NQF

Version Number: 3.1
Meeting Date: December 16-17, 2015

Measure Applications Partnership
Hospital Workgroup Discussion Guide

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Agenda

Agenda Synopsis

Day 1  
8:30 am   Breakfast
9:00 am   Welcome, Introductions, Disclosures of Interest, and Review of Meeting Objectives
9:15 am   CMS Opening Remarks
9:30 am   Overview of Pre-Rulemaking Approach
9:45 am    Overview of the Hospital Inpatient Quality Reporting (IQR)
9:50 am    Opportunity for Public Comment on Measures Under Consideration for IQR
10:00 am   Pre-Rulemaking Input on Hospital Inpatient Quality Reporting (IQR) Measure Set - Consent Calendar 1
   Pre-Rulemaking Input on Hospital Inpatient Quality Reporting (IQR) Measure Set - Consent Calendar 2
   Pre-Rulemaking Input on Hospital Inpatient Quality Reporting (IQR) Measure Set - Consent Calendar 3
11:30 am   Break
11:40am   CMS Measure Concepts Presentation
11:50 am   Overview of the Hospital Value-Based Purchasing Program (HVBP)
11:55 am   Opportunity for Public Comment on Measures Under Consideration for HVBP
12:05 pm   Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set - Consent Calendar 1
   Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set - Consent Calendar 2
   Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set - Consent Calendar 3
1:00 pm   Lunch
2:00 pm   Overview of the Hospital Acquired Condition Reduction Program (HACRP)
2:05 pm   Opportunity for Public Comment on Measures Under Consideration for HACRP
2:15 pm   Pre-Rulemaking Input on Hospital Acquired Condition Reduction Program Measure Set
3:15 pm   Overview of the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
3:20 pm   Opportunity for Public Comment on Measures Under Consideration for PCHQR
3:35 pm   Pre-Rulemaking Input on PPS-Exempt Cancer Hospital Quality Reporting Program Measure Set
4:40 pm   Opportunity for Public Comment
4:55 pm   Summary of Day
5:00 pm   Adjourn


Day 2  
8:30 am   Breakfast
9:00 am   Welcome and Review of Day 1
9:15 am   Overview of the End-Stage Renal Disease Quality Improvement Program (ESRD-QIP)
9:20 am   Opportunity for Public Comment on Measures Under Consideration for ESRD-QIP
9:30 am   Pre-Rulemaking Input on End-Stage Renal Disease Quality Improvement Program Measure Set
10:45 am   Break
11:00 am    Overview of the Hospital Outpatient Quality Reporting Program (HOQR)
11:05 am   Opportunity for Public Comment on Measures Under Consideration for HOQR
11:15 am   Pre-Rulemaking Input on Hospital Outpatient Quality Reporting Program Measure Set
12:00 pm   Lunch
1:00 pm   Overview of the Ambulatory Surgical Center Quality Reporting (ASCQR) Program
1:05 pm   Opportunity for Public Comment on Measures Under Consideration for ASCQR
1:15 pm   Pre-Rulemaking Input on Ambulatory Surgical Center Quality Reporting Program Measure Set
1:50 pm   Overview of the Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program
1:55 pm   Opportunity for Public Comment on Measures Under Consideration for IPFQR
2:05 pm   Pre-Rulemaking Input on Inpatient Psychiatric Facilities Quality Reporting Program Measure Set
2:40 pm   Opportunity for Public Comment
2:55 pm   Wrap Up
3:00 pm   Adjourn


Full Agenda

Day 1  
8:30 am   Breakfast
9:00 am   Welcome, Introductions, Disclosures of Interest, and Review of Meeting Objectives
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair; Ronald Walters, MAP Hospital Workgroup Co-Chair; Christine Cassel, President and CEO, NQF; Ann Hammersmith, General Counsel, NQF

9:15 am   CMS Opening Remarks
Pierre Yong, CMS

9:30 am   Overview of Pre-Rulemaking Approach
Erin O’Rourke, Senior Project Manager, NQF; Zehra Shahab, Project Manager, NQF

