of the disease or the impact of optimal treatment to slow down disease progression.
      • Impact on quality of care for patients:Non-exudative AMD comprises more than 90% of patients with AMD and generally has a much slower (over decades), progressive visual loss relative to exudative (wet) AMD). There is currently no cure for AMD, but treatments may prevent severe vision loss or slow the progression of the disease considerably. Not all patients with AMD are candidates for use of the AREDS vitamin formulation. Taking the AREDS vitamins was shown to reduce the risk of advanced AMD by 25%.
    • Preliminary analysis result: Encourage continued development


  8. Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (MUC ID: MUC15-392)
    • Description: Percentage of patients with a diagnosis of nonexudative age-related macular degeneration and taking AREDS supplements with a visual acuity loss of less than 0.3 logMar within the past 12 months (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  9. Diabetic Macular Edema: Loss of Visual Acuity (MUC ID: MUC15-393)
    • Description: Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an outcome measure for a large population at risk of vision loss. Vision loss associated in patients with diabetes can be reduced with good diabetes care. Care coordination among primary and eye care providers is essential to maintain vision.
      • Impact on quality of care for patients:Macular edema in common in diabetes. The lifetime risk for diabetics to develop macular edema is about 10%. The condition is closely associated with the degree of diabetic retinopathy (retinal disease). The standard of treatment for diabetic macular edema is glycemic control, optimal blood pressure control, and macular focal/grid laser photocoagulation. New treatments with steroids and anti-VEGF agents are available. Optimal treatment can reduce the risk of vision loss and associated functional limitations in patients with diabetes.
    • Preliminary analysis result: Encourage continued development


  10. Diabetic Macular Edema: Loss of Visual Acuity (MUC ID: MUC15-393)
    • Description: Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 0.3 logMar of visual acuity within the past 12 months (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  11. Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (MUC ID: MUC15-370)
    • Description: Percentage of corneal graft surgery patients with a visual acuity of 20/40 or better within 90 days following surgery (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:A functional outcome measure for eye care professionals. Data on current performance would provide better understanding on the opportunity for improvement.
      • Impact on quality of care for patients:More than 40,000 corneal transplants or grafts are performed each year in the US. Good vision after any eye procedure is the goal for patients and providers.
    • Preliminary analysis result: Encourage continued development


  12. Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (MUC ID: MUC15-370)
    • Description: Percentage of corneal graft surgery patients with a visual acuity of 20/40 or better within 90 days following surgery (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  13. Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (MUC ID: MUC15-375)
    • Description: Percentage of surgical ptosis patients with an improvement of MRD postoperatively (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 5
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an outcome measure for oculoplastic surgeons – a subspecialty with few or no measures. Improved marginal reflex distance is the desired goal of surgery to improve clinical and functional outcomes. As many surgeries are performed primarily for cosmetic reasons a patient-reported outcome measure is also needed.
      • Impact on quality of care for patients:Ptosis is a lowering of the eyelid to below its normal position. The distance between the corneal light reflex and the upper eyelid margin is termed the upper marginal reflex distance. The official definition of ptosis is an upper marginal reflex distance below 2 mm or an asymmetry of more than 2 mm between the eyes. Ptosis has many causes and is a presenting symptom in both emergency and outpatient settings. In many cases, ptosis improves with time, however, in the absence of improvement surgery may be considered. Data on current performance to determine the opportunity for improvement could not be identified.
    • Preliminary analysis result: Encourage continued development


  14. Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (MUC ID: MUC15-375)
    • Description: Percentage of surgical ptosis patients with an improvement of MRD postoperatively (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  15. Acquired Involutional Entropion: Normalized lid position after surgical repair (MUC ID: MUC15-377)
    • Description: Percentage of surgical entropion patients with a postoperative normalized lid position (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 5
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure adds a surgical outcome measure for ophthalmologists, however, It is unclear what the current performance is. As this procedure is sometimes done for cosmetic reasons, a patient-reported outcome would be important also.
      • Impact on quality of care for patients:Entropion is an inversion of the eyelid (i.e., inward turning of the eyelid margin) toward the globe. Lower lid entropion is a common condition in elderly individuals; the prevalence increases steadily with age. Involutional entropion is the most common form of entropion. Patients seek treatment due to eye irritation, watering of the eye or cosmetic concerns. Involutional entropion has a prevalence of 2.4% in whites and 0.8% in blacks. No data on current performance could be identified.
    • Preliminary analysis result: Encourage continued development


  16. Acquired Involutional Entropion: Normalized lid position after surgical repair (MUC ID: MUC15-377)
    • Description: Percentage of surgical entropion patients with a postoperative normalized lid position (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  17. Acute Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-394)
    • Description: Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an outcome measure evaluating the effectiveness of treatment for an eye condition not yet represented in the clinician measure set.
      • Impact on quality of care for patients:Anterior uveitis is an inflammation of the middle layer of the eye, which includes the iris (colored part of the eye) and adjacent tissue. If untreated, it can cause permanent damage and loss of vision from the development of glaucoma, cataract or retinal edema. It usually responds well to treatment with eye drops. The annual incidence rate is approximately 8 cases per 100,000 population, most commonly in the fourth and fifth decades of life.
    • Preliminary analysis result: Encourage continued development


  18. Acute Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-394)
    • Description: Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  19. Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-396)
    • Description: Percentage of patients with acute anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:It is unclear what this intermediate outcome measure adds to the functional outcome measure - Acute Anterior Uveitis: Post-treatment visual acuity.
      • Impact on quality of care for patients:The presence of Grade 0 anterior chamber cells indicates reduced inflammation in response to therapy. Though signs of improvement are welcome, the important outcomes are reduction in patient symptoms and good vision.
    • Preliminary analysis result: Encourage continued development


  20. Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-396)
    • Description: Percentage of patients with acute anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  21. Chronic Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-397)
    • Description: Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an outcome measure for patients with a chronic condition. It is not clear whether patients that fail treatment for acute uveitis in MUCFIFTEEN-394 Acute Anterior Uveitis: Post-treatment visual acuity are the patients in this measure or when the 90 days specified begins.
      • Impact on quality of care for patients:Chronic uveitis is active uveitis that persists longer than three months. Chronic anterior uveitis is insidious in onset, persistent, associated with a high incidence of visually threatening complications, and has a variable long term visual prognosis. It may be associated with systemic diseases such as juvenile chronic arthritis, Behçet's disease, and sarcoidosis. The aims of treatment are to control inflammation, prevent visual loss, and minimize long term complications of the disease and its treatment. Maintaining vision is critically important in treating this condition.
    • Preliminary analysis result: Encourage continued development


  22. Chronic Anterior Uveitis: Post-treatment visual acuity (MUC ID: MUC15-397)
    • Description: Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/40 or greater OR patients whose visual acuity had returned to their baseline value prior to onset of uveitis (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  23. Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-399)
    • Description: Percentage of patients with chronic anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:It is unclear what this intermediate outcome measure adds to the functional outcome measure - Chronic Anterior Uveitis: Post-treatment visual acuity.
    • Preliminary analysis result: Encourage continued development


  24. Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (MUC ID: MUC15-399)
    • Description: Percentage of patients with chronic anterior uveitis who post-treatment had Grade 0 anterior chamber cells. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


3:45 pm   Opportunity for Public Comment on Cancer Consent Calendar
4:00 pm   Consent Calendar- Cancer
Reactors: Janis Orlowski (MIPS); Constance Dahlin (MIPS); Amy Moyer (Physician Compare)
  1. Non-Recommended PSA-Based Screening (MUC ID: MUC15-1019)
    • Description: Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 42
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure fills a need for appropriate use/overuse measures that apply to a broad population of patients.
      • Impact on quality of care for patients:The USPSTF recommends against PSA-based screening for prostate cancer (grade D recommendation). This recommendation applies to men in the general U.S. population, regardless of age. Unnecessary screening tests are costly and create unnecessary anxiety and follow up evaluations for patients.
    • Preliminary analysis result: Encourage continued development


  2. Non-Recommended PSA-Based Screening (MUC ID: MUC15-1019)
    • Description: Percentage of men who were screened unnecessarily for prostate cancer using a prostate-specific antigen (PSA)-based screening. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure provides patients and other stakeholders with information about clinicians that do not follow guidelines and contribute to unnecessary costs.
    • Preliminary analysis result: Clinician web page


  3. Proportion admitted to hospice for less than 3 days (MUC ID: MUC15-415)
    • Description: Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses an important gap area in end-of-life care for reporting by oncologists, is fully-specified and tested, reflects patient-centered care, and addresses the important areas of care coordination and appropriate use. MAP has previously recommended expanding this measure beyond cancer patients.
      • Impact on quality of care for patients:Approximately 500,000 patients will die of cancer in 2015. A 2014 study (Obermeyer Z, Makar M, et al) found that in Medicare fee-for-service beneficiaries with poor-prognosis cancer, a comparison of those receiving hospice care (60%) vs not (control) showed that hospice patients had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.
    • Preliminary analysis result: Support


  4. Proportion admitted to hospice for less than 3 days (MUC ID: MUC15-415)

  5. Minimally invasive surgery performed for patients with endometrial cancer (MUC ID: MUC15-452)
    • Description: Proportion of patients who underwent minimally invasive hysterectomy for endometrial cancer (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an surgical appropriateness measure for uterine cancer care for GYN and GYN ONC. There are no other measures for endometrial cancer – an important condition in the Medicare population. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:Studies show that minimally invasive surgery (laparoscopic or robotic-assisted hysterectomy) has no difference in survival compared to open surgery, but patients undergoing minimally invasive surgery had reduced length of hospital stay, lower blood loss, and improved quality of life at 6 weeks. Measure submitter reports that data indicates variation in performance of 50-90%. Improvement in this measure would improve the quality of care for patients with endometrial cancer and reduce costs.
    • Preliminary analysis result: Encourage continued development


  6. Minimally invasive surgery performed for patients with endometrial cancer (MUC ID: MUC15-452)
    • Description: Proportion of patients who underwent minimally invasive hysterectomy for endometrial cancer (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  7. Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (MUC ID: MUC15-465)
    • Description: Performance of appropriate type of hysterectomy in women with early stage cervical cancer undergoing hysterectomy. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Data on current performance is needed to assess whether there is an opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:Radical hysterectomy is the standard procedure for women who undergo surgical treatment for cervical cancer. This is a more extensive surgery aimed at curing the cancer. If most women are receiving this standard of care, there will be little improvement from use of this measure.
    • Preliminary analysis result: Encourage continued development


  8. Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (MUC ID: MUC15-465)
    • Description: Performance of appropriate type of hysterectomy in women with early stage cervical cancer undergoing hysterectomy. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  9. Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (MUC ID: MUC15-460)
    • Description: The percentage of cervical cancer patients who undergoing curative intent radiation who receive brachytherapy in addition to external beam therapy (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is a process measure closely linked to clinical outcomes (patient survival) with a demonstrated quality problem/opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:In the US there were 12,900 cases and 4100 deaths from cervical cancer this year. Radiation therapy is included in treatment protocols for all but the earliest stage of cancer. Brachytherapy is internal radiation placed in and near the cervix with minimal radiation exposure to other areas. Brachytherapy is considered a critical component of treatment by the National Comprehensive Cancer Network. According to the American Brachytherapy Society Cervical Cancer Brachytherapy Task Group “The radiation dose delivered by brachytherapy is critical in curing patients of cervical cancer and has been the standard of treatment for over 100 years.” A recent study from the National Cancer Database with a median overall survival of 63.3 months in patients who did receive brachytherapy and 27.2 months among patients who did not (Lin JF et al. Gynecol Oncol. 2014;132:416-422). These studies also showed that only 47.5-58% of women are treated with brachytherapy in addition to their external beam therapy and that rates of use of brachytherapy have declined over time. The declination in use is attributed to inadequate training and unavailability of appropriate technology in small hospitals. Improvement in use of brachytherapy will improve survival in women with cervical cancer.
    • Preliminary analysis result: Encourage continued development


  10. Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (MUC ID: MUC15-460)
    • Description: The percentage of cervical cancer patients who undergoing curative intent radiation who receive brachytherapy in addition to external beam therapy (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  11. Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (MUC ID: MUC15-461)
    • Description: Percentage of patients with locally advanced cervical cancer who complete their chemoradiation in 60 days or less (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is closely related to patient survival. Data on current performance would provide a better understanding of the opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:Treatment for locally advanced cervical cancer consists of external beam radiation to the pelvis with concurrent chemotherapy. In this patient population, total radiation therapy treatment time beyond 7 to 9 weeks has been shown to result in increased treatment failure rates and decreased cancer specific and overall survival. If there is a gap in current performance, improved performance would improve patient survival.
    • Preliminary analysis result: Encourage continued development


  12. Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (MUC ID: MUC15-461)
    • Description: Percentage of patients with locally advanced cervical cancer who complete their chemoradiation in 60 days or less (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  13. Postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy with (or without) brachytherapy for patients with positive pelvic nodes, positive surgical margin, and/or positive parametrium. (MUC ID: MUC15-466)
    • Description: Proportion of patients with pelvic lymph node metastases, positive surgical margins, or positive parametrium who received postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy (with or without brachytherapy) (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:As combination therapy is the standard of care for patients with spread of cervical cancer beyond surgical margins, it is unclear whether there is an opportunity for improvement. Unless data can demonstrate there is a gap in care, this measure will add little to the current set. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:The National Cancer Institute recommends that platinum containing chemotherapy be added to post-operative radiation therapy for patients with tumor spread beyond the cervix. If patients are receiving this standard of care treatment, little additional gain is likely from use of this measure.
    • Preliminary analysis result: Encourage continued development


  14. Postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy with (or without) brachytherapy for patients with positive pelvic nodes, positive surgical margin, and/or positive parametrium. (MUC ID: MUC15-466)
    • Description: Proportion of patients with pelvic lymph node metastases, positive surgical margins, or positive parametrium who received postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy (with or without brachytherapy) (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  15. Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (MUC ID: MUC15-463)
    • Description: Percentage of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure for treatment of advanced cervical cancer is one of four new measures for cervical cancer management – an area that does not have current measures. Data on current performance is needed to understand the opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:A 2010 Cochrane review found that women who had chemoradiotherapy for cervical cancer were likely to live for longer than women who had just radiotherapy. Although this measure promotes the best recommended care and should improve the outcomes for women with cervical cancer, it is unclear how many patients are not receiving appropriate chemoradiation therapy. The impact will be limited if patients are already receiving this standard of care.
    • Preliminary analysis result: Encourage continued development


  16. Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (MUC ID: MUC15-463)
    • Description: Percentage of patients who receive concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  17. Platin or taxane administered within 42 days following cytoreduction to women with invasive stage I (grade 3), IC-IV ovarian, fallopian tube, or peritoneal cancer (MUC ID: MUC15-454)
    • Description: Measuring the percentage of patient who received Intra Venous (IV) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Currently there are few measures for ovarian cancer and GYN ONC specialists, however, there is no evidence that patients are not receiving this standard of care – the opportunity for improvement may be limited. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma according to analysis of patient data in the prospective OVCAD study. (Gynecologic oncology. 2013;131:15-20. PMID= 23877013). However, the impact is limited if there is no opportunity for improvement.
    • Preliminary analysis result: Encourage continued development


  18. Platin or taxane administered within 42 days following cytoreduction to women with invasive stage I (grade 3), IC-IV ovarian, fallopian tube, or peritoneal cancer (MUC ID: MUC15-454)
    • Description: Measuring the percentage of patient who received Intra Venous (IV) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  19. Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (MUC ID: MUC15-450)
    • Description: Measuring the percentage of patient who received Intra Peritoneal (IP) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:There is no information that there is an opportunity for improvement. The measures are being collected in the Society of Gynecologic Oncology Clinical Outcomes Registry.
      • Impact on quality of care for patients:It is unclear how many patients are not receiving this standard of care. The impact of the measure is limited if current performance is very high.
    • Preliminary analysis result: Encourage continued development


  20. Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (MUC ID: MUC15-450)
    • Description: Measuring the percentage of patient who received Intra Peritoneal (IP) chemotherapy after the debulking of advanced epithelial ovarian cancer (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


4:45 pm   Opportunity for Public Comment
5:00 pm   Adjourn


Day 2-December 10, 2015  
8:00 am   Breakfast
8:30 am   Welcome and Recap of Day 1
Bruce Bagley, Workgroup Chair; Eric Whitacre, Workgroup Chair

8:45 am   Opportunity for Public Comment on Interventional Radiology Consent Calendar
9:00 am   Consent Calendar- Interventional Radiology
Reactors: Paul N. Casale (MIPS); David J. Seidenwurm (MIPS); Rachel Grob (Physician Compare)
  1. Rate of adequate percutaneous image-guided biopsy (MUC ID: MUC15-420)
    • Description: The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was adequate for diagnosis on the final pathology report. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This intermediate outcome measure assesses imaging specialists for a wide variety of patient conditions. The mean pooled success rates ranged from 70-96% for adequacy of sampling across a range of biopsy locations in 23 studies. A consensus panel suggested a threshold of 70-75% adequate sampling rate for internal quality improvement purposes.
      • Impact on quality of care for patients:This is an intermediate outcome measure that would inform patients of the skill and effectiveness of clinicians performing image-guided biopsies
    • Preliminary analysis result: Encourage continued development


  2. Rate of adequate percutaneous image-guided biopsy (MUC ID: MUC15-420)
    • Description: The percentage of percutaneous image-guided (US, CT, fluoro) biopsy procedures performed in which sampling was adequate for diagnosis on the final pathology report. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an intermediate outcome measure that would inform patients of the skill and effectiveness of clinicians performing image-guided biopsies.
    • Preliminary analysis result: Clinician web page