9:45 am    Overview of the Hospital Inpatient Quality Reporting (IQR)
9:50 am    Opportunity for Public Comment on Measures Under Consideration for IQR
10:00 am   Pre-Rulemaking Input on Hospital Inpatient Quality Reporting (IQR) Measure Set - Consent Calendar 1
Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
  1. Adult Local Current Smoking Prevalence (MUC ID: MUC15-1013)
    • Description: Percentage of adult (age 18 and older) U.S. population that currently smoke, defined as adults who reported having smoked at least 100 cigarettes in their lifetime and currently smoke. (The endorsed specifications of the measure are: Percentage of adult (age 18 and older) U.S. population that currently smoke.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This structure measure addresses the high-priority domain “Best Practices of Healthy Living” but it does not fill any of the high-priority gap areas previously identified by CMS. CMS has indicated strong interest in exploring this measure with MAP. The measure is under development for the city and county level of analysis. The applicability of this population measure to the role of hospitals needs further exploration. Furthermore, this measure is focused on smoking and does not align with the tobacco use screening and treatment provided measures currently in the IPFQR program or other tobacco use measures in other programs.
      • Impact on quality of care for patients:This measure is an indicator of population health at the city or county level rather than the quality of care received in the acute inpatient setting. The updated tobacco use and dependence guideline recommends coordinated interventions between the clinician, health care administrator, insurer, and purchaser therefore quality measurement should focus on all entities to ensure tobacco users receive consistent and effective interventions.
    • Preliminary analysis result: Encourage further development


  2. American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC ID: MUC15-534)
    • Description: Organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients at least 18 years of age undergoing inpatient colon procedures and/or abdominal hysterectomies as reported through the ACS-NSQIP or CDC NHSN. The measure yields separate SIRs for each procedure. (The endorsed specifications of the measure are: Prototype measure for the facility adjusted Standardized Infection Ratio (SIR) of deep incisional and organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients aged >= 18 years as reported through the ACS National Surgical Quality Improvement Program (ACS-NSQIP) or CDC National Health and Safety Network (NHSN). Prototype also includes a systematic, retrospective sampling of operative procedures in healthcare facilities. This prototype measure is intended for time-limited use and is proposed as a first step toward a more comprehensive SSI measure or set of SSI measures that include additional surgical procedure categories and expanded SSI risk-adjustment by procedure type. This single prototype measure is applied to two operative procedures, colon surgeries and abdominal hysterectomies, and the measure yields separate SIRs for each procedure.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an update to the name of the measure from “reliability adjusted SIR” to “Adjusted Ranking Metric (ARM).”
      • Impact on quality of care for patients:The continued use of this measure will promote SSI prevention activities, which will lead to an improvement in patient outcomes, reducing avoidable medical costs, patient morbidity and mortality. Guidelines to prevent SSIs are available here (http://www.cdc.gov/hicpac/SSI/001_SSI.html).
    • Preliminary analysis result: Conditional support, pending NQF annual update


  3. INR Monitoring for Individuals on Warfarin after Hospital Discharge (MUC ID: MUC15-1015)
    • Description: Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic International Normalized Ratio (INR) who had an INR test within 14 days of hospital discharge (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This facility level measure has been submitted to NQF for endorsement and has been reviewed and recommended by the Patient Safety Standing Committee and is currently in the voting phase. This measure addresses two gap areas identified by CMS as high-priority, adverse drug events and care transitions. This measure also compliments the VTE (NQF #0373) and stroke (NQF #0436) measures currently in the IQR program which do not assess INR after discharge. The burden of implementing this hybrid measure should be minimal because the data sources include administrative claims and EHR.
      • Impact on quality of care for patients:Implementing this measure can help to ensure a timely INR after hospital discharge and help prevent readmissions and reduce mortality associated with warfarin-related bleeding and thromboembolic events.
    • Preliminary analysis result: Support


  4. IQI-22: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated (MUC ID: MUC15-1083)
    • Description: Vaginal births per 1,000 deliveries by patients with previous Cesarean deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure). (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This facility level measure is currently one of AHRQ’s IQIs and reported by multiple states. If implemented this measure will complement the elective delivery measure (NQF #0469) currently in the program.
      • Impact on quality of care for patients:Cesarean deliveries are a common surgical procedure in the United States, accounting for 1 in 3 US births. A planned labor after cesarean/vaginal birth after cesarean (LAC/VBAC) is an appropriate option for most women with a history of prior cesarean birth. Increased access to providers and facilities capable of managing LAC/VBAC are required to reduce the US cesarean rate and associated maternal morbidity while increasing choice for childbearing women and their families (http://www.annfammed.org/content/13/1/80.full).
    • Preliminary analysis result: Conditional support, pending NQF review and endorsement


  5. National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (MUC ID: MUC15-531)
    • Description: Assesses antimicrobial use (AU) in hospitals based on medication administration data hospitals collect electronically at the point of care and report via electronic file submissions to NHSN. AU data included in the measure are antibacterial agents administered to adult and pediatric patients in a specified set of hospital ward and intensive care unit locations. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure has been submitted to NQF for endorsement. The Patient Safety Standing Committee and comments received during the public comment period expressed concerns about the reliability and validity of the measure due to the small sample size used to conduct the initial analysis. In the submission, the measure developer stated that the measure is intended for use in the National Healthcare Safety Network (NHSN) and wishes to gain greater experience and gather more information before using it for reporting or payment. MAP recognizes the high importance of antimicrobial stewardship and would conditionally support the inclusion of this measure in the IQR program to allow for the opportunity for additional testing to address feasibility issues. However, MAP notes these issues should be addressed before the measure is reported on Hospital Compare.
      • Impact on quality of care for patients:The measure provides summary results that hospital and health system antimicrobial stewardship programs (ASPs) can use as quantitative aids in their efforts to evaluate and improve antibiotic prescribing.
    • Preliminary analysis result: Conditional support, pending additional use


Pre-Rulemaking Input on Hospital Inpatient Quality Reporting (IQR) Measure Set - Consent Calendar 2
Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
  1. Aortic Aneurysm Procedure Clinical Episode-Based Payment Measure (MUC ID: MUC15-835)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to an aortic aneurysm procedure inpatient (IP) stay and attributes them to the hospital where the index IP stay occurred. It includes abdominal aortic aneurysm and thoracic aortic aneurysm subtypes. (Measure Specifications)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure does not address any of the high-priority domains identified by CMS for future measure consideration. Analytic evidence demonstrating that a performance gap exists or that there is a variation in performance among providers for aortic aneurysm procedures was not provided as required for measures that may be considered for potential adoption in the IQR program. Furthermore, a similar measure, NQF #2151 Medicare Spending Per Beneficiary (MSPB), is already in the program and captures a broader population than the MUC, which is procedure specific.
      • Impact on quality of care for patients:Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406).
    • Preliminary analysis result: Do not support


  2. Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Measure (MUC ID: MUC15-836)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a Cholecystectomy and Common Duct Exploration IP stay and attributes them to the hospital where the index IP stay occurred. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure does not address any of the high-priority domains identified by CMS for future measure consideration. Analytic evidence demonstrating that a performance gap exists or that there is a variation in performance among providers for cholecystectomy and common duct exploration procedures was not provided as required for measures that may be considered for potential adoption in the IQR program. Furthermore, a similar measure, NQF #2151 Medicare Spending Per Beneficiary (MSPB), is already in the program and captures a broader population than the MUC, which is procedure specific.
      • Impact on quality of care for patients:Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406).
    • Preliminary analysis result: Do not support