  3. Efficacy of uterine artery embolization for symptomatic uterine fibroids (MUC ID: MUC15-423)
    • Description: The percentage of patients who demonstrate an improvement in their symptoms following uterine fibroids embolization as assessed using a disease-specific survey administered before and 6 months after the procedure (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This patient-reported outcome measure provides the patient perspective on the outcome of this procedure for a common condition -- uterine fibroids. This measure is also valuable for public reporting to patients and consumers. It is unclear how the results of the UFS-QOL survey would be submitted to MIPS. It is also unclear whether the UFS-QOL survey is the only acceptable tool – the cost of the survey is $2500.
      • Impact on quality of care for patients:Uterine artery embolization (UAE) is an alternative treatment for women with symptomatic fibroids of the uterus. Since the purpose of the procedure is to reduce symptoms, the patient is in the best position to know whether the treatment improved her symptoms or not. Aggregate data from the literature reports that 80-85% of women report improvement in their symptoms. UAE avoids the risks of major surgery (hysterectomy) though the costs are similar. 20% of patients require additional treatment after UAE. If UAE is promoted as a less invasive, safer treatment than traditional surgery, it is important to know that the results for patients are good.
    • Preliminary analysis result: Encourage continued development


  4. Efficacy of uterine artery embolization for symptomatic uterine fibroids (MUC ID: MUC15-423)
    • Description: The percentage of patients who demonstrate an improvement in their symptoms following uterine fibroids embolization as assessed using a disease-specific survey administered before and 6 months after the procedure (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Patient-reported outcome measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  5. Common femoral arterial access site complication (MUC ID: MUC15-424)
    • Description: The percentage of groin arterial access procedures with a vascular complication other than a modest hematoma with an access system of 8Fr or less. Access site complications tracked with this measure include pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an adverse outcome measure for vascular access performed commonly across a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures.
      • Impact on quality of care for patients:Arterial access is performed for a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures. Clinical guidelines have noted that “modest hematomas from femoral arterial access occur in up to 10% of patients, where as major hematomas are rare (0.5%). The frequency of other arterial access site complications is more variable.” Measurement of adverse outcomes provides meaningful information for patients. It is unclear whether the distinction between “modest hematoma” (which does not count in the measure) and “major hematoma” will result in reliable results without better definitions.
    • Preliminary analysis result: Encourage continued development


  6. Common femoral arterial access site complication (MUC ID: MUC15-424)
    • Description: The percentage of groin arterial access procedures with a vascular complication other than a modest hematoma with an access system of 8Fr or less. Access site complications tracked with this measure include pseudoaneurysms, arteriovenous fistulae, large hematomas, arterial dissection requiring intervention, arterial thromboembolism, and infectious (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  7. 30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (MUC ID: MUC15-402)
    • Description: Percent of patients with prior neurological symptoms experiencing Stroke or Death within 30 days of Carotid Artery Stenting (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This adverse outcome measure is a “companion” measure to PQRS #345 - Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) and captures a different patient population – those with symptoms (but not acute emergencies.) This measure is intended for interventional radiologists and addresses the quality domain of patient safety. CONDITION: The measure should be submitted to NQF for endorsement.
      • Impact on quality of care for patients:Minimizing complications from a procedure is important and comparing complication rates among providers is critical for patients and families when making decisions about healthcare. The American Heart Association and American Stroke Association recommend a complication rate less than 6% for carotid artery stenting. Complication rates higher than 6% negate the potential benefit of stroke risk reduction. The CREST trial, compared stenting to surgery found that there was no significant differences out to four years of follow-up between surgery and carotid stenting when counting all three, but carotid endarterectomy (CEA) has a higher risk of heart attacks and CAS has a higher risk of minor stroke than open surgery.[1] Overall, younger patients (<70 years old) had better outcomes with stenting than with surgery.
    • Preliminary analysis result: Conditional support


  8. 30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (MUC ID: MUC15-402)
    • Description: Percent of patients with prior neurological symptoms experiencing Stroke or Death within 30 days of Carotid Artery Stenting (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  9. Patient reported outcomes following ilio-femoral venous stenting (MUC ID: MUC15-411)
    • Description: Percentage of patients who demonstrate improvement in a disease specific patient reported quality of life score after ilio-femoral venous stenting (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This PRO adds important information for public reporting and quality of care that is meaningful to patients and their families. The measure is intended for interventional radiologists. No information is provided on cost of the survey and it is unclear how the survey results will be transmitted to MIPS.
      • Impact on quality of care for patients:Ilio-femoral vein stenting has become a safe and effective alternative to traditional open surgery to correct iliac vein obstruction. A RAND evidence review in 2013 reported relief of pain (86-94%), relief from swelling (66%-89%) and healing of venous ulcers (55-89%) in published studies. The RAND summary concluded the benefits outweigh the risks (1B). This PRO can provide important information on performance for patients and other stakeholders seeking information on outcomes from the patient perspective and high-quality care.
    • Preliminary analysis result: Encourage continued development


  10. Patient reported outcomes following ilio-femoral venous stenting (MUC ID: MUC15-411)
    • Description: Percentage of patients who demonstrate improvement in a disease specific patient reported quality of life score after ilio-femoral venous stenting (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Patient-reported outcome measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  11. Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (MUC ID: MUC15-412)
    • Description: Percentage of patients who demonstrate improvement signs and symptoms of post-thrombotic syndrome as assessed using the Villalta Score following ilio-femoral venous stenting (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:A patient-centered outcome measure for a common complication of DVT would be a great addition to the measure set, however, the performance measure must also be tested, not just the assessment instrument.
      • Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The Villialta score captures patient reported symptoms.
    • Preliminary analysis result: Encourage continued development


  12. Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (MUC ID: MUC15-412)
    • Description: Percentage of patients who demonstrate improvement signs and symptoms of post-thrombotic syndrome as assessed using the Villalta Score following ilio-femoral venous stenting (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
      • Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The Villialta score captures patient reported symptoms.
    • Preliminary analysis result: Spreadsheet


  13. Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (MUC ID: MUC15-413)
    • Description: Percentage of patients who demonstrate improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is very similar and overlapping with MUCFIFTEEN-412 Assessment of post-thrombotic syndrome following ilio-femoral venous stenting – it specifies a different assessment tool. If both tools are useful in assessing the patient, these two measures could be combined into a single measure for better alignment and efficiency of measurement.
      • Impact on quality of care for patients:The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT) with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Venous stenting has become the treatment of choice with significant reduction in swelling, pain, ulcer healing and quality of life. At least two instruments are available to assess PTS (Villalta and Venous Clinical Severity Score). Comparison of the two instruments found “there exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.” The VCSS “has proved to be a valuable tool for evaluating changes in condition over time with or without intervention”.
    • Preliminary analysis result: Encourage continued development


  14. Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (MUC ID: MUC15-413)
    • Description: Percentage of patients who demonstrate improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


10:00 am   Break
10:15 pm   Opportunity for Public Comment on Urogynecology Consent Calendar
10:30 pm   Consent Calendar- Urogynecology
Reactors: Luther T. Clark (MIPS);  James Pacala (MIPS); Barb Landreth (Physician Compare)
  1. Route of hysterectomy (MUC ID: MUC15-437)
    • Description: Percentage of patients who underwent vaginal hysterectomy (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure provides an intermediate outcome addressing appropriate use and patient safety for a commonly performed surgical procedure for gynecologists. It is unclear what level of performance is desirable and case-mix adjustment may be necessary to make fair comparisons among gynecologists.
      • Impact on quality of care for patients:Hysterectomy is one of the most frequently performed surgical procedures in the US. ACOG concludes that “evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications.” 2010 data indicate that hysterectomies are performed vaginally (19%), abdominally (56%), or with laparoscopic (25%) or robotic assistance. ACOG notes that “abdominal hysterectomy is also an important surgical procedure, especially when the vaginal or laparoscopic approach is not appropriate to manage the patient's clinical situation or when facilities cannot support a specific procedure.” While encouraging vaginal hysterectomy as the safer procedure, it is unclear how many patients are not candidates for a vaginal hysterectomy and what the target for this measure should be or whether the patient clinical factors are equally distributed among gynecologists.
    • Preliminary analysis result: Encourage continued development


  2. Route of hysterectomy (MUC ID: MUC15-437)
    • Description: Percentage of patients who underwent vaginal hysterectomy (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Patients and other stakeholders are interested in how hysterectomies are performed.
    • Preliminary analysis result: Clinician web page


  3. Over-utilization of mesh in the posterior compartment (MUC ID: MUC15-436)
    • Description: Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure adds an appropriate use measure to the group of measures for pelvic prolapse – a common condition in older women.
      • Impact on quality of care for patients:Posterior repair with and without mesh have been compared with similar outcomes. Mesh has been shown to have significant complications including expulsion of the mesh in 17%. This measure will promote reduced use of mesh and the associated costs (mesh and complications) without affecting patient outcomes.
    • Preliminary analysis result: Encourage continued development


  4. Over-utilization of mesh in the posterior compartment (MUC ID: MUC15-436)
    • Description: Percentage of patients undergoing vaginal surgery for pelvic organ prolapse involving the posterior compartment where a synthetic mesh augment is utilized. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  5. Testing for uterine disease prior to obliterative procedures (MUC ID: MUC15-439)
    • Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse (similar to CMS proposed measure named Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair, see 80 FR 41852). (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is a patient safety measure for appropriate work-up prior to surgery for elderly females. Applicable to gynecologists and female pelvic medicine and reconstructive surgery (FPMRS) specialists.
      • Impact on quality of care for patients:The lifetime risk of having surgery for prolapse or incontinence by age 80-85 is 11-19% and projected to increase. Obliterative surgery (colpocleisis) closes the vagina to keep the organs within the pelvis and is an alternative for patients who cannot tolerate extensive surgery and no longer desire preservation of sexual function. Before surgery, work-up should eliminate any co-existing malignant condition before access to the organs is closed off. Data could not be found on the number of these surgeries performed each year.
    • Preliminary analysis result: Encourage continued development


  6. Testing for uterine disease prior to obliterative procedures (MUC ID: MUC15-439)
    • Description: Percentage of patients having documented assessment of abnormal uterine or postmenopausal bleeding prior to surgery for pelvic organ prolapse (similar to CMS proposed measure named Preoperative exclusion of uterine malignancy prior to any pelvic organ prolapse repair, see 80 FR 41852). (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  7. Documentation of offering a trial of conservative management prior to fecal incontinence surgery (MUC ID: MUC15-440)
    • Description: The percentage of patients who have been offered non-surgical treatment of fecal incontinence prior to surgical intervention (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure uses chart review or entry into the PFD Registry. Encourage further specification to require documentation of the duration and results of attempted conservative therapy. Strongly consider developing a patient-reported outcome for fecal incontinence surgery.
      • Impact on quality of care for patients:A serious trial of conservative therapy of sufficient duration involving several modalities might avoid surgery with good control of patient symptoms.
    • Preliminary analysis result: Encourage continued development


  8. Documentation of offering a trial of conservative management prior to fecal incontinence surgery (MUC ID: MUC15-440)
    • Description: The percentage of patients who have been offered non-surgical treatment of fecal incontinence prior to surgical intervention (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  9. Documentation of offering a trial of conservative management prior to urgency incontinence surgery (MUC ID: MUC15-441)
    • Description: The percentage of patients who have been offered non-surgical treatment of urgency urinary incontinence prior to surgical intervention (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure uses chart review or entry into the PFD Registry. Encourage further specification to require documentation of the duration and results of attempted conservative therapy. Strongly consider developing a patient-reported outcome for urinary incontinence surgery.
      • Impact on quality of care for patients:A serious trial of conservative therapy of sufficient duration involving several modalities might avoid surgery with good control of patient symptoms.
    • Preliminary analysis result: Encourage continued development


  10. Documentation of offering a trial of conservative management prior to urgency incontinence surgery (MUC ID: MUC15-441)
    • Description: The percentage of patients who have been offered non-surgical treatment of urgency urinary incontinence prior to surgical intervention (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


11:30 pm   Opportunity for Public Comment on Gastroenterology Consent Calendar
11:45 pm   Consent Calendar- Gastroenterology
Reactors: Diane Padden (MIPS); Peter Briss (MIPS);  Stephanie Glier (Physician Compare)
  1. Surveillance endoscopy for dysplasia in Barrett's Esophagus (MUC ID: MUC15-208)
    • Description: Percentage of patients with diagnosis of Barrett’s Esophagus that have documented endoscopy in the measurement period (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses a new topic area and provides an additional measure for gastroenterologists. Though other measure addressing GI endoscopy are in the clinician measure set, none address Barrett’s esophagus. Data on current performance would provide a better understanding of the opportunity for improvement.
      • Impact on quality of care for patients:Barrett’s esophagus is a serious complication occurring in about 10-15% of patients with GERD (reflux).Esophageal dyslasia and esophageal cancer occur at increased rates in patients with Barrett's esophagus although less than 1% of patients develop cancer. Nov 2015 guidelinees from American College of Gastroenterology recommend endoscopic surveillance every 3-5 years (strong recommendation, moderate evidence).
    • Preliminary analysis result: Encourage continued development


  2. Surveillance endoscopy for dysplasia in Barrett's Esophagus (MUC ID: MUC15-208)
    • Description: Percentage of patients with diagnosis of Barrett’s Esophagus that have documented endoscopy in the measurement period (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  3. Surveillance colonoscopy for dysplasia in Ulcerative Colitis (MUC ID: MUC15-221)
    • Description: Percentage of patients with diagnosis of Ulcerative Colitis for 10 years or more that have documented colonoscopy in the measurement period or 1 year prior to measurement period. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:There are no measures that focus on Ulcerative Colitis in the current measures list and this measure would compliment other colonoscopy measures. The registry is not specified. Data on current performance would provide a better understanding of the gap in care.
      • Impact on quality of care for patients:American College of Gastroenterology guidelines state “after 8 – 10 years of colitis, annual or biannual surveillance colonoscopywith multiple biopsies at regular intervals should be performed (Evidence B). Aft er 10 years of universaldisease, the cancer risk has been widely reported in the range of 0.5 – 1 % per year. However, a recent nation-wide population-based analysis from the Netherlands found that 20% of all UC-related cancers were detected before 8 years of diseasehad elapsed.
    • Preliminary analysis result: Encourage continued development


  4. Surveillance colonoscopy for dysplasia in Ulcerative Colitis (MUC ID: MUC15-221)
    • Description: Percentage of patients with diagnosis of Ulcerative Colitis for 10 years or more that have documented colonoscopy in the measurement period or 1 year prior to measurement period. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  5. Surveillance colonoscopy for dysplasia in colonic Crohns Disease (MUC ID: MUC15-212)
    • Description: Percentage of patients with diagnosis of colonic Crohn’s Disease for 10 years or more that have documented colonoscopy in the measurement period or 1 year prior to measurement period. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:There are no measures that focus on Crohn’s Disease in the current measures set and this measure would complement other colonoscopy measures. Data on current performance would provide a better understanding of the gap in care. Registry not specified.
      • Impact on quality of care for patients:Crohn's disease is a chronic inflammatory disease of the digestive tract. Symptoms include abdominal pain and diarrhea, sometimes bloody, and weight loss. Crohn’s patients are at higher risk for colon cancer. Early detection of cancer can improve long term survival. ASGE guidelines recommend that patients with Crohn’s Disease for more than 10 years should have a surveillance colonoscopy every 1-2 years
    • Preliminary analysis result: Encourage continued development


  6. Surveillance colonoscopy for dysplasia in colonic Crohns Disease (MUC ID: MUC15-212)
    • Description: Percentage of patients with diagnosis of colonic Crohn’s Disease for 10 years or more that have documented colonoscopy in the measurement period or 1 year prior to measurement period. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  7. Non-selective beta blocker use in patients with esophageal varices (MUC ID: MUC15-209)
    • Description: Percentage of patients with diagnosis of esophageal varices that have documented use of non-selective beta blocker in the measurement period (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses a new topic area and provides an additional measure for gastroenterologists. Further development is indicated with strong consideration to limit to patients with medium/large varices for which the evidence of benefit of non-selective beta blockers is strong. Testing for reliability and validity at the clinician-level of analysis is needed. The registry is not specified.
      • Impact on quality of care for patients:The 2014 AASLD guidelines recommend use of nonselective beta-blockers to prevent hemorrhage in patients with esophageal varicies but the level of evidence varies depending on the size of the varices: consensus opionion only for small varicies but high level evidence for medium/large varices. As side-effects are significant with these medications patients with small varices might suffer from use of medication for which there is no clear evidence of benefit.
    • Preliminary analysis result: Encourage continued development


  8. Non-selective beta blocker use in patients with esophageal varices (MUC ID: MUC15-209)
    • Description: Percentage of patients with diagnosis of esophageal varices that have documented use of non-selective beta blocker in the measurement period (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  9. Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (MUC ID: MUC15-229)
    • Description: Percentage of Patients aged 18 years and older with a diagnosis of hepatitis C who have completed a full course of antiviral treatment with undetectable hepatitis C virus (HCV) ribonucleic acid (RNA) 11 weeks after cessation of treatment. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 6
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an intermediate outcome measure related process measure PQRS#087/NQF #0398 Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment. Data on current performance would provide a better understanding of gap in care.
      • Impact on quality of care for patients:This is an intermediate outcome that reflects the treatment for Hepatitis C. Recent studies report that combining several oral antivirals—drugs taken in pill form, not as injections—clear the virus from the liver in more than 95% of people in just 12 weeks. The new medications are very expensive though cost-effectiveness studies conclude that treatment is cost-effective in most patients. This measure only captures patients that begin treatment – patient that cannot afford the medications are not included.
    • Preliminary analysis result: Encourage continued development