  3. Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (MUC ID: MUC15-378)
    • Description: This measure estimates hospital-level, risk-standardized payment for a pneumonia episode of care starting with inpatient admission to a short term acute-care facility and extending 30 days post-admission for Medicare fee-for-service (FFS) patients who are 65 years of age or older with a principal discharge diagnosis of pneumonia, aspiration pneumonia, and sepsis in cases where sepsis is accompanied by secondary diagnosis of pneumonia present on admission. (The endorsed specifications of the measure are: This measure estimates hospital-level, risk-standardized payment for a pneumonia episode of care starting with inpatient admission to a short term acute-care facility and extending 30 days post-admission for Medicare fee-for-service (FFS) patients who are 65 years of age or older with a principal discharge diagnosis of pneumonia.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This NQF-endorsed cost and resource measure is already in the IQR program and addresses the previously identified gap of affordability/cost measures. CMS is expanding the cohort to match the pneumonia mortality measure which includes patients with a principle diagnosis of aspiration pneumonia and sepsis in cases where sepsis is accompanied by secondary diagnosis of pneumonia present on admission. CMS is encouraged to submit the updated specifications to NQF when revisions to the measure are complete.
      • Impact on quality of care for patients:A measure of payments for Medicare patients to hospitals that is aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure will reflect differences in the management of care for patients with pneumonia both during hospitalization and immediately post-discharge. Pneumonia is a condition with substantial range in costs of care and for which there are well-established publicly reported quality measures and is therefore an ideal condition for assessing relative value for an episode-of-care that begins with an acute hospitalization. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care.
    • Preliminary analysis result: Conditional support, pending NQF review and endorsement of revised specifications


  4. Spinal Fusion Clinical Episode-Based Payment Measure (MUC ID: MUC15-837)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a Spinal Fusion IP stay and attributes them to the hospital where the index IP stay occurred. (Measure Specifications)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure does not address any of the high-priority domains identified by CMS for future measure consideration. Analytic evidence demonstrating that a performance gap exists or that there is a variation in performance among providers for spinal fusion procedures was not provided as required for measures that may be considered for potential adoption in the IQR program. Furthermore, a similar measure, NQF #2151 Medicare Spending Per Beneficiary (MSPB), is already in the program and captures a broader population than the MUC, which is procedure specific. *The stage of development for this MUC was updated to "Fully Developed" on December 2, 2015, after the MUC was publicly released.
      • Impact on quality of care for patients:Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406).
    • Preliminary analysis result: Do not support


  5. Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Clinical Episode-Based Payment Measure (MUC ID: MUC15-838)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a TURP IP stay and attributes them to the hospital where the index IP stay occurred. (Measure Specifications)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure does not address any of the high-priority domains identified by CMS for future measure consideration. Analytic evidence demonstrating that a performance gap exists or that there is a variation in performance among providers for transurethral resection of the prostate (TURP) for benign prostatic hyperplasia procedures was not provided as required for measures that may be considered for potential adoption in the IQR program. Furthermore, a similar measure, NQF #2151 Medicare Spending Per Beneficiary (MSPB), is already in the program and captures a broader population than the MUC, which is procedure specific.
      • Impact on quality of care for patients:Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406).
    • Preliminary analysis result: Do not support


Pre-Rulemaking Input on Hospital Inpatient Quality Reporting (IQR) Measure Set - Consent Calendar 3
Programs under consideration: Hospital Inpatient Quality Reporting and EHR Incentive Program
  1. Excess Days in Acute Care after Hospitalization for Pneumonia (MUC ID: MUC15-391)
    • Description: This measure assesses the difference (“excess”) between the average number of risk-adjusted days a hospital’s patients spend in an ED, observation, or readmission in the 30 days following a hospitalization for pneumonia (“predicted”) and the number of days in acute care that they would have been expected to spend if discharged from an average hospital. (Measure Specifications)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an update to a measure previously supported by the MAP with the condition that NQF review and endorse the measure. The cohort has been expanded to include patients with principle discharge diagnosis of aspiration pneumonia and sepsis with an accompanying secondary diagnosis of pneumonia that is present on admission and aligns with NQF #0468 - Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia hospitalization and NQF #0506 - Hospital 30-day all-cause risk-standardized readmission rate (RSRR) following pneumonia hospitalization.
      • Impact on quality of care for patients:Existing measures publicly report readmission rates and mortality rates following hospitalization for pneumonia. These measures do not include all post-discharge outcomes that matter to patients, such as having to return to the ED or spend time under observation. Moreover, the increasing use of observation care may be replacing some readmissions. Hospitals with high rates of observation stays in the post-discharge period may therefore have low readmission rates that do not fully reflect the quality of care. This measure adds to the existing measurement landscape by including other outcomes (i.e., ED visits, observation stays), by capturing the total amount of time patients spend in acute care, and by accounting for time at risk of an event (i.e. survival time).
    • Preliminary analysis result: Conditional support, pending NQF review and endorsement