  10. Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (MUC ID: MUC15-229)
    • Description: Percentage of Patients aged 18 years and older with a diagnosis of hepatitis C who have completed a full course of antiviral treatment with undetectable hepatitis C virus (HCV) ribonucleic acid (RNA) 11 weeks after cessation of treatment. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  11. Hepatitis B vaccination for patients with chronic Hepatitis C (MUC ID: MUC15-220)
    • Description: Percentage of patients with diagnosis of chronic Hepatitis C that have documented hepatitis B vaccination (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 6
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Strong consideration should be given to consolidating this measure as Hepatitis B vaccination for all patients with chronic liver disease, including hepatitis C as recommended by CDC. (combine this measure with the MUC for Hepatitis B vaccination for patients with cirrhosis.) Importantly, the specifications should specify that all doses of the vaccine should be given to get credit for this measure. This measure is duals sensitive. Data on current performance would provide better understanding of the gap in care. The registry is not specified.
      • Impact on quality of care for patients:CDC recommends that all patients with chronic liver disease are vaccinated for hepatitis B.
    • Preliminary analysis result: Encourage continued development


  12. Hepatitis B vaccination for patients with chronic Hepatitis C (MUC ID: MUC15-220)
    • Description: Percentage of patients with diagnosis of chronic Hepatitis C that have documented hepatitis B vaccination (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
      • Impact on quality of care for patients:Vaccination against viral hepatitis for patients with chronic hepatitis C can improve long term clinical outcomes
    • Preliminary analysis result: Clinician web page


  13. Hepatitis B vaccination for patients with cirrhosis (MUC ID: MUC15-211)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis B vaccination (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 7
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Strong consideration should be given to focusing this measure on patients with chronic liver disease, including Hepatitis C, rather than multiple measures. The measure is duals sensitive. The registry is not specified. Data on current performance would provide a better understanding of the gap in care.
      • Impact on quality of care for patients:The CDC recommendation for Hepatitis B vaccination includes persons with chronic liver disease as a preventive health measure.
    • Preliminary analysis result: Encourage continued development


  14. Hepatitis B vaccination for patients with cirrhosis (MUC ID: MUC15-211)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis B vaccination (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  15. Hepatitis A vaccination for patients with cirrhosis (MUC ID: MUC15-210)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis A vaccination (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 7
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure must be fully harmonized with PQRS#183/NQF#0399 Hepatitis C: Hepatitis vaccination or better yet, consolidate both into a single vaccination measure for patients with chronic liver disease as recommended by ACIP. The measure is duals sensitive. The registry is not specified. Data on current performance would provide a better understanding of the gap in care.
      • Impact on quality of care for patients:The ACIP recommends Hepatitis A vaccination:“Although not at increased risk for Hep A infection, persons with chronic liver disease are at increased risk for fulminant hepatitis A. Death certificate data indicate a higher prevalence of chronic liver disease among persons who died of fulminant hepatitis A compared with persons who died of other causes. Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (ACIP 2014)
    • Preliminary analysis result: Encourage continued development


  16. Hepatitis A vaccination for patients with cirrhosis (MUC ID: MUC15-210)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented hepatitis A vaccination (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  17. Screening endoscopy for varices in patients with cirrhosis (MUC ID: MUC15-251)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented endoscopy (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:While this measure would address a new topic area in the set, the screening recommendation is not based on solid empirical evidence. The submitter did not provide any information on opportunity for improvement.
      • Impact on quality of care for patients:Esophageal varices (dilated veins) are a serious complications of cirrhosis of the liver. Screening for varices allows treatment to prevent variceal hemorrhage. Endoscopy is the standard for diagnosing varices. .AASLD guidelines recommend endoscopy at the time of diagnosis when the prevalence of medium/large varices is 15-25% (Class IIa, Level C evidence.) Follow up screening every 1-2 years is recommended depending on the initial findings. If patients have small varices, follow up endoscopy is not necessary. All recommendations are Level C evidence so there is little empirical evidence that screening endoscopy will impact patient outcomes. Endoscopy carries significant costs, so evidence-based indications are needed.
    • Preliminary analysis result: Do not encourage further consideration


  18. Screening endoscopy for varices in patients with cirrhosis (MUC ID: MUC15-251)
    • Description: Percentage of patients with diagnosis of cirrhosis that have documented endoscopy (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Impact on quality of care for patients:Early detection of varices in cirrhotic patients can improve long term survival
    • Preliminary analysis result: NA


  19. Screening for Hepatoma in patients with Chronic Hepatitis B (MUC ID: MUC15-217)
    • Description: Percentage of patients with a diagnosis of Chronic Hepatitis B that have had a documented abdominal US, CT Scan, or MRI in the measurement period (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 7
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses a new topic area of Hepatitis B and is related to PQRS# 401 Screening for Hepatocellular Carcinoma (HCC) in patients with Hepatitis C Cirrhosis. A systematic review of Screening for Hepatocellular Carcinoma in Chronic Liver Disease concluded that “There is very-low-strength evidence about the effects of HCC screening on mortality in patients with chronic liver disease. Screening tests can identify early-stage HCC, but whether systematic screening leads to a survival advantage over clinical diagnosis is uncertain.” The frequency of imaging is not specified. The registry is not specified.
      • Impact on quality of care for patients:The current evidence indicates that the benefit to patients is uncertain. The costs of screening without evidence of a benefit are not justified.
    • Preliminary analysis result: Do not encourage further consideration


  20. Screening for Hepatoma in patients with Chronic Hepatitis B (MUC ID: MUC15-217)
    • Description: Percentage of patients with a diagnosis of Chronic Hepatitis B that have had a documented abdominal US, CT Scan, or MRI in the measurement period (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis result: NA


12:30 pm   Lunch
1:45 pm   Opportunity for Public Comment on Miscellaneous Consent Calendar
1:00 pm   Consent Calendar-Miscellaneous
Reactors: Terry Adirim (MIPS); Winfred Wu (MIPS);  Girma Alemu (MIPS); Cynthia Pellegrini (Physician Compare)
  1. Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (MUC ID: MUC15-928)
    • Description: This three-component paired measure assesses whether the PHQ-9 screening tool was used among patients with a diagnosis of major depression or dysthymia, and using patient reports, whether patients with an initial PHQ score >9 demonstrate remission (i.e., PHQ score >5) at six or 12 months. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This NQF-endorsed measure is a patient-reported outcome. This updated three-part measure consolidates two current measures in the PQRS and Meaningful Use programs..
      • Impact on quality of care for patients:In 2006 and 2008, an estimated 9.1% of U.S. adults reported symptoms for current depression.1 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. There is an opportunity for improvement for the population captured by this paired measure, which includes two PROs.
    • Preliminary analysis result: Support


  2. Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (MUC ID: MUC15-928)
    • Description: This three-component paired measure assesses whether the PHQ-9 screening tool was used among patients with a diagnosis of major depression or dysthymia, and using patient reports, whether patients with an initial PHQ score >9 demonstrate remission (i.e., PHQ score >5) at six or 12 months. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Outcome measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  3. PQI 91 Prevention Quality Acute Composite (MUC ID: MUC15-577)
    • Description: PQI composite of acute conditions per 100,000 population, ages 18 years and older. Includes admissions with a principal diagnosis of one of the following conditions: dehydration, bacterial pneumonia, or urinary tract infection. (Includes PQIs 10, 11, and 12) (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services. This measure is sensitive to dual eligible patients. CONDITION: Successful testing for reliability and validity at the clinician level of analysis and submission of the composite to NQF.
    • Preliminary analysis result: Conditional support


  4. PQI 91 Prevention Quality Acute Composite (MUC ID: MUC15-577)
    • Description: PQI composite of acute conditions per 100,000 population, ages 18 years and older. Includes admissions with a principal diagnosis of one of the following conditions: dehydration, bacterial pneumonia, or urinary tract infection. (Includes PQIs 10, 11, and 12) (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Composite measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  5. Prevention Quality Indicators 92 Prevention Quality Chronic Composite (MUC ID: MUC15-576)
    • Description: PQI composite of chronic conditions 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, or angina without a cardiac procedure. (Includes PQIs 1, 3, 5, 7, 8, 13, 14, 15, and 16) (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This composite measure for population health encourages care coordination and efficient use of healthcare services and is sensitive to dual eligible patients. However, the measure should reconsider some of the components and must be fully developed and tested with appropriate risk-adjustment at the clinician level of analysis.
      • Impact on quality of care for patients:This measure encourages appropriate care of chronic conditions in the ambulatory setting to avoid hospitalization which is highly desirable for patients and families and reduces costs.
    • Preliminary analysis result: Encourage continued development


  6. Prevention Quality Indicators 92 Prevention Quality Chronic Composite (MUC ID: MUC15-576)
    • Description: PQI composite of chronic conditions 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, or angina without a cardiac procedure. (Includes PQIs 1, 3, 5, 7, 8, 13, 14, 15, and 16) (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Composite measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  7. Potential Opioid Overuse (MUC ID: MUC15-1169)
    • Description: Percentage of patients aged 18 years or older who receive opioid therapy for 90 days or longer and are prescribed at least 90 milligrams morphine equivalent daily dosage. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 5
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an appropriate use/overuse and patient safety measure that is not duplicative of other measures in the clinician measure set. This MUC directly measures opioid over-prescribing. Data to determine the performance gap is needed.
      • Impact on quality of care for patients:The CDC reports that drug overdoses are the leading cause of injury-related death in the United States and that the death rate from drug overdose has risen dramatically over the last decade. This increase is thought to be attributable primarily to the misuse and abuse of prescription drugs, especially opioid analgesics, sedatives/tranquilizers, and stimulants. There is substantial variation in opioid prescribing patterns across regions and providers, indicating a need for improvement in practices.
    • Preliminary analysis result: Encourage continued development


  8. Potential Opioid Overuse (MUC ID: MUC15-1169)
    • Description: Percentage of patients aged 18 years or older who receive opioid therapy for 90 days or longer and are prescribed at least 90 milligrams morphine equivalent daily dosage. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Appropriate care measures are generally meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  9. HIV Screening for Patients with Sexually Transmitted Disease (STD) (MUC ID: MUC15-230)
    • Description: Percentage of patients diagnosed with an acute STD indicative of elevated risk for HIV exposure who were tested for HIV (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses public health and prevention and is an eMeasure. In 2015 MAP encouraged further development of this measure that is currently in field testing. Patient confidentiality must be considered as a spouse, adult child or adolescent on the family insurance may not want to have HIV testing on the insurance billing and may opt to have the HIV test elsewhere.
      • Impact on quality of care for patients:CDC emphasizes the need for HIV testing for people with STIs as they are considered at higher risk for acquiring HIV. 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
    • Preliminary analysis result: Encourage continued development


  10. HIV Screening for Patients with Sexually Transmitted Disease (STD) (MUC ID: MUC15-230)
    • Description: Percentage of patients diagnosed with an acute STD indicative of elevated risk for HIV exposure who were tested for HIV (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Prevention measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  11. New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (MUC ID: MUC15-296)
    • Description: The percentage of patients aged 18 years and older who undergo anesthesia care and who did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area. Anesthesia care for surgery of the face will be reported separately from anesthesia care for other procedures. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This patient safety-focused outcome measure is relevant for anesthesia providers and is not duplicative of other measures in the clinician measure set.
      • Impact on quality of care for patients:Corneal abrasion/injury is a common complication of surgery involving general anesthesia. These injuries are painful for the patient and may lead to other adverse effects, and can also result in increased costs and length of stay.
    • Preliminary analysis result: Encourage continued development


  12. New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (MUC ID: MUC15-296)
    • Description: The percentage of patients aged 18 years and older who undergo anesthesia care and who did not have a new diagnosis of corneal injury in the post-anesthesia care unit/recovery area. Anesthesia care for surgery of the face will be reported separately from anesthesia care for other procedures. (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Adverse outcome measures are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  13. Performance of objective measure of functional hearing status (MUC ID: MUC15-307)
    • Description: Percentage of patients 5 years and older with documentation of a standardized, objective measure of functional hearing status using open-set speech recognition (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The MUC adds another measure for audiologist that have only 1 measure in the current set. It is unclear whether this is currently standard of care for audiologists. Consider strengthening the measure by including counseling the patient, family and caregiver on the results and recommendations of the auditory assessment and report to physician on the need for treatment or further testing. ASHA is building a registry with anticipated completion date of Fall, 2016.
      • Impact on quality of care for patients:Documentation measures have limited impact on patient outcomes without measuring follow-up or interventions. Including functional assessment evaluate listening behavior in real world settings - outside the confines of the soundproof booth where most formal audiological testing takes place, may guide management plans, however, it is unclear that evidence supports a relationship with specific patient outcomes. No data on current performance could be found to support an opportunity for improvement.
    • Preliminary analysis result: Encourage continued development


  14. Performance of objective measure of functional hearing status (MUC ID: MUC15-307)
    • Description: Percentage of patients 5 years and older with documentation of a standardized, objective measure of functional hearing status using open-set speech recognition (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is technical and more meaningful to clinicians than patients.
    • Preliminary analysis result: Spreadsheet


  15. Patient-Reported Functional Communication (MUC ID: MUC15-313)
    • Description: Percentage of patients 18 years and older with documentation of a standardized patient-reported functional communication assessment (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an additional measure for audiologists that have only 1 measure in the current set. It is unclear whether this is currently standard of care for audiologists or whether there is an opportunity for improvement. Consider strengthening the measure by using the results of the patient assessment. ASHA is building a registry with anticipated completion date of Fall, 2016.
      • Impact on quality of care for patients:Documentation measures have limited impact on patient outcomes without measuring follow-up or interventions. No data on current performance could be found to support an opportunity for improvement.
    • Preliminary analysis result: Encourage continued development


  16. Patient-Reported Functional Communication (MUC ID: MUC15-313)
    • Description: Percentage of patients 18 years and older with documentation of a standardized patient-reported functional communication assessment (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Measures using patient reported data are meaningful to patients and other stakeholders.
    • Preliminary analysis result: Clinician web page


  17. Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (MUC ID: MUC15-275)
    • Description: The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System (MIPS)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is duplicative of PQRS #349 (NQF#0076) Optimal Vascular Care that has been in the PQRS program for several years. The 2016 PFS final rule has removed PQRS#349 because the composite is duplicative of the Million Hearts measures. ?
      • Impact on quality of care for patients:Composite measures of evidence-based processes and intermediate clinical outcomes combine multiple factors important to care and address whether a patients is receiving all the evidence-based care they receive. Most of the atherosclerotic disease measures enjoy high performance individually, but the composite reveals that the results are not uniformly high for individual patients – further opportunity for improvement exists which can further reduce the risks of poor outcomes for patients. and represents measure that promote high performance.
    • Preliminary analysis result: Do not support


  18. Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (MUC ID: MUC15-275)
    • Description: The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use (Measure Specifications)
    • Programs under consideration: Physician Compare
    • Public comments received: 0
    • Preliminary analysis result: NA


2:00 pm   Workgroup Discussion – Gaps in the Clinician program measure sets
2:30 pm   Workgroup Discussion – Alignment
Alignment of clinician measures across clinician programs; Alignment of clinician measures with measures in hospital and PAC/LTC programs

3:00 pm    Workgroup discussion – Public reporting of clinician measures
3:30 pm   Opportunity for Public Comment
3:45 pm   Summary of the MAP Clinician Workgroup pre-rulemaking input
4:00 pm   Adjourn

Appendix A: Measure Information

Measure Index

Merit-Based Incentive Payment System (MIPS)

Medicare Shared Savings Program

Physician Compare


Full Measure Information

30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-402)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This measure complements the companion measure in symptomatic patients. The rationale for separating asymptomatic and symptomatic patients is that the recommended treatment criteria for each is different (stenosis grade) and a worse outcome score could be acceptable in symptomatic patients. This measure represents an unmet outcome measure for patients in multiple CMS programs.


Acquired Involutional Entropion: Normalized lid position after surgical repair (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-377)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Normalized lid position is the desired goal of surgery to improve clinical and functional outcomes for the patient


Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-396)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Reduction of inflammation is a desired treatment goal for improved clinical and functional outcome


Acute Anterior Uveitis: Post-treatment visual acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-394)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improvement of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-412)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The Villalta score is a well-recognized composite score that integrates patient reported symptoms with signs of the severity of post-thrombotic syndrome in patients with ilio-femoral venous disease (hence represents both PRO and an intermediate outcome measures). It is simple to administer clinically and is a reliable measure to ascertain both the clinical severity as well as morbidity associated with post-thrombotic syndrome. There is a measure gap in the area of venous disease and this measure will help to address this. The Villalta score can be integrated into structured reporting that is being piloted by the SIR, potentially enabling QCDR level reporting of the measure. An advantage over surveys is that this scoring system can be use uniformly by many sites. A disadvantage over surveys is that patients must be seen to have the follow-up score documented.


Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-399)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Reduction of inflammation is a desired treatment goal for improved clinical and functional outcome


Chronic Anterior Uveitis: Post-treatment visual acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-397)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improvement of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Common femoral arterial access site complication (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-424)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Arterial access is a critical step for any arterial vascular intervention and is performed commonly across a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures. Arterial access site complications are a significant contributor to patient discomfort and morbidity in the perioperative period, and are a fortunately rare cause for mortality. Common femoral arterial access is by far the most common site of access for a variety of endovascular procedures. The size of the arterial access and the presence of underlying vascular disease are predisposing factors to arterial access site complications. This measure is intended to focus on access site complications using 8Fr or small sheath sizes, and can be reported in any center performing arterial procedures as a measure of quality patient care. The rationale to limit the upper size of the access to 8Fr is to limit the measure to procedures with exclusively percutaneous access. Physicians using this measure are free to utilize Ultrasound for arterial access and can report the measure regardless if they use closure devices or rely on manual pressure as a strategy for achieving hemostasis. There is significant morbidity that may result from procedures performed downstream on patients with access site complications, including open repair of the injured artery site. The SIR Clinical Practice Guidelines (JVIR 2003, Vol 14, Issue 9, Part 2, S283-288) have noted that modest hematomas from femoral arterial access occur in up to 10% of patients, whereas major hematomas are rare (0.5%). The frequency of other arterial access site complications is more variable. As proposed this measure compliments a measure being considered for the 2016 PQRS program entitled ""Rate of surgical conversion from lower extremity endovascular revascularization procedure"" by detailing access site complications specifically. Access site complications are a modifiable risk factor for surgical conversion in lower extremity arterial procedures specifically."


Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-461)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The primary treatment for locally advanced cervical cancer consists of external beam radiation to the pelvis +/-para-aortic region with concurrent chemotherapy. In this patient population, total radiation therapy treatment time beyond 7 to 9 weeks has been shown to result in increased pelvic failure rates and decreased cancer specific and overall survival. Pelvic failure rates were reported at 26% for women who required greater than 56 days compared to 9% (hazard ratio 3.8; p=0.02). In an ancillary analysis of a Gynecologic Oncology Group study (protocol 165), women who had prolongation of radiation for any cause had a poorer progression free survival (HR 1.98; CI 1.16-3.38) and overall survival (HR 1.88; CI 1.08-3.26) compared to those who completed therapy within 8 weeks. Further studies have shown that prolongation of radiation is associated with a decreased survival of 0.6% and pelvic control rates of 0.7% for each additional day beyond 55 days for all stages of disease. More recent studies have shown that this effect remains even in the setting of chemoradiation. References: 1. Song S, Rudra S, Hasselle MD, et al. The effect of treatment time in locally advanced cervical cancer in the era of concurrent chemoradiotherapy. Cancer 2013;119(2):325-331. 2. Fyles A, Keane TJ, Barton M, Simm J. The effect of treatment duration in the local control of cervix cancer. Radiother Oncol 1992;25(4): 273-9. 3. Nugent EK, Case AS, Hoff JT, et al. Chemoradiation in locally advanced cervical carcinoma: an analysis of cisplatin dosing and other clinical prognostic factors. Gynecol Oncol 2010;116(3):438-41. 4. Monk BJ, Tian C, Rose PG, Lanciano R. Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials. Gynecol Oncol 2007;427-433. 5. Petereit DG, Sarkaria JN, Chappell R, Fowler JF, Harmann TJ, Kinsella TJ et al . The adverse effect of treatment prolongation in cervical carcinoma. Int J Radiation Oncology Biol Phys 1995;32(5):1301-1307. 6. Perez CA, Grigsby PW, Castro-Vita H, Lockett MA. Carcinoma of the uterine cervix. Impact of prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy. Int J Radiation Oncology Biol Phys 1995;32(5): 1275-1288.


Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-370)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improved visual acuity is a desired surgical goal to improve patient's daily activities of daily living and quality of life


Diabetic Macular Edema: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-393)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Documentation of offering a trial of conservative management prior to fecal incontinence surgery (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-440)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This measure is intended to ensure that patients are offered the opportunity to pursue conservative management prior to surgery. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback is associated with satisfaction rates of up to 76%, and continence in 55%. Patient education on all the treatment options can help with patient satisfaction and better outcomes as they still can be used as adjunct therapies to surgery. Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Whitehead WE, Rao SS, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton FA. Am J Gastroenterol. 2015 Jan;110(1):138-46; quiz 147. doi: 10.1038/ajg.2014.303. Epub 2014 Oct 21. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, Mott L, Rogers RG, Zinsmeister AR, Whitehead WE, Rao SS, Hamilton FA. Am J Gastroenterol. 2015 Jan;110(1):127-36. doi: 10.1038/ajg.2014.396. Epub 2014 Dec 23.


Documentation of offering a trial of conservative management prior to urgency incontinence surgery (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-441)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Urge urinary incontinence negatively impacts patients' quality of life, as patients may limit activities outside the home, socializing, and sexual activity due to the fear of leaking. Current guidelines issued by the American Urologic Association state that behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) should be first line therapy. Clinicians should offer oral anti-muscarinics or oral beta 3-adrenoceptor agonists as second-line therapy. Third line therapies include intradetrusor Botox injections, peripheral tibial nerve stimulation, or sacral neuromodulation. Website reference: https://www.auanet.org/education/guidelines/overactive-bladder.cfm


Efficacy of uterine artery embolization for symptomatic uterine fibroids (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-423)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Uterine artery embolization is a well-established procedure for the treatment of symptomatic uterine fibroids, with reported success rates of 85% in patients with isolated uterine fibroids as the etiology of their symptoms. Although there are a variety of techniques that are used clinically, such variance has little impact on the overall patient outcome. The development of uterine fibroid disease specific surveys, such as the Uterine Fibroid Symptom Health-related Quality of Life Questionnaire (UFS-QOL) has enabled robust reporting of patient-reported outcomes for this disease (http://www.sirfoundation.org/registries/). Importantly, this survey enables assessment both of the patient's subjective symptoms as well as their experience. The routine use of this survey instrument would objectively assess the procedural efficacy at the patient level.


Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-379)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Glaucoma - Intraocular Pressure (IOP) Reduction (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-372)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome


Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-374)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome


Hepatitis A vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-210)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (Advisory Committee on Immunization Practices 2014)


Hepatitis B vaccination for patients with chronic Hepatitis C (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-220)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Vaccination against viral hepatitis for patients with chronic hepatitis C can improve long term clinical outcomes


Hepatitis B vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-211)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (Advisory Committee on Immunization Practices 2014)


Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-229)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Achieving SVR is the first step toward reducing future HCV morbidity and mortality. Once achieved, an SVR is associated with long-term clearance of HCV infection, which is regarded as a virologic ‘‘cure,’’ as well as with improved morbidity and mortality. Patients who achieve an SVR usually have improvement in liver histology and clinical outcomes. Nineteen cohort studies (n=105 to 16,864) evaluated the association between SVR after antiviral therapy and mortality or complications of chronic HCV infection. Duration of follow-up ranged from 3 to 9 years. Ten studies were conducted in Asia (60, 67-72, 75, 77, 78). Eight (64-66, 72, 75-78) were rated as poor-quality and the remainder as fair quality. Although all studies reported adjusted risk estimates, only 8 (60, 61, 63, 67-70, 73) evaluated 5 key confounders (age, sex, genotype, viral load, and fibrosis stage). No study clearly described assessment of outcomes blinded to SVR status. The largest study (n=16,864) had the fewest methodological shortcomings (61). It adjusted for multiple potential confounders, including age, sex viral load, presence of cirrhosis, multiple comorbid conditions, aminotransferase levels, and others. It also stratified results by genotype. In a predominantly male, Veterans Affairs population, SVR after antiviral therapy was associated with lower risk for all-cause mortality than was SVR , after median of 3.8 years (adjusted hazard ration, 0.71 [CI, 0.60 to 0.861], 0.62[CI, 0.44 to 0.87], and 0.51 [CI, 0.35 to 0.75] for genotypes 1, 2, and 3 respectively). Mortality curves began to separate as soon as 3 to 6 months after SVR assessment. Eighteen other cohort studies also found SVR to be associated with decreased risk for all-cause mortality (adjusted hazard rations, 0.07 to 0.39)(60, 69, 72, 73, 75-78), liver-related mortality (adjusted hazard rations, 0.12 to 0.46)(60, 62, 63, 67, 68, 71, 73-76, 78), and other complications of end-stage liver disease versus no SVR, with effects larger than in the Veterans Affairs study. The subgroup of studies that focused on patients with advanced fibrosis or cirrhosis at baseline (60, 67-72, 75, 77, 78) reported similar risk estimates. (Chou et. al., 2015) Chou R, Hartung D, Rahman B, Wasson N, Cottrell EB, Fu R. Comparative effectiveness of antiviral treatment for hepatitis C virus infection in adults: a systematic review. Ann Intern Med. 2013 Jan 15;158(2):114-23. Review. PubMed PMID: 23437439


HIV Screening for Patients with Sexually Transmitted Disease (STD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-230)

Measure Specifications

Preliminary Analysis of Measure

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 U.S. Preventive Services Task Force (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 underlying the USPSTF recommendation 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) Notably, the current USPSTF 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. CDC's newly published 2015 STD Treatment Guidelines also underscore the need for HIV testing in the context of certain STD diagnoses, noting that: “Persons at high risk for HIV infection with early syphilis, gonorrhea, or chlamydia should be screened at the time of the STD diagnosis, even if an HIV test was recently performed. Some STDs, especially rectal gonorrhea and syphilis, are a risk marker for HIV acquisition." Relevant references supporting the 2015 STD Treatment Guidelines include: • Zetola NM, Bernstein KT, Wong E, et al. Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs. J Acquir Immune Defic Syndr 2009;50:546–51. • Pathela P, Braunstein SL, Blank S, et al. HIV incidence among men with and those without sexually transmitted rectal infections: estimates from matching against an HIV case registry. Clin Infect Dis 2013;57:1203–9. • Peterman TA, Newman DR, Maddox L, Schmitt K, Shiver S. Risk for HIV following a diagnosis of syphilis, gonorrhoea or chlamydia: 328,456 women in Florida, 2000-2011. Int J STD AIDS. 2015 Feb;26(2):113-9. doi: 10.1177/0956462414531243. Epub 2014 Apr 8. • Taylor MM, Newman DR, Gonzalez J, Skinner J, Khurana R, Mickey T. HIV status and viral loads among men testing positive for rectal gonorrhoea and chlamydia, Maricopa County, Arizona, USA, 2011-2013. HIV Med. 2015 Apr;16(4):249-54. doi: 10.1111/hiv.12192. Epub 2014 Sep 17


Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-413)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The venous clinical severity score replace the older CEAP (clinical grade, etiology, anatomy, pathophysiology) grading system to assess the severity of chronic venous disease. Unlike the CEAP system, the venous clinical severity score is more useful in the assessment of changes in venous disease and thus is most appropriate to apply to patients undergoing treatment to assess outcomes from therapy, such as ilio-femoral venous stenting. This measure addresses a measurement gap across multiple programs. By encouraging the routine use of the venous clinical severity score centers will be able to objectively assess the intermediate outcome of venous stenting on the symptoms and signs of chronic venous disease. This score focuses more on the clinical signs, rather than patient symptoms, which was demonstrated to be a more useful marker for subtle changes in the severity of venous disease.


Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-450)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a subooptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686). IP chemotherapy provides a superior OS in patients after optimal cytoreductive surgery (Walker JL, Armstrong DK, Huang HQ, Fowler J, Webster K, Burger RA, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III ovarian and primary peritoneal cancer: a Gynecologic Oncology Group Study. Gynecologic oncology. 2006;100:27-32. PMID=16368440)


Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-275)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. References: Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce : Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines- http://circ.ahajournals.org/search?tocsectionid=ACC/AHA+Prevention+Guideline&sortspec=date&submit=Submit AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update http://content.onlinejacc.org/article.aspx?articleid=1127560 The All or None (Composite) method was chosen because of the benefits it provides to both the patient and the practitioner. First, this methodology more closely reflects the interests and likely desires of the patient. With the data collected in one score patients can easily look and see how their provider group is performing on these criteria rather than trying to make sense of multiple scores on individual measures. Second, this method represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. Third, this method gives a more sensitive scale for improvement. For those organizations scoring high marks on individual measures, the All-or-None measure will give room for benchmarks and additional improvements to be made.


Minimally invasive surgery performed for patients with endometrial cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-452)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
A total of 8 randomized clinical trials investigating minimally invasive surgery compared to laparotomy in over 3500 patients showed no difference in overall or disease free survival (Cochrane Database Syst Rev. 2012 Sep 12;9; J Clin Oncol. 2012 Mar 1;30(7):695-700; J Clin Oncol. 2009 Nov 10;27(32):5331-6). However, patients undergoing minimally invasive surgery (laparoscopic or robotic-assisted hysterectomy) had reduced length of hospital stay, lower blood loss, and improved quality of life at 6 weeks (Lancet Oncol. 2010 Aug;11(8):772-80.; J Clin Oncol. 2009 Nov 10;27(32):5337-42). Furthermore, the rate of severe postoperative adverse events was lower in patients undergoing minimally invasive surgery (Cochrane Database Syst Rev. 2012 Sep 12;9). Despite these known benefits, utilization rates of minimally invasive surgery vary from 50-90% between surgeons and institutions (unpublished data from Nationwide inpatient sample - delete this sentence if reference required). References: 1: Galaal K, Bryant A, Fisher AD, Al-Khaduri M, Kew F, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2012 Sep 12;9:CD006655. doi: 10.1002/14651858.CD006655.pub2. Review. PubMed PMID: 22972096. 2: Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Barakat R, Pearl ML, Sharma SK. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol. 2012 Mar 1;30(7):695-700. doi: 10.1200/JCO.2011.38.8645. Epub 2012 Jan 30. Erratum in: J Clin Oncol. 2012 May 1;30(13):1570. PubMed PMID: 22291074; PubMed Central PMCID: PMC3295548. 3: Janda M, Gebski V, Brand A, Hogg R, Jobling TW, Land R, Manolitsas T, McCartney A, Nascimento M, Neesham D, Nicklin JL, Oehler MK, Otton G, Perrin L, Salfinger S, Hammond I, Leung Y, Walsh T, Sykes P, Ngan H, Garrett A, Laney M, Ng TY, Tam K, Chan K, Wrede CD, Pather S, Simcock B, Farrell R, Obermair A. Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial. Lancet Oncol. 2010 Aug;11(8):772-80. doi: 10.1016/S1470-2045(10)70145-5. Epub 2010 Jul 16. PubMed PMID: 20638899. 4: Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Spiegel G, Barakat R, Pearl ML, Sharma SK. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009 Nov 10;27(32):5331-6. doi: 10.1200/JCO.2009.22.3248. Epub 2009 Oct 5. PubMed PMID: 19805679; PubMed Central PMCID: PMC2773219. 5: Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D. Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol. 2009 Nov 10;27(32):5337-42. doi: 10.1200/JCO.2009.22.3529. Epub 2009 Oct 5. Erratum in: J Clin Oncol. 2010 Jun 1;28(16):2805. PubMed PMID: 19805678; PubMed Central PMCID: PMC2773220.


New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-296)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Corneal abrasion/injury is the most common ophthalmologic complication that occurs during general anesthesia for non-ocular surgery. These injuries are painful for the patient, and can lead to significant microbial keratitis with possibility of permanent scarring. There is no standardized method for protecting the eyes during an anesthetic for non-ocular surgery. Adhesive tape, individual single, sterile packaged eye covers, small bio-occlusive dressings, used with or without eye ointment are some of the options used. Some practitioners may simply observe closed, non-taped eyes. The specific type of eye ointment also varies significantly. Some ointment is made with petrolatum, some is water soluble, with or without preservatives. If ointment is used, preservative-free eye ointment is preferred, because preservative can cause corneal epithelial sloughing and conjunctiva hyperemia. None of the methods described in the literature are entirely effective at preventing corneal injury and some are associated with unwanted side effects. It is important to know that petrolatum is flammable and should be avoided when cautery will be used near the face. Several large studies have demonstrated that applying these techniques while measuring performance can lead to significant improvements in patient care. Measuring the incidence of corneal injury will give practices the data they need to assess performance, compare to national benchmarks, and if gaps are identified, undertake measures to improve eye protection for patients. The net result will be reduced corneal injuries and patient discomfort. All eye trauma cases and all eye surgery cases will be excluded from the measure. Reporting separately those procedures done on the face, including the ear, nose, and mandible, will serve as stratification allowing comparison of procedures which most anesthesiologists believe have a higher risk of corneal injury and which also remove the eyes from the direct control of the anesthesiologist.


NMSC: Biopsy Reporting Time - Pathologist (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-216)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The communication between pathologists and physicians about patient outcomes is fragmented. Effective and timely communication through the biopsy report between the two practitioners is essential; as delay may directly affect patient care. Furthermore, lack of timely delivery can increase the cost of medical care and error. This measure seeks to standardize the amount of time it takes for the pathologist to send the final biopsy report to the biopsying physician to ensure timely communication and effective treatment for the patient.


Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-392)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-215)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Effective and timely communication between the physician and patient about biopsy results is essential; as delay may directly affect patient care. Furthermore, lack of timely delivery can negatively affect patient experience and satisfaction by increasing the anxiety the patient experiences while waiting for results. This measure seeks to standardize the amount of time it takes for the clinician to notify patients of the final biopsy results, to ensure timely communication and effective treatment for the patient.


Non-Recommended PSA-Based Screening (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1019)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The USPSTF recommends against PSA-based screening for prostate cancer (grade D recommendation). This recommendation applies to men in the general U.S. population, regardless of age.” The Agency for Healthcare Research and Quality (AHRQ) looked at five randomized controlled trials (RCTs) and two meta-analyses and found inconsistency regarding the efficacy of PSA-based screening, although the high-quality surveyed studies are limited to interim results and do not consider potential psychological harms.


Non-selective beta blocker use in patients with esophageal varices (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-209)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Use on non-selective beta blockers in the setting of esophageal varices can reduce portal pressure and improve long term clinical outcomes. American Association for the Study of Liver Diseases Guidelines 2009


Over-utilization of mesh in the posterior compartment (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-436)

Measure Specifications

Preliminary Analysis of Measure

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), with the lifetime risk for undergoing surgery for pelvic organ prolapse recently estimated to have doubled to 20% (Obstet and Gynecol 2014;123:1201-6). Repairs of the posterior compartment can include a midline fascial plication, site-specific repair, or a graft-augmented repair. Studies have failed to demonstrate any significant benefit to the utilization of synthetic mesh augments in the posterior compartment (Am J Obstet Gynecol 2006;195:1762-71) and recent concerns have come to light regarding the use of synthetic mesh augments (FDA Urogynecologic Surgical Mesh : Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse; July 2011). Implementation of this measure will determine if best care practices are being followed when treating women with disorder.


Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-928)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Depression is a common and treatable mental disorder. The Centers for Disease Control and Prevention states that an estimated 6.6% of the U.S. adult population (14.8 million people) experiences a major depressive disorder during any given 12-month period. Additionally, dysthymia accounts for an additional 3.3 million Americans. In 2006 and 2008, an estimated 9.1% of U.S. adults reported symptoms for current depression.[1] 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.[2] Depression is associated with higher mortality rates in all age groups. People who are depressed are 30 times more likely to take their own lives than people who are not depressed and five times more likely to abuse drugs.[3] Depression is the leading cause of medical disability for people aged 14 – 44.[4] Depressed people lose 5.6 hours of productive work every week when they are depressed, fifty percent of which is due to absenteeism and short-term disability. People who suffer from depression have lower incomes, lower educational attainment and fewer days working days each year, leading to seven fewer weeks of work per year, a loss of 20% in potential income and a lifetime loss for each family who has a depressed family member of $300,000.[5] The cost of depression (lost productivity and increased medical expense) in the United States is $83 billion each year.[6] 1. CDC. Current Depression Among Adults --- United States, 2006 and 2008. MMWR 2010;59(38);1229-1235. 2. Strine TW, Mokdad AH, Balluz LS, et al. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv 2008;59:1383--90. 3. Joiner, Thomas Myths about suicide. Cambridge, MA, US: Harvard University Press. (2010). 288 pp. 4. Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein, D. (2003). Cost of lost productive work time among US workers with depression. Journal of the American Medical Association, 289, 3135-3144. 5. Smith, J. P., & Smith, G. C. (2010). Long-term economic costs of psychological problems during childhood. Social Science & Medicine, 71, 110-115. 6. Greenberg, P. E., Kessler, R. C., Birnbaum, H. G., Leong, S. A., Lowe, S. W., Berglund, P. A., et al. (2003). The economic burden of depression in the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry, 64, 1465-1475. More detailed information about the rationale and history of this measure and its components are available in the MNCM measure submission forms for the most recent NQF Behavioral Health measure endorsement project. Links are in the final committee report available here: http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspx.


Patient reported outcomes following ilio-femoral venous stenting (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-411)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Ilio-venous stenting is a commonly performed procedure in patients with deep venous disease including acute, acute-on-chronic, and chronic venous thrombosis. Such interventions are also performed in patients with venous stenosis, such as patient with May-Turner syndrome. The procedural outcome of such procedures does not necessarily reflect resolution of patient symptoms, however. Standardizing the use of disease-specific surveys in this patient population is necessary to objectively assess the success of ilio-femoral venous stenting. Each survey is different; an objective outcome of any improvement would be the most appropriate assessment to encourage use of this measure by a wide variety of providers. This measure compliments a measure being considered for the 2016 PQRS program, focused on the PRO in patients undergoing saphenous vein ablation.


Patient-Reported Functional Communication (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-313)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Patient engagement and their perceptions of their hearing abilities is necessary to determine patient-centered goals and treatment. There are several standardized, validated patient questionnaires available to capture the patient's perception of their communication abilities in their activities of daily living that can be used with objective measures of communication and hearing to offer a complete picture of the patient's functional ability. Using these tools assists the audiologist with rehabilitation goals and care planning, and engages the patient in the development of their own functional goals. The AQC proposes this measure will assist audiologists adapt their practices to patient-centered, functional care and actively engage patients in the diagnosis and treatment of their hearing loss.


Performance of objective measure of functional hearing status (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-307)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Functional hearing measurements are necessary to supplement the findings of the hearing thresholds and capture the patient's ability to communicate, and should be incorporated into the diagnosis and treatment of bilateral, permanent hearing loss. The data captured in objective measurement of open-set speech recognition, introduced with the presence of noise, can help audiologists objectively measure improvement and outcomes with amplification and rehabilitation and be used as a tool to educate patients on their hearing perception abilities. Additionally, functional hearing is a necessary measurement to determine cochlear implant candidacy. The AQC proposes this measure will assist audiologists adapt their practices to patient-centered, functional care.


Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-465)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The primary treatment of stage IB1-IIA is radical hysterectomy. Unlike simple hysterectomy, radical hysterectomy includes removal of the paracervical tissue including the parametrium, uterosacral ligament, and uper vagina. Radical hysterectomy has long been considered the most appropriate type of hysterectomy for invasive cervical cancer. The procedure requires expertise and technical skill to perform. Radical hysterectomy can be performed via laparotomy, through minimally invasive technology (robotic or laparoscopic) or vaginally.


Platin or taxane administered within 42 days following cytoreduction to women with invasive stage I (grade 3), IC-IV ovarian, fallopian tube, or peritoneal cancer (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-454)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a suboptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686). Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a subooptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686).


Postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy with (or without) brachytherapy for patients with positive pelvic nodes, positive surgical margin, and/or positive parametrium. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-466)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
There have been multiple prospective randomized trials demonstrating the disease free and overall survival for cervical cancer patients with post-operative involvement of surgical margins, and/or regional lymph nodes. These collective studies have resulted in the recommendation by the National Cancer Institute that platinum containing chemotherapy be added to post-operative radiation therapy for patients with positive surgical margins including the parametrium and vagina, as well as positive lymph nodes. The following articles are referenced in the NCI alert: Morris et al NEJM 1999;340:1137-1143, Peters et al JCO 2000;18:1606-1613, Rose, P. et al NEJM 1999;340:1144-1153


Potential Opioid Overuse (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1169)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Considerable evidence indicates that opioid overuse is an important issue. The 2014 U.S. Department of Health and Human Services (HHS) National Action Plan for Adverse Drug Event Prevention highlighted the need for safer prescribing and monitoring of opioids. Patients prescribed high-dose opioids have an approximately 10-fold increase in risk of overdose compared with those prescribed low-dose opioids (Edlund et al. 2014). Patients on high-dose opioids are less likely to receive care consistent with guidelines and appropriate monitoring (Morasco et al. 2010). High daily dose is the most common indicator of potential opioid misuse or inappropriate prescribing practices for opioids (Liu et al. 2013). The Secretary’s Opioid Initiative (2015) includes improved prescribing practices as one of the Departments top three priorities on opioids: http://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths .


PQI 91 Prevention Quality Acute Composite (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-577)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care sensitive conditions." These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. The PQIs are population based.


Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-576)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
2 component measures already in the program.


Proportion admitted to hospice for less than 3 days (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-415)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Earlier referral and admission to hospice allows patients to derive the maximal benefit from it

Summary of NQF Endorsement Review




Rate of adequate percutaneous image-guided biopsy (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-420)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The success rate of percutaneous biopsy is determined by the suitability of the sample for pathological analysis. Patients in whom a biopsy procedure yields inadequate specimens for analysis may be referred for repeat percutaneous biopsy, open biopsy, or undergo imaging to assess for alternative sites for biopsy increasing costs to the system, necessitating a second procedure or imaging test, and resulting in a delay in diagnosis. This measure provides an overall assessment of effective biopsy sampling, which directly influences the patient experience and is an important component of efficient patient care. Evidence to support this measure comes from several published studies which were reviewed in a SIR Standards of Practice Document published in 2010 (Gupta S, Wallace MJ, Cardella JF et al. Quality Improvement Guidelines for Percutaneous Needle Biopsy. JVIR 2010; 21:969=975). The mean pooled success rates ranged from 70-96% for adequacy of sampling across a range of biopsy locations in 23 studies. The consensus panel suggested a threshold of 70-75% adequate sampling rate for internal quality improvement purposes. It is important to note that when a biopsy sample is considered inadequate for analysis, the patient will likely require a second biopsy procedure, either by the same operator or via a second approach with a different operator increasing costs to payers. The proposed metric is intended not to penalize operators for attempting difficult percutaneous biopsies, but rather to place a priority on working with pathology to ensure adequacy of sampling in a single procedure. This measure is a modified measure as submitted for consideration last year, focusing on a different strategy for data capture.


Route of hysterectomy (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-437)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The purpose of this measure is to ensure that vaginal hysterectomy, the safest mode of hysterectomy, is optimized as a treatment option for patients requiring hysterectomy for benign indications. A Cochrane review evaluating route of hysterectomy asserts that vaginal hysterectomy is the safest mode of hysterectomy and is associated with fewer complications and better outcomes (Cochrane Database of Systematic Reviews 2009, Issue 3), and the American College of Obstetrics and Gynecology Committee Opinion (Number 444 Nov 2009) asserts that vaginal hysterectomy is the approach of choice whenever feasible.


Screening endoscopy for varices in patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-251)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of varices in cirrhotic patients can improve long term survival


Screening for Hepatoma in patients with Chronic Hepatitis B (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-217)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of hepatomas in patients with Chronic Hepatitis B can improve long term survival.


Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-375)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improved marginal reflex distance is the desired goal of surgery to improve clinical and functional outcomes


Surgical staging with lymph node removal for any grade 3 and/or myometrial invasion >50% with endometrial cancer (Measure removed from consideration by CMS on 12/1/2015) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-459)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Grade 3 tumors with greater than 50% myometrial invasion are at a higher risk of distant/metastatic spread. The decision to recommend adjuvant chemotherapy and/or radiation has advantages to patient outcomes in advanced stage diseases and if a lymph node dissection is not performed, patient stage status is known and women maybe undertreated or overtreated. The absence of an appropriate measure of this nature has the risk of women having surgery performed by General Gynecologists without the surgical expertise to perform a lymph node dissection. (1)National Cancer Center Network Clinical Practice Guidelines in Oncology. Uterine Neoplasms. 2014


Surveillance colonoscopy for dysplasia in colonic Crohns Disease (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-212)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of dysplasia or cancer in colonic Crohn’s Disease patients can improve long term survival. All patients with diagnosis colonic Crohn’s Disease for > 10 years should have a surveillance colonoscopy every 1-2 years (American Society of Gastrointestinal Endoscopy Guidelines 2006)


Surveillance colonoscopy for dysplasia in Ulcerative Colitis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-221)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of dysplasia or cancer in ulcerative colitis patients can improve long term survival ACG guideline 2010


Surveillance endoscopy for dysplasia in Barrett's Esophagus (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-208)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Esophageal dyslasia and esophageal cancer occur at increased rates in patients with Barrett's Esophagus. Patients with esophageal dyslasia and esophageal cancer are often asymptomatic until later stages. Earlier detection can improve outcomes. American College of Gastroenterology Guidelines 2008


Testing for uterine disease prior to obliterative procedures (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-439)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to colpocleisis. Thus avoiding the lack of access to the uterus for proper work up and allowing proper referral 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%). 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.


Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-460)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Women with early stage cervical cancer who are not operative candidates and those with stage 1B2 or higher stage cancers are typically recommended to undergo radiation therapy with external beam radiation and brachytherapy. Brachytherapy is considered a critical component of treatment by the National Comprehensive Cancer Network. Four year causes specific survival improved with the use of brachytherapy (64.3% with brachytherapy v. 51.1% without) as did overall survival (58.2% with brachytherapy v. 46.2% without) based on SEER data (Han K et al. Int J Rad Onc, Biol, Phys. 2013;87:111-119). Similar results were seen in a recent study from the National Cancer Database with a median overall survival of 63.3 months in patients who did receive brachytherapy and 27.2 months among patients who did not (Lin JF et al. Gynecol Oncol. 2014;132:416-422). These studies also showed that only 47.5-58% of women are treated with brachytherapy in addition to their external beam therapy and that rates of use of brachytherapy have declined over time. The declination in use is attributed to inadequate training and unavailability of appropriate technology in small hospitals.


Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-463)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The addition of platinum-based chemotherapy to primary radiation therapy in the treatment of patients with stage IIB-IV cervical cancer is associated with a significant progression-free and overall survival benefit. This finding was demonstrated in five landmark randomized clinical trials, which led to the National Cancer Institute (NCI) clinical alert in 1999 that established the addition of chemotherapy to radiation therapy as standard of care for cervical cancer patients. Subsequently, the Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration published a Cochrane Database systemic review and meta-analysis, confirming the findings of the initial trials. The review and meta-analysis demonstrated that the addition of platinum-based chemotherapy was associated with a 17% improvement in overall survival (HR = 0.83, 95% CI 0.71- 0.97, P = 0.017). The addition of chemotherapy to radiation therapy also improved disease-free survival by 22% (HR 0.78, 95% CI 0.70 - 0.87, P < 0.001). The benefit of platinum-based chemotherapy to primary radiation therapy in the treatment of stage IIB-IV cervical cancer patients has been clearly demonstrated. However, there is a paucity of data on how often healthcare providers and institutions are meeting this standard of care. REFERENCES Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing uncertainties about the effects of chemoradiotherapy for cervical cancer: individual patient data meta-analysis. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD008285. doi: 10.1002/14651858.CD008285.


Use of Mohs Surgery For Squamous Cell Carcinoma In Situ And Keratoacanthoma Type - Squamous Cell Carcinoma on The Trunk that are 1 cm or smaller (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-179)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The use of Mohs surgery has increased substantially over the past decade. To prevent its over-utilization on low-risk tumors, appropriate use criteria (AUC) have been developed which indicate that treatment of truncal squamous cell carcinoma in situ (SCCis) and keratoacanthoma type squamous cell carcinoma (SCC-KA) that are 1 cm or smaller in immunocompetent patients is an inappropriate use of this treatment modality. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk SCCis or SSC-KA on the trunk which should result in savings for the healthcare system.


Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-178)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The use of Mohs surgery has increased substantially over the past decade. To prevent its over-utilization on low-risk tumors, appropriate use criteria (AUC) have been developed which indicate that treatment of superficial basal cell carcinoma (BCC) on the trunk in immune-competent patients is an inappropriate use of this treatment modality. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk SCCis or SSC-KA on the trunk which should result in savings for the healthcare system.


Use Of Preventive Screening Protocol For Transplant Patients (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-177)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
It is well-established in the literature that organ transplant recipients (OTRs) have increased incidences of NMSC overtime. It is essential to provide a protocol to ensure that OTRs receive appropriate levels of health promotion from their provider. This measure seeks to ensure health promotion using three tiers to increase knowledge, screenings, and protective methods to limit the morbidity and mortality that can result from non-melanoma skin cancer (NMSC).


Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection (Measure removed from consideration by CMS on 12/1/2015) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-434)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Given the increasing number of women undergoing ambulatory surgical procedures for UI from 34,968 in 1996 to 105,656 in 2006, the need and demand for treatment of UI will rise significantly due to current changes in demographics (Erekson EA, 2010, Ambulatory procedures for female pelvic disorders in the United States). The procedures include the slings if the urethra hypermobile or bulking agents for fixed (ISD) urethra. The effectiveness of a sling decreases from 90% to 50% in someone with ISD. ISD criteria usually: not mobile urethra, VLPP less than 60mm H2O or MUCP less than 20mm H2O. Patients with ISD. Bulking agents are effective 70-80% in patients with ISD. Use of bulking agents should be utilized in appropriate patients with ISD.


Advance Care Plan (Program: Medicare Shared Savings Program; MUC ID: MUC15-578)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Addresses a gap in patient and family centered care, aligns with PQRS, and aligns with recent CMS payment policy supporting advance care planning between providers and patients/caregivers.

Summary of NQF Endorsement Review




Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls (Program: Medicare Shared Savings Program; MUC ID: MUC15-579)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Complications associated with falls affect many patients.

Summary of NQF Endorsement Review




Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Medicare Shared Savings Program; MUC ID: MUC15-275)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. References: Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce : Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines- http://circ.ahajournals.org/search?tocsectionid=ACC/AHA+Prevention+Guideline&sortspec=date&submit=Submit AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update http://content.onlinejacc.org/article.aspx?articleid=1127560 The All or None (Composite) method was chosen because of the benefits it provides to both the patient and the practitioner. First, this methodology more closely reflects the interests and likely desires of the patient. With the data collected in one score patients can easily look and see how their provider group is performing on these criteria rather than trying to make sense of multiple scores on individual measures. Second, this method represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. Third, this method gives a more sensitive scale for improvement. For those organizations scoring high marks on individual measures, the All-or-None measure will give room for benchmarks and additional improvements to be made.


PQI 91 Prevention Quality Acute Composite (Program: Medicare Shared Savings Program; MUC ID: MUC15-577)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care sensitive conditions." These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. The PQIs are population based.


Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Medicare Shared Savings Program; MUC ID: MUC15-576)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
2 component measures already in the program.


30 Day Stroke and Death Rate for Symptomatic Patients undergoing carotid stent placement (Program: Physician Compare; MUC ID: MUC15-402)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This measure complements the companion measure in symptomatic patients. The rationale for separating asymptomatic and symptomatic patients is that the recommended treatment criteria for each is different (stenosis grade) and a worse outcome score could be acceptable in symptomatic patients. This measure represents an unmet outcome measure for patients in multiple CMS programs.


Acquired Involutional Entropion: Normalized lid position after surgical repair (Program: Physician Compare; MUC ID: MUC15-377)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Normalized lid position is the desired goal of surgery to improve clinical and functional outcomes for the patient


Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Physician Compare; MUC ID: MUC15-396)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Reduction of inflammation is a desired treatment goal for improved clinical and functional outcome


Acute Anterior Uveitis: Post-treatment visual acuity (Program: Physician Compare; MUC ID: MUC15-394)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improvement of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Assessment of post-thrombotic syndrome following ilio-femoral venous stenting (Program: Physician Compare; MUC ID: MUC15-412)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The Villalta score is a well-recognized composite score that integrates patient reported symptoms with signs of the severity of post-thrombotic syndrome in patients with ilio-femoral venous disease (hence represents both PRO and an intermediate outcome measures). It is simple to administer clinically and is a reliable measure to ascertain both the clinical severity as well as morbidity associated with post-thrombotic syndrome. There is a measure gap in the area of venous disease and this measure will help to address this. The Villalta score can be integrated into structured reporting that is being piloted by the SIR, potentially enabling QCDR level reporting of the measure. An advantage over surveys is that this scoring system can be use uniformly by many sites. A disadvantage over surveys is that patients must be seen to have the follow-up score documented.


Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells (Program: Physician Compare; MUC ID: MUC15-399)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Reduction of inflammation is a desired treatment goal for improved clinical and functional outcome


Chronic Anterior Uveitis: Post-treatment visual acuity (Program: Physician Compare; MUC ID: MUC15-397)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improvement of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Common femoral arterial access site complication (Program: Physician Compare; MUC ID: MUC15-424)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Arterial access is a critical step for any arterial vascular intervention and is performed commonly across a wide range of interventional radiology, interventional cardiology, and vascular surgery procedures. Arterial access site complications are a significant contributor to patient discomfort and morbidity in the perioperative period, and are a fortunately rare cause for mortality. Common femoral arterial access is by far the most common site of access for a variety of endovascular procedures. The size of the arterial access and the presence of underlying vascular disease are predisposing factors to arterial access site complications. This measure is intended to focus on access site complications using 8Fr or small sheath sizes, and can be reported in any center performing arterial procedures as a measure of quality patient care. The rationale to limit the upper size of the access to 8Fr is to limit the measure to procedures with exclusively percutaneous access. Physicians using this measure are free to utilize Ultrasound for arterial access and can report the measure regardless if they use closure devices or rely on manual pressure as a strategy for achieving hemostasis. There is significant morbidity that may result from procedures performed downstream on patients with access site complications, including open repair of the injured artery site. The SIR Clinical Practice Guidelines (JVIR 2003, Vol 14, Issue 9, Part 2, S283-288) have noted that modest hematomas from femoral arterial access occur in up to 10% of patients, whereas major hematomas are rare (0.5%). The frequency of other arterial access site complications is more variable. As proposed this measure compliments a measure being considered for the 2016 PQRS program entitled ""Rate of surgical conversion from lower extremity endovascular revascularization procedure"" by detailing access site complications specifically. Access site complications are a modifiable risk factor for surgical conversion in lower extremity arterial procedures specifically."


Completion of external beam radiation within 60 days for women receiving primary radiotherapy as treatment for locally advanced cervical cancer (LACC) (Program: Physician Compare; MUC ID: MUC15-461)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The primary treatment for locally advanced cervical cancer consists of external beam radiation to the pelvis +/-para-aortic region with concurrent chemotherapy. In this patient population, total radiation therapy treatment time beyond 7 to 9 weeks has been shown to result in increased pelvic failure rates and decreased cancer specific and overall survival. Pelvic failure rates were reported at 26% for women who required greater than 56 days compared to 9% (hazard ratio 3.8; p=0.02). In an ancillary analysis of a Gynecologic Oncology Group study (protocol 165), women who had prolongation of radiation for any cause had a poorer progression free survival (HR 1.98; CI 1.16-3.38) and overall survival (HR 1.88; CI 1.08-3.26) compared to those who completed therapy within 8 weeks. Further studies have shown that prolongation of radiation is associated with a decreased survival of 0.6% and pelvic control rates of 0.7% for each additional day beyond 55 days for all stages of disease. More recent studies have shown that this effect remains even in the setting of chemoradiation. References: 1. Song S, Rudra S, Hasselle MD, et al. The effect of treatment time in locally advanced cervical cancer in the era of concurrent chemoradiotherapy. Cancer 2013;119(2):325-331. 2. Fyles A, Keane TJ, Barton M, Simm J. The effect of treatment duration in the local control of cervix cancer. Radiother Oncol 1992;25(4): 273-9. 3. Nugent EK, Case AS, Hoff JT, et al. Chemoradiation in locally advanced cervical carcinoma: an analysis of cisplatin dosing and other clinical prognostic factors. Gynecol Oncol 2010;116(3):438-41. 4. Monk BJ, Tian C, Rose PG, Lanciano R. Which clinical/pathologic factors matter in the era of chemoradiation as treatment for locally advanced cervical carcinoma? Analysis of two Gynecologic Oncology Group (GOG) trials. Gynecol Oncol 2007;427-433. 5. Petereit DG, Sarkaria JN, Chappell R, Fowler JF, Harmann TJ, Kinsella TJ et al . The adverse effect of treatment prolongation in cervical carcinoma. Int J Radiation Oncology Biol Phys 1995;32(5):1301-1307. 6. Perez CA, Grigsby PW, Castro-Vita H, Lockett MA. Carcinoma of the uterine cervix. Impact of prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy. Int J Radiation Oncology Biol Phys 1995;32(5): 1275-1288.


Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (Program: Physician Compare; MUC ID: MUC15-370)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improved visual acuity is a desired surgical goal to improve patient's daily activities of daily living and quality of life


Diabetic Macular Edema: Loss of Visual Acuity (Program: Physician Compare; MUC ID: MUC15-393)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Documentation of offering a trial of conservative management prior to fecal incontinence surgery (Program: Physician Compare; MUC ID: MUC15-440)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This measure is intended to ensure that patients are offered the opportunity to pursue conservative management prior to surgery. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation. Conservative medical management consisting of patient education, fiber supplements or antidiarrheals, behavioral techniques such as scheduled toileting, and pelvic floor exercises restores continence in up to 25% of patients. Biofeedback is associated with satisfaction rates of up to 76%, and continence in 55%. Patient education on all the treatment options can help with patient satisfaction and better outcomes as they still can be used as adjunct therapies to surgery. Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Whitehead WE, Rao SS, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton FA. Am J Gastroenterol. 2015 Jan;110(1):138-46; quiz 147. doi: 10.1038/ajg.2014.303. Epub 2014 Oct 21. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, Mott L, Rogers RG, Zinsmeister AR, Whitehead WE, Rao SS, Hamilton FA. Am J Gastroenterol. 2015 Jan;110(1):127-36. doi: 10.1038/ajg.2014.396. Epub 2014 Dec 23.


Documentation of offering a trial of conservative management prior to urgency incontinence surgery (Program: Physician Compare; MUC ID: MUC15-441)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Urge urinary incontinence negatively impacts patients' quality of life, as patients may limit activities outside the home, socializing, and sexual activity due to the fear of leaking. Current guidelines issued by the American Urologic Association state that behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, fluid management) should be first line therapy. Clinicians should offer oral anti-muscarinics or oral beta 3-adrenoceptor agonists as second-line therapy. Third line therapies include intradetrusor Botox injections, peripheral tibial nerve stimulation, or sacral neuromodulation. Website reference: https://www.auanet.org/education/guidelines/overactive-bladder.cfm


Efficacy of uterine artery embolization for symptomatic uterine fibroids (Program: Physician Compare; MUC ID: MUC15-423)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Uterine artery embolization is a well-established procedure for the treatment of symptomatic uterine fibroids, with reported success rates of 85% in patients with isolated uterine fibroids as the etiology of their symptoms. Although there are a variety of techniques that are used clinically, such variance has little impact on the overall patient outcome. The development of uterine fibroid disease specific surveys, such as the Uterine Fibroid Symptom Health-related Quality of Life Questionnaire (UFS-QOL) has enabled robust reporting of patient-reported outcomes for this disease (http://www.sirfoundation.org/registries/). Importantly, this survey enables assessment both of the patient's subjective symptoms as well as their experience. The routine use of this survey instrument would objectively assess the procedural efficacy at the patient level.


Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Physician Compare; MUC ID: MUC15-379)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Glaucoma - Intraocular Pressure (IOP) Reduction (Program: Physician Compare; MUC ID: MUC15-372)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome


Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (Program: Physician Compare; MUC ID: MUC15-374)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Intraocular pressure is the only modifiable risk factor so control of IOP is relevant to clinical outcome


Hepatitis A vaccination for patients with cirrhosis (Program: Physician Compare; MUC ID: MUC15-210)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (Advisory Committee on Immunization Practices 2014)


Hepatitis B vaccination for patients with chronic Hepatitis C (Program: Physician Compare; MUC ID: MUC15-220)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Vaccination against viral hepatitis for patients with chronic hepatitis C can improve long term clinical outcomes


Hepatitis B vaccination for patients with cirrhosis (Program: Physician Compare; MUC ID: MUC15-211)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Vaccination against viral hepatitis for patients with cirrhosis can improve long term clinical outcomes. (Advisory Committee on Immunization Practices 2014)


Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (Program: Physician Compare; MUC ID: MUC15-229)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Achieving SVR is the first step toward reducing future HCV morbidity and mortality. Once achieved, an SVR is associated with long-term clearance of HCV infection, which is regarded as a virologic ‘‘cure,’’ as well as with improved morbidity and mortality. Patients who achieve an SVR usually have improvement in liver histology and clinical outcomes. Nineteen cohort studies (n=105 to 16,864) evaluated the association between SVR after antiviral therapy and mortality or complications of chronic HCV infection. Duration of follow-up ranged from 3 to 9 years. Ten studies were conducted in Asia (60, 67-72, 75, 77, 78). Eight (64-66, 72, 75-78) were rated as poor-quality and the remainder as fair quality. Although all studies reported adjusted risk estimates, only 8 (60, 61, 63, 67-70, 73) evaluated 5 key confounders (age, sex, genotype, viral load, and fibrosis stage). No study clearly described assessment of outcomes blinded to SVR status. The largest study (n=16,864) had the fewest methodological shortcomings (61). It adjusted for multiple potential confounders, including age, sex viral load, presence of cirrhosis, multiple comorbid conditions, aminotransferase levels, and others. It also stratified results by genotype. In a predominantly male, Veterans Affairs population, SVR after antiviral therapy was associated with lower risk for all-cause mortality than was SVR , after median of 3.8 years (adjusted hazard ration, 0.71 [CI, 0.60 to 0.861], 0.62[CI, 0.44 to 0.87], and 0.51 [CI, 0.35 to 0.75] for genotypes 1, 2, and 3 respectively). Mortality curves began to separate as soon as 3 to 6 months after SVR assessment. Eighteen other cohort studies also found SVR to be associated with decreased risk for all-cause mortality (adjusted hazard rations, 0.07 to 0.39)(60, 69, 72, 73, 75-78), liver-related mortality (adjusted hazard rations, 0.12 to 0.46)(60, 62, 63, 67, 68, 71, 73-76, 78), and other complications of end-stage liver disease versus no SVR, with effects larger than in the Veterans Affairs study. The subgroup of studies that focused on patients with advanced fibrosis or cirrhosis at baseline (60, 67-72, 75, 77, 78) reported similar risk estimates. (Chou et. al., 2015) Chou R, Hartung D, Rahman B, Wasson N, Cottrell EB, Fu R. Comparative effectiveness of antiviral treatment for hepatitis C virus infection in adults: a systematic review. Ann Intern Med. 2013 Jan 15;158(2):114-23. Review. PubMed PMID: 23437439


HIV Screening for Patients with Sexually Transmitted Disease (STD) (Program: Physician Compare; MUC ID: MUC15-230)

Measure Specifications

Preliminary Analysis of Measure

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 U.S. Preventive Services Task Force (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 underlying the USPSTF recommendation 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) Notably, the current USPSTF 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. CDC's newly published 2015 STD Treatment Guidelines also underscore the need for HIV testing in the context of certain STD diagnoses, noting that: “Persons at high risk for HIV infection with early syphilis, gonorrhea, or chlamydia should be screened at the time of the STD diagnosis, even if an HIV test was recently performed. Some STDs, especially rectal gonorrhea and syphilis, are a risk marker for HIV acquisition." Relevant references supporting the 2015 STD Treatment Guidelines include: • Zetola NM, Bernstein KT, Wong E, et al. Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs. J Acquir Immune Defic Syndr 2009;50:546–51. • Pathela P, Braunstein SL, Blank S, et al. HIV incidence among men with and those without sexually transmitted rectal infections: estimates from matching against an HIV case registry. Clin Infect Dis 2013;57:1203–9. • Peterman TA, Newman DR, Maddox L, Schmitt K, Shiver S. Risk for HIV following a diagnosis of syphilis, gonorrhoea or chlamydia: 328,456 women in Florida, 2000-2011. Int J STD AIDS. 2015 Feb;26(2):113-9. doi: 10.1177/0956462414531243. Epub 2014 Apr 8. • Taylor MM, Newman DR, Gonzalez J, Skinner J, Khurana R, Mickey T. HIV status and viral loads among men testing positive for rectal gonorrhoea and chlamydia, Maricopa County, Arizona, USA, 2011-2013. HIV Med. 2015 Apr;16(4):249-54. doi: 10.1111/hiv.12192. Epub 2014 Sep 17


Improvement in the Venous Clinical Severity Score after ilio-femoral venous stenting (Program: Physician Compare; MUC ID: MUC15-413)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The venous clinical severity score replace the older CEAP (clinical grade, etiology, anatomy, pathophysiology) grading system to assess the severity of chronic venous disease. Unlike the CEAP system, the venous clinical severity score is more useful in the assessment of changes in venous disease and thus is most appropriate to apply to patients undergoing treatment to assess outcomes from therapy, such as ilio-femoral venous stenting. This measure addresses a measurement gap across multiple programs. By encouraging the routine use of the venous clinical severity score centers will be able to objectively assess the intermediate outcome of venous stenting on the symptoms and signs of chronic venous disease. This score focuses more on the clinical signs, rather than patient symptoms, which was demonstrated to be a more useful marker for subtle changes in the severity of venous disease.


Intraperitoneal chemotherapy administered within 42 days of optimal cytoreduction to women with invasive stage III ovarian, fallopian tube, or peritoneal cancer (Program: Physician Compare; MUC ID: MUC15-450)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a subooptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686). IP chemotherapy provides a superior OS in patients after optimal cytoreductive surgery (Walker JL, Armstrong DK, Huang HQ, Fowler J, Webster K, Burger RA, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III ovarian and primary peritoneal cancer: a Gynecologic Oncology Group Study. Gynecologic oncology. 2006;100:27-32. PMID=16368440)


Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Physician Compare; MUC ID: MUC15-275)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
There has been important evidence from clinical trials that further supports and broadens the merits of risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. References: Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce : Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines- http://circ.ahajournals.org/search?tocsectionid=ACC/AHA+Prevention+Guideline&sortspec=date&submit=Submit AHA/ACC Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease: 2001 Update http://content.onlinejacc.org/article.aspx?articleid=1127560 The All or None (Composite) method was chosen because of the benefits it provides to both the patient and the practitioner. First, this methodology more closely reflects the interests and likely desires of the patient. With the data collected in one score patients can easily look and see how their provider group is performing on these criteria rather than trying to make sense of multiple scores on individual measures. Second, this method represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. Third, this method gives a more sensitive scale for improvement. For those organizations scoring high marks on individual measures, the All-or-None measure will give room for benchmarks and additional improvements to be made.


Minimally invasive surgery performed for patients with endometrial cancer (Program: Physician Compare; MUC ID: MUC15-452)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
A total of 8 randomized clinical trials investigating minimally invasive surgery compared to laparotomy in over 3500 patients showed no difference in overall or disease free survival (Cochrane Database Syst Rev. 2012 Sep 12;9; J Clin Oncol. 2012 Mar 1;30(7):695-700; J Clin Oncol. 2009 Nov 10;27(32):5331-6). However, patients undergoing minimally invasive surgery (laparoscopic or robotic-assisted hysterectomy) had reduced length of hospital stay, lower blood loss, and improved quality of life at 6 weeks (Lancet Oncol. 2010 Aug;11(8):772-80.; J Clin Oncol. 2009 Nov 10;27(32):5337-42). Furthermore, the rate of severe postoperative adverse events was lower in patients undergoing minimally invasive surgery (Cochrane Database Syst Rev. 2012 Sep 12;9). Despite these known benefits, utilization rates of minimally invasive surgery vary from 50-90% between surgeons and institutions (unpublished data from Nationwide inpatient sample - delete this sentence if reference required). References: 1: Galaal K, Bryant A, Fisher AD, Al-Khaduri M, Kew F, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev. 2012 Sep 12;9:CD006655. doi: 10.1002/14651858.CD006655.pub2. Review. PubMed PMID: 22972096. 2: Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Barakat R, Pearl ML, Sharma SK. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol. 2012 Mar 1;30(7):695-700. doi: 10.1200/JCO.2011.38.8645. Epub 2012 Jan 30. Erratum in: J Clin Oncol. 2012 May 1;30(13):1570. PubMed PMID: 22291074; PubMed Central PMCID: PMC3295548. 3: Janda M, Gebski V, Brand A, Hogg R, Jobling TW, Land R, Manolitsas T, McCartney A, Nascimento M, Neesham D, Nicklin JL, Oehler MK, Otton G, Perrin L, Salfinger S, Hammond I, Leung Y, Walsh T, Sykes P, Ngan H, Garrett A, Laney M, Ng TY, Tam K, Chan K, Wrede CD, Pather S, Simcock B, Farrell R, Obermair A. Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE): a randomised trial. Lancet Oncol. 2010 Aug;11(8):772-80. doi: 10.1016/S1470-2045(10)70145-5. Epub 2010 Jul 16. PubMed PMID: 20638899. 4: Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Spiegel G, Barakat R, Pearl ML, Sharma SK. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009 Nov 10;27(32):5331-6. doi: 10.1200/JCO.2009.22.3248. Epub 2009 Oct 5. PubMed PMID: 19805679; PubMed Central PMCID: PMC2773219. 5: Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D. Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol. 2009 Nov 10;27(32):5337-42. doi: 10.1200/JCO.2009.22.3529. Epub 2009 Oct 5. Erratum in: J Clin Oncol. 2010 Jun 1;28(16):2805. PubMed PMID: 19805678; PubMed Central PMCID: PMC2773220.


New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (Program: Physician Compare; MUC ID: MUC15-296)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Corneal abrasion/injury is the most common ophthalmologic complication that occurs during general anesthesia for non-ocular surgery. These injuries are painful for the patient, and can lead to significant microbial keratitis with possibility of permanent scarring. There is no standardized method for protecting the eyes during an anesthetic for non-ocular surgery. Adhesive tape, individual single, sterile packaged eye covers, small bio-occlusive dressings, used with or without eye ointment are some of the options used. Some practitioners may simply observe closed, non-taped eyes. The specific type of eye ointment also varies significantly. Some ointment is made with petrolatum, some is water soluble, with or without preservatives. If ointment is used, preservative-free eye ointment is preferred, because preservative can cause corneal epithelial sloughing and conjunctiva hyperemia. None of the methods described in the literature are entirely effective at preventing corneal injury and some are associated with unwanted side effects. It is important to know that petrolatum is flammable and should be avoided when cautery will be used near the face. Several large studies have demonstrated that applying these techniques while measuring performance can lead to significant improvements in patient care. Measuring the incidence of corneal injury will give practices the data they need to assess performance, compare to national benchmarks, and if gaps are identified, undertake measures to improve eye protection for patients. The net result will be reduced corneal injuries and patient discomfort. All eye trauma cases and all eye surgery cases will be excluded from the measure. Reporting separately those procedures done on the face, including the ear, nose, and mandible, will serve as stratification allowing comparison of procedures which most anesthesiologists believe have a higher risk of corneal injury and which also remove the eyes from the direct control of the anesthesiologist.


NMSC: Biopsy Reporting Time - Pathologist (Program: Physician Compare; MUC ID: MUC15-216)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The communication between pathologists and physicians about patient outcomes is fragmented. Effective and timely communication through the biopsy report between the two practitioners is essential; as delay may directly affect patient care. Furthermore, lack of timely delivery can increase the cost of medical care and error. This measure seeks to standardize the amount of time it takes for the pathologist to send the final biopsy report to the biopsying physician to ensure timely communication and effective treatment for the patient.


Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Physician Compare; MUC ID: MUC15-392)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Maintenance of visual acuity is a desired treatment goal to continue the level of the patient's daily activities of daily living and quality of life


Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (Program: Physician Compare; MUC ID: MUC15-215)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Effective and timely communication between the physician and patient about biopsy results is essential; as delay may directly affect patient care. Furthermore, lack of timely delivery can negatively affect patient experience and satisfaction by increasing the anxiety the patient experiences while waiting for results. This measure seeks to standardize the amount of time it takes for the clinician to notify patients of the final biopsy results, to ensure timely communication and effective treatment for the patient.


Non-Recommended PSA-Based Screening (Program: Physician Compare; MUC ID: MUC15-1019)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The USPSTF recommends against PSA-based screening for prostate cancer (grade D recommendation). This recommendation applies to men in the general U.S. population, regardless of age.” The Agency for Healthcare Research and Quality (AHRQ) looked at five randomized controlled trials (RCTs) and two meta-analyses and found inconsistency regarding the efficacy of PSA-based screening, although the high-quality surveyed studies are limited to interim results and do not consider potential psychological harms.


Non-selective beta blocker use in patients with esophageal varices (Program: Physician Compare; MUC ID: MUC15-209)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Use on non-selective beta blockers in the setting of esophageal varices can reduce portal pressure and improve long term clinical outcomes. American Association for the Study of Liver Diseases Guidelines 2009


Over-utilization of mesh in the posterior compartment (Program: Physician Compare; MUC ID: MUC15-436)

Measure Specifications

Preliminary Analysis of Measure

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), with the lifetime risk for undergoing surgery for pelvic organ prolapse recently estimated to have doubled to 20% (Obstet and Gynecol 2014;123:1201-6). Repairs of the posterior compartment can include a midline fascial plication, site-specific repair, or a graft-augmented repair. Studies have failed to demonstrate any significant benefit to the utilization of synthetic mesh augments in the posterior compartment (Am J Obstet Gynecol 2006;195:1762-71) and recent concerns have come to light regarding the use of synthetic mesh augments (FDA Urogynecologic Surgical Mesh : Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse; July 2011). Implementation of this measure will determine if best care practices are being followed when treating women with disorder.


Paired Measure: Depression Utilization of the PHQ-9 Tool; Depression Remission at Six Months; Depression Remission at Twelve Months (Program: Physician Compare; MUC ID: MUC15-928)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Depression is a common and treatable mental disorder. The Centers for Disease Control and Prevention states that an estimated 6.6% of the U.S. adult population (14.8 million people) experiences a major depressive disorder during any given 12-month period. Additionally, dysthymia accounts for an additional 3.3 million Americans. In 2006 and 2008, an estimated 9.1% of U.S. adults reported symptoms for current depression.[1] 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.[2] Depression is associated with higher mortality rates in all age groups. People who are depressed are 30 times more likely to take their own lives than people who are not depressed and five times more likely to abuse drugs.[3] Depression is the leading cause of medical disability for people aged 14 – 44.[4] Depressed people lose 5.6 hours of productive work every week when they are depressed, fifty percent of which is due to absenteeism and short-term disability. People who suffer from depression have lower incomes, lower educational attainment and fewer days working days each year, leading to seven fewer weeks of work per year, a loss of 20% in potential income and a lifetime loss for each family who has a depressed family member of $300,000.[5] The cost of depression (lost productivity and increased medical expense) in the United States is $83 billion each year.[6] 1. CDC. Current Depression Among Adults --- United States, 2006 and 2008. MMWR 2010;59(38);1229-1235. 2. Strine TW, Mokdad AH, Balluz LS, et al. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv 2008;59:1383--90. 3. Joiner, Thomas Myths about suicide. Cambridge, MA, US: Harvard University Press. (2010). 288 pp. 4. Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein, D. (2003). Cost of lost productive work time among US workers with depression. Journal of the American Medical Association, 289, 3135-3144. 5. Smith, J. P., & Smith, G. C. (2010). Long-term economic costs of psychological problems during childhood. Social Science & Medicine, 71, 110-115. 6. Greenberg, P. E., Kessler, R. C., Birnbaum, H. G., Leong, S. A., Lowe, S. W., Berglund, P. A., et al. (2003). The economic burden of depression in the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry, 64, 1465-1475. More detailed information about the rationale and history of this measure and its components are available in the MNCM measure submission forms for the most recent NQF Behavioral Health measure endorsement project. Links are in the final committee report available here: http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspx.


Patient reported outcomes following ilio-femoral venous stenting (Program: Physician Compare; MUC ID: MUC15-411)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Ilio-venous stenting is a commonly performed procedure in patients with deep venous disease including acute, acute-on-chronic, and chronic venous thrombosis. Such interventions are also performed in patients with venous stenosis, such as patient with May-Turner syndrome. The procedural outcome of such procedures does not necessarily reflect resolution of patient symptoms, however. Standardizing the use of disease-specific surveys in this patient population is necessary to objectively assess the success of ilio-femoral venous stenting. Each survey is different; an objective outcome of any improvement would be the most appropriate assessment to encourage use of this measure by a wide variety of providers. This measure compliments a measure being considered for the 2016 PQRS program, focused on the PRO in patients undergoing saphenous vein ablation.


Patient-Reported Functional Communication (Program: Physician Compare; MUC ID: MUC15-313)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Patient engagement and their perceptions of their hearing abilities is necessary to determine patient-centered goals and treatment. There are several standardized, validated patient questionnaires available to capture the patient's perception of their communication abilities in their activities of daily living that can be used with objective measures of communication and hearing to offer a complete picture of the patient's functional ability. Using these tools assists the audiologist with rehabilitation goals and care planning, and engages the patient in the development of their own functional goals. The AQC proposes this measure will assist audiologists adapt their practices to patient-centered, functional care and actively engage patients in the diagnosis and treatment of their hearing loss.


Performance of objective measure of functional hearing status (Program: Physician Compare; MUC ID: MUC15-307)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Functional hearing measurements are necessary to supplement the findings of the hearing thresholds and capture the patient's ability to communicate, and should be incorporated into the diagnosis and treatment of bilateral, permanent hearing loss. The data captured in objective measurement of open-set speech recognition, introduced with the presence of noise, can help audiologists objectively measure improvement and outcomes with amplification and rehabilitation and be used as a tool to educate patients on their hearing perception abilities. Additionally, functional hearing is a necessary measurement to determine cochlear implant candidacy. The AQC proposes this measure will assist audiologists adapt their practices to patient-centered, functional care.


Performance of radical hysterectomy in patients with IB1-IIA cervical cancer who undergo hysterectomy. (Program: Physician Compare; MUC ID: MUC15-465)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The primary treatment of stage IB1-IIA is radical hysterectomy. Unlike simple hysterectomy, radical hysterectomy includes removal of the paracervical tissue including the parametrium, uterosacral ligament, and uper vagina. Radical hysterectomy has long been considered the most appropriate type of hysterectomy for invasive cervical cancer. The procedure requires expertise and technical skill to perform. Radical hysterectomy can be performed via laparotomy, through minimally invasive technology (robotic or laparoscopic) or vaginally.


Platin or taxane administered within 42 days following cytoreduction to women with invasive stage I (grade 3), IC-IV ovarian, fallopian tube, or peritoneal cancer (Program: Physician Compare; MUC ID: MUC15-454)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a suboptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686). Starting the chemotherapy within 42 days (6 weeks) from surgery is consistent with the previous GOG (Gynecologic Oncology Group) randomized trials that utilized this timeline as a standard. The most important of those trials is GOG-158 (Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2003;21:3194-200. PMID= 12860964) Although there is no randomized trial to accurately quantify the importance of initiating chemotherapy within 42 days from the debulking surgery, but analysis of patient data from the prospective OVCAR study suggested that delaying chemotherapy is associated with poorer survival, albeit it is only for overall survival in a subooptimally debulked ovarian cancer (Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecologic oncology. 2013;131:15-20. PMID= 23877013). A second study presented at the SGO 2013 by Eskander, R et al was a Gynecologic Oncology Group ancillary data study. This study showed a negative survival impact associated with >25 day interval from surgical cytoreduction to initiation of systemic therapy in advanced ovarian carcinoma. The largest study come some from Colorectal literature when a metaanalysis of more than 15,000 patients, showed that a delay of initiation of chemotherapy past 4 weeks after surgery is positively correlated to a worse survival (Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305:2335-42. PMID=21642686).


Postoperative pelvic radiation with concurrent cisplatin-containing chemotherapy with (or without) brachytherapy for patients with positive pelvic nodes, positive surgical margin, and/or positive parametrium. (Program: Physician Compare; MUC ID: MUC15-466)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
There have been multiple prospective randomized trials demonstrating the disease free and overall survival for cervical cancer patients with post-operative involvement of surgical margins, and/or regional lymph nodes. These collective studies have resulted in the recommendation by the National Cancer Institute that platinum containing chemotherapy be added to post-operative radiation therapy for patients with positive surgical margins including the parametrium and vagina, as well as positive lymph nodes. The following articles are referenced in the NCI alert: Morris et al NEJM 1999;340:1137-1143, Peters et al JCO 2000;18:1606-1613, Rose, P. et al NEJM 1999;340:1144-1153


Potential Opioid Overuse (Program: Physician Compare; MUC ID: MUC15-1169)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Considerable evidence indicates that opioid overuse is an important issue. The 2014 U.S. Department of Health and Human Services (HHS) National Action Plan for Adverse Drug Event Prevention highlighted the need for safer prescribing and monitoring of opioids. Patients prescribed high-dose opioids have an approximately 10-fold increase in risk of overdose compared with those prescribed low-dose opioids (Edlund et al. 2014). Patients on high-dose opioids are less likely to receive care consistent with guidelines and appropriate monitoring (Morasco et al. 2010). High daily dose is the most common indicator of potential opioid misuse or inappropriate prescribing practices for opioids (Liu et al. 2013). The Secretary’s Opioid Initiative (2015) includes improved prescribing practices as one of the Departments top three priorities on opioids: http://aspe.hhs.gov/basic-report/opioid-abuse-us-and-hhs-actions-address-opioid-drug-related-overdoses-and-deaths .


PQI 91 Prevention Quality Acute Composite (Program: Physician Compare; MUC ID: MUC15-577)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care sensitive conditions." These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. The PQIs are population based.


Prevention Quality Indicators 92 Prevention Quality Chronic Composite (Program: Physician Compare; MUC ID: MUC15-576)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
2 component measures already in the program.


Proportion admitted to hospice for less than 3 days (Program: Physician Compare; MUC ID: MUC15-415)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Earlier referral and admission to hospice allows patients to derive the maximal benefit from it

Summary of NQF Endorsement Review




Rate of adequate percutaneous image-guided biopsy (Program: Physician Compare; MUC ID: MUC15-420)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The success rate of percutaneous biopsy is determined by the suitability of the sample for pathological analysis. Patients in whom a biopsy procedure yields inadequate specimens for analysis may be referred for repeat percutaneous biopsy, open biopsy, or undergo imaging to assess for alternative sites for biopsy increasing costs to the system, necessitating a second procedure or imaging test, and resulting in a delay in diagnosis. This measure provides an overall assessment of effective biopsy sampling, which directly influences the patient experience and is an important component of efficient patient care. Evidence to support this measure comes from several published studies which were reviewed in a SIR Standards of Practice Document published in 2010 (Gupta S, Wallace MJ, Cardella JF et al. Quality Improvement Guidelines for Percutaneous Needle Biopsy. JVIR 2010; 21:969=975). The mean pooled success rates ranged from 70-96% for adequacy of sampling across a range of biopsy locations in 23 studies. The consensus panel suggested a threshold of 70-75% adequate sampling rate for internal quality improvement purposes. It is important to note that when a biopsy sample is considered inadequate for analysis, the patient will likely require a second biopsy procedure, either by the same operator or via a second approach with a different operator increasing costs to payers. The proposed metric is intended not to penalize operators for attempting difficult percutaneous biopsies, but rather to place a priority on working with pathology to ensure adequacy of sampling in a single procedure. This measure is a modified measure as submitted for consideration last year, focusing on a different strategy for data capture.


Route of hysterectomy (Program: Physician Compare; MUC ID: MUC15-437)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The purpose of this measure is to ensure that vaginal hysterectomy, the safest mode of hysterectomy, is optimized as a treatment option for patients requiring hysterectomy for benign indications. A Cochrane review evaluating route of hysterectomy asserts that vaginal hysterectomy is the safest mode of hysterectomy and is associated with fewer complications and better outcomes (Cochrane Database of Systematic Reviews 2009, Issue 3), and the American College of Obstetrics and Gynecology Committee Opinion (Number 444 Nov 2009) asserts that vaginal hysterectomy is the approach of choice whenever feasible.


Screening endoscopy for varices in patients with cirrhosis (Program: Physician Compare; MUC ID: MUC15-251)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of varices in cirrhotic patients can improve long term survival


Screening for Hepatoma in patients with Chronic Hepatitis B (Program: Physician Compare; MUC ID: MUC15-217)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of hepatomas in patients with Chronic Hepatitis B can improve long term survival.


Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (Program: Physician Compare; MUC ID: MUC15-375)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improved marginal reflex distance is the desired goal of surgery to improve clinical and functional outcomes


Surgical staging with lymph node removal for any grade 3 and/or myometrial invasion >50% with endometrial cancer (Measure removed from consideration by CMS on 12/1/2015) (Program: Physician Compare; MUC ID: MUC15-459)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Grade 3 tumors with greater than 50% myometrial invasion are at a higher risk of distant/metastatic spread. The decision to recommend adjuvant chemotherapy and/or radiation has advantages to patient outcomes in advanced stage diseases and if a lymph node dissection is not performed, patient stage status is known and women maybe undertreated or overtreated. The absence of an appropriate measure of this nature has the risk of women having surgery performed by General Gynecologists without the surgical expertise to perform a lymph node dissection. (1)National Cancer Center Network Clinical Practice Guidelines in Oncology. Uterine Neoplasms. 2014


Surveillance colonoscopy for dysplasia in colonic Crohns Disease (Program: Physician Compare; MUC ID: MUC15-212)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of dysplasia or cancer in colonic Crohn’s Disease patients can improve long term survival. All patients with diagnosis colonic Crohn’s Disease for > 10 years should have a surveillance colonoscopy every 1-2 years (American Society of Gastrointestinal Endoscopy Guidelines 2006)


Surveillance colonoscopy for dysplasia in Ulcerative Colitis (Program: Physician Compare; MUC ID: MUC15-221)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early detection of dysplasia or cancer in ulcerative colitis patients can improve long term survival ACG guideline 2010


Surveillance endoscopy for dysplasia in Barrett's Esophagus (Program: Physician Compare; MUC ID: MUC15-208)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Esophageal dyslasia and esophageal cancer occur at increased rates in patients with Barrett's Esophagus. Patients with esophageal dyslasia and esophageal cancer are often asymptomatic until later stages. Earlier detection can improve outcomes. American College of Gastroenterology Guidelines 2008


Testing for uterine disease prior to obliterative procedures (Program: Physician Compare; MUC ID: MUC15-439)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This measure will help ensure that patients who do have a uterine malignancy are diagnosed prior to colpocleisis. Thus avoiding the lack of access to the uterus for proper work up and allowing proper referral 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%). 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.