  2. Hospital 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Measure (MUC ID: MUC15-294)
    • Description: This stroke mortality measure will estimate the hospital-level, risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. The outcome is all-cause 30-day mortality, defined as death from any cause within 30 days of the index admission date, including in-hospital death, for stroke patients. The measure uses Medicare fee-for-service (FFS) administrative claims to derive the cohort and outcome, and for risk adjustment. The major revision is to include NIH Stroke Scale as a measure of stroke severity in the risk-adjustment. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This outcome mortality measure adjusts for stroke severity using the NIHSS as recommended by the clinical practice guidelines. The current publicly reported stroke mortality measure does not include stroke severity in the risk adjustment model.
      • Impact on quality of care for patients:There is a need to define the relevant stroke outcomes to measure and the factors that should be accounted for to make comparisons across different facilities valid so that the quality of stroke care can be evaluated and optimized. Stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor in hospital-level performance therefore inclusion in the risk model is recommended in a Statement for Healthcare Professional from the American Heart Association/American Stroke Association
    • Preliminary analysis result: Conditional support, pending NQF endorsement


  3. Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Claims and Clinical Electronic Health Record (EHR) Risk Adjustment Variables (MUC ID: MUC15-1135)
    • Description: This hybrid stroke mortality measure will estimate the hospital-level, risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. The outcome is all-cause 30-day mortality, defined as death from any cause within 30 days of the index admission date, including in-hospital death, for stroke patients. The measure is referred to as a hybrid because it will use Medicare fee-for-service (FFS) administrative claims to derive the cohort and outcome, and claims and clinical EHR data for risk adjustment. (Measure Specifications)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This outcome mortality measure adjusts for stroke severity using the NIHSS as recommended by the clinical practice guidelines. The currently publicly reported stroke mortality measure uses administrative claims data only for risk adjustment, and does not include an assessment of stroke severity. *The stage of development for this MUC was updated to "Fully Developed" on December 3, 2015, after the MUC was publicly released.
      • Impact on quality of care for patients:There is a need to define the relevant stroke outcomes to measure and the factors that should be accounted for to make comparisons across different facilities valid so that the quality of stroke care can be evaluated and optimized. Stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor in hospital-level performance therefore inclusion in the risk model is recommended in a Statement for Healthcare Professional from the American Heart Association/American Stroke Association
    • Preliminary analysis result: Conditional support, pending NQF review and endorsement


  4. Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Electronic Health Record (EHR)-Extracted Risk Adjustment Variables (MUC ID: MUC15-1033)
    • Description: This hybrid stroke mortality measure will estimate the hospital-level, risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. The outcome is all-cause 30-day mortality, defined as death from any cause within 30 days of the index admission date, including in-hospital death, for stroke patients. The measure is referred to as a hybrid because it will use Medicare fee-for-service (FFS) administrative claims to derive the cohort and outcome, and clinical data (EHR extracted) for risk adjustment. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This outcome mortality measure adjusts for stroke severity using the NIHSS as recommended by the clinical practice guidelines. The currently publicly reported stroke mortality measure uses administrative claims data only for risk adjustment, and does not include an assessment of stroke severity. *The stage of development for this MUC was updated to "Fully Developed" on December 3, 2015, after the MUC was publicly released.
      • Impact on quality of care for patients:There is a need to define the relevant stroke outcomes to measure and the factors that should be accounted for to make comparisons across different facilities valid so that the quality of stroke care can be evaluated and optimized. Stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor in hospital-level performance therefore inclusion in the risk model is recommended in a Statement for Healthcare Professional from the American Heart Association/American Stroke Association.
    • Preliminary analysis result: Conditional support, pending NQF review and endorsement


  5. Patient Safety and Adverse Events Composite (MUC ID: MUC15-604)
    • Description: Patient Safety and Adverse Events Composite (Patient Safety Indicator, or PSI90) is a composite measure of 10 individual PSIs, each measuring a different aspect of harm associated with patient safety. Each PSI is reliability-adjusted (smoothed) and indirectly standardized (risk adjusted). The composite is the weighted average of the reliability-adjusted, indirectly standardized, observed-to-expected ratios for component indicators. The final weight for each component is the product of harm weights and volume weights (numerator weights). Harm weights are calculated by multiplying empirical estimates of excess harms associated with the patient safety event by utility weights linked to each of the harms. Excess harms are estimated using statistical models comparing patients with a safety-related event to those without that safety-related event in a CMS Medicare fee-for-service sample that allowed up to one year of follow-up from the discharge date of the hospital stay associated with the index event. Volume weights, the second part of the final weight, are calculated on the basis of the number of safety-related events for the component indicators in the all-payer reference population. The observed to expected ratios (indirect standardization) of the reliability adjusted (smoothed) rates are multiplied by a component weight and the weighted scores are summed to determine the final PSI 90 score. A score of 1 means that the hospital performs as expected, scores greater than one indicate worse performance than expected. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This updated version of PSI 90 addresses a number of concerns raised by the NQF Safety Standing Committee. Three additional PSIs have been added to the measure. Two of the component PSIs were redesigned; specifically PSI 12 with the removal of isolated calf deep vein thromboses (DVT) which have limited clinical relevance and PSI 15 with a greater focus on accidental punctures and lacerations that occur during abdominal/pelvic surgery and those that result in re-operation within one day which reflect events that are more likely preventable. PSIs were better linked to important changes in clinical status with “harm weights” that are based on diagnoses that were assigned after the complication. This is intended to allow the measure to more accurately reflect the impact of the events.
      • Impact on quality of care for patients:The PSI measures were developed to identify harmful healthcare related events that are potentially preventable. Patients that experience a PSI event are hospitalized for two to three times longer, have twp to twenty times higher rates of inpatient mortality and two to eight times higher total hospital charges. The composite measure was constructed to increase the statistical precision by increasing the sample size and to assist consumers, providers, and payers with their decision-making. This updated version would three additional PSIs: PSI09 Postoperative Hemorrhage or Hematoma, PSI10 Physiologic and Metabolic Derangement, and PSI11 Postoperative Respiratory Failure.
    • Preliminary analysis result: Support


11:30 am   Break
11:40am   CMS Measure Concepts Presentation
Tara Lemons, CMS

11:50 am   Overview of the Hospital Value-Based Purchasing Program (HVBP)
11:55 am   Opportunity for Public Comment on Measures Under Consideration for HVBP
12:05 pm   Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set - Consent Calendar 1
Programs under consideration: Hospital Value-Based Purchasing Program
  1. Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (MUC ID: MUC15-378)
    • Description: This measure estimates hospital-level, risk-standardized payment for a pneumonia episode of care starting with inpatient admission to a short term acute-care facility and extending 30 days post-admission for Medicare fee-for-service (FFS) patients who are 65 years of age or older with a principal discharge diagnosis of pneumonia, aspiration pneumonia, and sepsis in cases where sepsis is accompanied by secondary diagnosis of pneumonia present on admission. (The endorsed specifications of the measure are: This measure estimates hospital-level, risk-standardized payment for a pneumonia episode of care starting with inpatient admission to a short term acute-care facility and extending 30 days post-admission for Medicare fee-for-service (FFS) patients who are 65 years of age or older with a principal discharge diagnosis of pneumonia.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add another measure to the Efficiency domain of the program. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. However, this measure would overlap with the current Medicare Spending Per Beneficiary Measure and MAP has previously advocated keeping a parsimonious set of measures for the VBP program to avoid rewarding or penalizing a provider mulitple times for the same case.
      • Impact on quality of care for patients:Pneumonia is the second leading cause of hospitalization for Americans over 65 years old resulting in 1.2 million hospital admissions with annual expenditures of over $10 billion.Costs of care for an pneumonia episode vary significantly. Implementing this measure could help lower costs related to variations in quality.
    • Preliminary analysis result: Do not support