Use of brachytherapy for cervical cancer patients treated with primary radiation with curative intent. (Program: Physician Compare; MUC ID: MUC15-460)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Women with early stage cervical cancer who are not operative candidates and those with stage 1B2 or higher stage cancers are typically recommended to undergo radiation therapy with external beam radiation and brachytherapy. Brachytherapy is considered a critical component of treatment by the National Comprehensive Cancer Network. Four year causes specific survival improved with the use of brachytherapy (64.3% with brachytherapy v. 51.1% without) as did overall survival (58.2% with brachytherapy v. 46.2% without) based on SEER data (Han K et al. Int J Rad Onc, Biol, Phys. 2013;87:111-119). Similar results were seen in a recent study from the National Cancer Database with a median overall survival of 63.3 months in patients who did receive brachytherapy and 27.2 months among patients who did not (Lin JF et al. Gynecol Oncol. 2014;132:416-422). These studies also showed that only 47.5-58% of women are treated with brachytherapy in addition to their external beam therapy and that rates of use of brachytherapy have declined over time. The declination in use is attributed to inadequate training and unavailability of appropriate technology in small hospitals.


Use of concurrent platinum-based chemotherapy for patients with stage IIB-IV cervical cancer receiving primary radiation therapy. (Program: Physician Compare; MUC ID: MUC15-463)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The addition of platinum-based chemotherapy to primary radiation therapy in the treatment of patients with stage IIB-IV cervical cancer is associated with a significant progression-free and overall survival benefit. This finding was demonstrated in five landmark randomized clinical trials, which led to the National Cancer Institute (NCI) clinical alert in 1999 that established the addition of chemotherapy to radiation therapy as standard of care for cervical cancer patients. Subsequently, the Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration published a Cochrane Database systemic review and meta-analysis, confirming the findings of the initial trials. The review and meta-analysis demonstrated that the addition of platinum-based chemotherapy was associated with a 17% improvement in overall survival (HR = 0.83, 95% CI 0.71- 0.97, P = 0.017). The addition of chemotherapy to radiation therapy also improved disease-free survival by 22% (HR 0.78, 95% CI 0.70 - 0.87, P < 0.001). The benefit of platinum-based chemotherapy to primary radiation therapy in the treatment of stage IIB-IV cervical cancer patients has been clearly demonstrated. However, there is a paucity of data on how often healthcare providers and institutions are meeting this standard of care. REFERENCES Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing uncertainties about the effects of chemoradiotherapy for cervical cancer: individual patient data meta-analysis. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD008285. doi: 10.1002/14651858.CD008285.


Use of Mohs Surgery For Squamous Cell Carcinoma In Situ And Keratoacanthoma Type - Squamous Cell Carcinoma on The Trunk that are 1 cm or smaller (Program: Physician Compare; MUC ID: MUC15-179)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The use of Mohs surgery has increased substantially over the past decade. To prevent its over-utilization on low-risk tumors, appropriate use criteria (AUC) have been developed which indicate that treatment of truncal squamous cell carcinoma in situ (SCCis) and keratoacanthoma type squamous cell carcinoma (SCC-KA) that are 1 cm or smaller in immunocompetent patients is an inappropriate use of this treatment modality. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk SCCis or SSC-KA on the trunk which should result in savings for the healthcare system.


Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (Program: Physician Compare; MUC ID: MUC15-178)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The use of Mohs surgery has increased substantially over the past decade. To prevent its over-utilization on low-risk tumors, appropriate use criteria (AUC) have been developed which indicate that treatment of superficial basal cell carcinoma (BCC) on the trunk in immune-competent patients is an inappropriate use of this treatment modality. This measure evaluates the utilization of Mohs and promotes the routine use of less expensive treatment modalities such as traditional surgical excision or destructive methods like curettage and electrodessication destruction for low-risk SCCis or SSC-KA on the trunk which should result in savings for the healthcare system.


Use Of Preventive Screening Protocol For Transplant Patients (Program: Physician Compare; MUC ID: MUC15-177)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
It is well-established in the literature that organ transplant recipients (OTRs) have increased incidences of NMSC overtime. It is essential to provide a protocol to ensure that OTRs receive appropriate levels of health promotion from their provider. This measure seeks to ensure health promotion using three tiers to increase knowledge, screenings, and protective methods to limit the morbidity and mortality that can result from non-melanoma skin cancer (NMSC).


Verification of Intrinsic Sphincter Deficiency prior to transurethral bulking injection (Measure removed from consideration by CMS on 12/1/2015) (Program: Physician Compare; MUC ID: MUC15-434)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Given the increasing number of women undergoing ambulatory surgical procedures for UI from 34,968 in 1996 to 105,656 in 2006, the need and demand for treatment of UI will rise significantly due to current changes in demographics (Erekson EA, 2010, Ambulatory procedures for female pelvic disorders in the United States). The procedures include the slings if the urethra hypermobile or bulking agents for fixed (ISD) urethra. The effectiveness of a sling decreases from 90% to 50% in someone with ISD. ISD criteria usually: not mobile urethra, VLPP less than 60mm H2O or MUCP less than 20mm H2O. Patients with ISD. Bulking agents are effective 70-80% in patients with ISD. Use of bulking agents should be utilized in appropriate patients with ISD.



Appendix B: Program Summaries

The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

Program Index


Full Program Summaries

Medicare Shared Savings Program 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

Program History and Structure: Section 3022 of the Affordable Care Act (ACA) requires the Centers for Medicare & Medicaid Services (CMS) to establish a Shared Savings Program that promotes accountability for a patient population, coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high-quality and efficient service delivery. The Medicare Shared Savings Program (Shared Savings Program) was designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). If ACOs meet program requirements and the ACO quality performance standard, they are eligible to share in savings, if earned. There are two shared savings options: 1) one-sided risk model (sharing of savings only for the first two years, and sharing of savings and losses in the third year) and 2) two-sided risk model (sharing of savings and losses for all three years).

Current Program Measure Information: The Affordable Care Act specifies appropriate measures of clinical processes and outcomes; patient, and, wherever practicable, caregiver experience of care; and utilization (such as rates of hospital admission for ambulatory sensitive conditions) and that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

The Shared Savings Program quality reporting requirements are aligned with PQRS. Quality measure data for the Shared Savings Program is collected via claims and administrative data, CG-CAHPS, and the PQRS GPRO web interface.

Measure Requirements: Specific measure requirements include:

  1. Outcome measures that address conditions that are high-cost and affect a high volume of Medicare patients.
  2. Measures that are targeted to the needs and gaps in care of Medicare fee-for-service patients and their caregivers.
  3. Measures that align with CMS quality reporting initiatives, such as PQRS and the VM.
  4. Measures that support improved individual and population health.

Current Measures: NQF staff have compiled the 2016 MSSP measures in a spreadsheet organized according to concepts.

Merit-Based Incentive Payment System (MIPS) 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

Program History and Structure: The Merit-Based Incentive Payment System (MIPS) is established by H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which repeals the Medicare sustainable growth rate (SGR) and improves Medicare payment for physician services. The MACRA consolidates the current programs of the Physician Quality Reporting System (PQRS), The Value-Based Modifier (VM), and the Electronic Health Records (EHR) Incentive Program into one program (MIPS) that streamlines and improves on the three distinct incentive programs. MIPS will apply to doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists beginning in 2019. Other professionals paid under the physician fee schedule may be included in the MIPS beginning in 2021, provided there are viable performance metrics available. Positive and negative adjustments will be applied to items and services furnished beginning January 1, 2019 based on providers meeting a performance threshold four performance categories: quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology. Adjustments will be capped at 4 percent in 2019; 5 percent in 2020; 7 percent in 2021; and 9 percent in 2022 and future years.

High Priority Domains for Future Measure Consideration: In the CY 2016 PFS Rule, CMS will not propose the implementation of measures that do not meet the MIPS criteria of performance and measure set gaps. MIPS has a priority focus on outcome measures and
15
measures that are relevant for specialty providers. CMS identifies the following domains as high-priority for future measure consideration:

  1. Person and caregiver-centered Experience and Outcomes
    1. CMS wants to specifically focus on patient reported outcome measures (PROMs)
  2. Communication and Care Coordination
    1. Measures addressing coordination of care and treatment with other providers
  3. Appropriate Use and Resource Use

Measure Requirements: CMS applies criteria for measures that may be considered for potential inclusion in the MIPS. At a minimum, the following criteria and requirements must be met for selection in the MIPS:
CMS is statutorily required to select measures that reflect consensus among affected parties, and to the extent feasible, include measures set forth by one or more national consensus building entities.
To the extent practicable, quality measures selected for inclusion on the final list will address at least one of the following quality domains: clinical care, safety, care coordination, patient and caregiver experience, and population health and prevention.

Current Measures: NQF staff have compiled the 2016 MIPS measures in a spreadsheet organized according to concepts.

Physician Compare 
The material for this program was drawn directly from the CMS Program Specific Measure Priorities and Needs document, which was released in May 2015.

Program History and Structure: Section 10331 of the 2010 Patient Protection & Affordable Care Act (ACA) requires CMS to establish the Physician Compare website to publicly report physician performance data. The goal of the Physician Compare website is to provide reliable information for consumers to encourage informed health care decisions; and to create explicit incentives for physicians to maximize performance. To meet the statutory mandate, CMS repurposed the Medicare.gov Healthcare Provider Directory into Physician Compare. On December 30, 2010, CMS officially launched the Physician Compare website using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) as its underlying data source. Based on stakeholder feedback and understanding the Affordable Care Act (ACA) requirements for the site, CMS redesigned Physician Compare in June 2013. Since that time, CMS has been working continually to enhance the site and its functionality, improve the information available, and include more and increasingly useful information about the physicians and other health care professionals who are on the website.

The 2012 Physician Fee Schedule final rule indicated that the first measures available for public reporting on Physician Compare would be a sub-set of the 2012 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) measures collected via the Web Interface. CMS publicly reported this first set of measure data in February 2014 for the 66 group practices and 141 ACOs. In December 2014, the next phase of public reporting was accomplished with the posting of a sub-set of the 2013 PQRS GPRO Diabetes Mellitus (DM) and Coronary Artery Disease (CAD) measures collected via the Web Interface for 139 group practices and 214 Shared Savings Program and 23 Pioneer ACOS. In addition, CAHPS for ACO summary survey measures were added to Physician Compare. The following quality measures were publicly reported in December 2014:

2013 PQRS GPRO and ACO measures


2013 CAHPS for ACOs measures

For 2014 data, all PQRS GPRO measures collected via the Web Interface, as well as a sub-set of measures reported via registry and EHR are available for public reporting on Physician Compare. All measures reported by Shared Savings Program and Pioneer ACOs are also available for public reporting. CMS will continue to publicly report 2014 CAHPS for ACOs and will publish the first set of CAHPS for PQRS measures for groups of 100 or more EPs who participate in PQRS GPRO and for group practices of 25-99 EPs reporting via a certified CAHPS vendor. In addition, twenty individual measures reported by EPs under the 2014 PQRS via claims, EHR, or registry are available for public reporting. All 2014 data are targeted for publication in late 2015.

For 2015 data, at the group practice level, all 2015 PQRS GPRO measures reported via the Web Interface, registry, or EHR are available for public reporting. In addition, the 12 summary survey 2015 CAHPS for PQRS and CAHPS for ACO measures are available for public reporting for group practices of 2 or more EPs and ACOs reporting via a CMS-approved certified survey vendor. At the individual EP level, all 2015 PQRS measures reported via registry, EHR, or claims are available for public reporting. In addition, individual EP-level 2015 Qualified Clinical Data Registry (QCDR) measures, which include PQRS and non-PQRS data, will be available for public reporting on Physician Compare in late 2016.

Current Program Measure Information: Table 1 below provides the number of quality measures under each domain of measurement from the National Quality Strategy (NQS) priorities that were finalized in the 2012, 2013, 2014 and 2015 PFS final rules as available for public reporting. Only those measures that are comparable, valid, reliable, and suitable for public reporting will be publicly reported on Physician Compare (see “Measure Requirements” below).

Table 1: Quality Measures Finalized for Public Reporting by the 2012, 2013, 2014, & 2015 PFS Final Rules

NQS Priority Domains
Number of Measures Finalized for Potential Reporting on Physician Compare
2012 PFS Final Rule
2013 PFS Final Rule
2014 PFS Final Rule
2015 PFS Final Rule
Groups
ACOs
Groups
ACOs
EPs
Groups
ACOs
EPs
Groups
ACOs
Effective Clinical Care
27
20
20
20
13
14
14
110
138
8
Patient Safety
1
1
1
1
2
2
2
26
34
2
Communication/Care Coordination
1
1
1
1
0
0

29
37
0
Community/Population Health
0
0
0
0
5
5
5
14
15
5
Efficiency and Cost Reduction
0
0
0
0
0
0
0
15
16
0
Person and Caregiver Centered Experience and Outcomes
0
0
25
35
0
12
12
12
14
12

High Priority Domains for Future Measure Consideration: As we move more toward expanded public reporting, it is critical to include consumer-friendly measures. This means that measure development needs to focus on creating measures that look at the types of information consumers need to know to make informed health care decisions. PQRS was originally a pay-for-reporting program without explicit intent to publicly report quality measures. However, starting with 2015 data, all PQRS measures are available for public reporting on Physician Compare. Based on this expansion of public reporting and the changing use of PQRS measures, it is critical to consider public reporting and the consumer perspective during measure development. CMS identified the key areas to consider when developing consumer-friendly measures.

Consumer testing has also shown that users prefer outcome measures over process measures. In order for quality measures to be meaningful to consumers, they must resonate with consumers. We often hear that consumers do not think process measures are useful. They want to understand if patients like them better or if a procedure was successful. This is the information that will help them make informed decisions.

Composite measures can help consumers accurately interpret measures in a way that is meaningful to them while also removing the burden of interpretation from them. Composite measures help make data more digestible. It is much easier for a consumer to understand that a doctor is good at diabetes care, for instance, than it is to understand why it is important for a doctor to perform well across a series of technical measures about glucose levels and treatment best practices. Similarly, risk adjustment can ensure that consumers are more accurately comparing health care professionals and group practices.

Consumers can provide valuable feedback when engaged early in the measure development process. They can determine if measures are understandable and useful in decision making. We understand that all measures are not intended for public reporting. However, the continued growth of public reporting makes the consumer perspective increasingly important. Moving towards more consumer-friendly measures, specifically outcome measures, composite measures, and risk-adjusted measures, will be instrumental toward achieving Physician Compare’s goal, as defined by the Affordable Care Act, of providing consumers useful quality data to inform health care decisions.

Measure Requirements: Although CMS has finalized the quality measures listed in Table 1 for public reporting, not all of these quality measures may ultimately be suitable for public reporting. Only comparable, valid, reliable, and accurate data will be publicly reported. For example, the performance results for certain measures may not be statistically reliable if the total number of patients reported on is low. Hence, to select a sub-set of quality measures finalized for public reporting, CMS will need to analyze the actual measure performance results collected for each program year. At minimum, any quality measures selected for public reporting must meet the following criteria:

In addition, CMS will not publish any measures that are in their first year and only those measures that prove to resonate with consumers and are deemed to be relevant to consumers will be included on the profile pages of the website. All other comparable, valid, reliable, and accurate measures would be included in a publicly available downloadable database, similar to the databases currently available on data.medicare.gov.

Current Measures: The measures for Physician Compare are drawn from PQRS/MIPS, and NQF staff compiled the 2016 MIPS measures in a spreadsheet.


Appendix C: Public Comments

Index of Measures (by Program)

All measures are included in the index, even if there were not any public comments about that measure for that program.

General Comments

Merit-Based Incentive Payment System (MIPS)

Medicare Shared Savings Program

Physician Compare


Full Comments (Listed by Measure)

General
Non-Recommended PSA-Based Screening (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1019)
Potential Opioid Overuse (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-1169)
Use Of Preventive Screening Protocol For Transplant Patients (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-177)
Use Of Mohs Surgery For Superficial Basal Cell Carcinomas On The Trunk (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-178)
Use of Mohs Surgery For Squamous Cell Carcinoma In Situ And Keratoacanthoma Type - Squamous Cell Carcinoma on The Trunk that are 1 cm or smaller (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-179)
Surveillance endoscopy for dysplasia in Barrett's Esophagus (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-208)
Non-selective beta blocker use in patients with esophageal varices (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-209)
Hepatitis A vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-210)
Hepatitis B vaccination for patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-211)
Surveillance colonoscopy for dysplasia in colonic Crohns Disease (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-212)
Non-Melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Clinician (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-215)
NMSC: Biopsy Reporting Time - Pathologist (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-216)
Screening for Hepatoma in patients with Chronic Hepatitis B (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-217)
Hepatitis B vaccination for patients with chronic Hepatitis C (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-220)
Surveillance colonoscopy for dysplasia in Ulcerative Colitis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-221)
Hepatitis C Virus (HCV)- Sustained Virological Response (SVR) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-229)
HIV Screening for Patients with Sexually Transmitted Disease (STD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-230)
Screening endoscopy for varices in patients with cirrhosis (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-251)
Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-275)
Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) (Program: Medicare Shared Savings Program; MUC ID: MUC15-275)
New Corneal Injury Not Diagnosed in the Post-Anesthesia Care Unit/Recovery Area (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-296)
Performance of objective measure of functional hearing status (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-307)
Patient-Reported Functional Communication (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-313)
Corneal Graft Surgery - Postoperative improvement in visual acuity to 20/40 or better (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-370)
Glaucoma - Intraocular Pressure (IOP) Reduction (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-372)
Glaucoma - Intraocular Pressure (IOP) Reduction Following Laser Trabeculosplasty (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-374)
Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD) (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-375)
Acquired Involutional Entropion: Normalized lid position after surgical repair (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-377)
Exudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-379)
Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-392)
Diabetic Macular Edema: Loss of Visual Acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-393)
Acute Anterior Uveitis: Post-treatment visual acuity (Program: Merit-Based Incentive Payment System (MIPS); MUC ID: MUC15-394)