  2. Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for Acute Myocardial Infarction (AMI) (MUC ID: MUC15-369)
    • Description: This measure estimates hospital-level, risk-standardized payment for an AMI episode-of-care starting with inpatient admission to a short term acute-care facility and extending 30 days post-admission for Medicare fee-for-service (FFS) patients who are 65 years of age or older with a principal discharge diagnosis of AMI. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add another measure to the Efficiency domain of the program. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. However, this measure would overlap with the current Medicare Spending Per Beneficiary Measure and MAP has previously advocated keeping a parsimonious set of measures for the VBP program to avoid rewarding or penalizing a provider mulitple times for the same case.
      • Impact on quality of care for patients:AMI is a leading cause of hospitalizations for Americans over 65 years old and costs approximately $18 billion annually. Costs of care for an AMI episode vary significantly. Implementing this measure could help lower costs related to variations in quality.
    • Preliminary analysis result: Do not support


  3. Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for heart failure (HF) (MUC ID: MUC15-322)
    • Description: This measure estimates a hospital-level, risk-standardized payment for a heart failure episode-of-care starting with inpatient admission to a short term acute-care facility and extending 30 days post-admission for Medicare fee-for-service (FFS) patients who are 65 years of age or older with a principal discharge diagnosis of heart failure. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add another measure to the Efficiency domain of the program. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. However, this measure would overlap with the current Medicare Spending Per Beneficiary Measure and MAP has previously advocated keeping a parsimonious set of measures for the VBP program to avoid rewarding or penalizing a provider mulitple times for the same case.
      • Impact on quality of care for patients:This measure addresses the cost of care for a common condition. Heart failure is a common condition and one of the leading causes of hospitalization for Americans over 65 years old. Costs related to heart failure total approximately $34 billion annually. Unadjusted 30 day episode of care payments for heart failure have been found to range significantly. Payments range from $6,865 to $26,696 with a mean of $13,081. Use of this measure could drive improvement in variation in costs related to quality of care.
    • Preliminary analysis result: Do not support


  4. Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) (MUC ID: MUC15-295)
    • Description: This measure estimates hospital-level, risk-standardized payments for a primary elective total THA/TKA episode of care starting with inpatient admission to a short term acute-care facility for Medicare fee-for-service (FFS) patients who are 65 years of age or older. (Measure Specifications)
    • Public comments received: 5
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add another measure to the Efficiency domain of the program. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. However, this measure would overlap with the current Medicare Spending Per Beneficiary Measure and MAP has previously advocated keeping a parsimonious set of measures for the VBP program to avoid rewarding or penalizing a provider mulitple times for the same case.
      • Impact on quality of care for patients:This measure addresses the cost of care for a common condition. Over 33% of Americans 65 and older suffer from osteoarthritis. Joint replacement surgeries are becoming more commonly utilized as Medicare covered 337,419 THA procedures and 750,569 TKA procedures between 2009 and 2012 and annual Medicare payments for THA and TKA exceed $15 billion annually. There is significant variation in costs for these procedures that are often related to quality of care as complications and readmissions increase the total payment for post-surgical care. The mean 90-day risk-standardized payment among Medicare FFS patients with a qualifying THA/TKA procedure in 2010–2012 was$23,248, and ranged from $16,421 to$35,12. Use of this measure could drive improvement in variation in costs related to quality of care.
    • Preliminary analysis result: Do not support


Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set - Consent Calendar 2
Programs under consideration: Hospital Value-Based Purchasing Program
  1. Cellulitis Clinical Episode-Based Payment Measure (MUC ID: MUC15-1143)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a cellulitis IP stay and attributes them to the hospital where the index IP stay occurred. It includes subtypes for diabetics, decubitus pressure ulcers, and other cellulitis patients. (Measure Specifications)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add another measure to the Efficiency domain of the program. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. However, this measure would overlap with the current Medicare Spending Per Beneficiary Measure and MAP has previously advocated keeping a parsimonious set of measures for the VBP program to avoid rewarding or penalizing a provider mulitple times for the same case.
      • Impact on quality of care for patients:While the costs can be high, only a small subset of patients with cellulitis require hospitalization. (Acumen. Methodology for Developing the Six Hospital-based Episode Measures: Supplemental Documentation for the Fiscal Year 2015 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing) CMS has noted that the variations in cost associated with treating cellulitis are the result of post discharge costs that reflect variations in quality. An episode-based approach could help drive improvement in both cost and quality. (http://content.healthaffairs.org/content/28/5/1406.full.pdf)
    • Preliminary analysis result: Do not support


  2. Gastrointestinal Intestinal (GI) Hemorrhage Clinical Episode-Based Payment Measure (MUC ID: MUC15-1144)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a GI hemorrhage IP stay and attributes them to the hospital where the index IP stay occurred. It includes subtypes for 1) upper, 2) lower, 3) upper and lower, and 4) undefined bleeds. (Measure Specifications)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add another measure to the Efficiency domain of the program. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. However, this measure would overlap with the current Medicare Spending Per Beneficiary Measure and MAP has previously advocated keeping a parsimonious set of measures for the VBP program to avoid rewarding or penalizing a provider mulitple times for the same case.
      • Impact on quality of care for patients:CMS has noted that the variations in cost associated with treating GI hemorrhages are the result of post discharge costs that reflect variations in quality. An episode-based approach could help drive improvement in both cost and quality. (http://content.healthaffairs.org/content/28/5/1406.full.pdf)
    • Preliminary analysis result: Do not support


  3. Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (MUC ID: MUC15-1145)
    • Description: The measure constructs a clinically coherent group of services to inform providers about resource use and effectiveness. It sums Parts A and B payments related to a kidney/urinary tract infection IP stay and attributes them to the hospital where the index IP stay occurred. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add another measure to the Efficiency domain of the program. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. However, this measure would overlap with the current Medicare Spending Per Beneficiary Measure and MAP has previously advocated keeping a parsimonious set of measures for the VBP program to avoid rewarding or penalizing a provider mulitple times for the same case.
      • Impact on quality of care for patients:CMS has noted that the variations in cost associated with treating kidney/urinary tract infections are the result of post discharge costs that reflect variations in quality. An episode-based approach could help drive improvement in both cost and quality. (http://content.healthaffairs.org/content/28/5/1406.full.pdf)
    • Preliminary analysis result: Do not support


Pre-Rulemaking Input on Hospital Value-Based Purchasing Program Measure Set - Consent Calendar 3
Programs under consideration: Hospital Value-Based Purchasing Program
  1. American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC ID: MUC15-534)
    • Description: Organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients at least 18 years of age undergoing inpatient colon procedures and/or abdominal hysterectomies as reported through the ACS-NSQIP or CDC NHSN. The measure yields separate SIRs for each procedure. (The endorsed specifications of the measure are: Prototype measure for the facility adjusted Standardized Infection Ratio (SIR) of deep incisional and organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients aged >= 18 years as reported through the ACS National Surgical Quality Improvement Program (ACS-NSQIP) or CDC National Health and Safety Network (NHSN). Prototype also includes a systematic, retrospective sampling of operative procedures in healthcare facilities. This prototype measure is intended for time-limited use and is proposed as a first step toward a more comprehensive SSI measure or set of SSI measures that include additional surgical procedure categories and expanded SSI risk-adjustment by procedure type. This single prototype measure is applied to two operative procedures, colon surgeries and abdominal hysterectomies, and the measure yields separate SIRs for each procedure.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an update to the name of the measure from “reliability adjusted SIR” to “Adjusted Ranking Metric (ARM).”
      • Impact on quality of care for patients:The continued use of this measure will promote SSI prevention activities, which will lead to an improvement in patient outcomes, reducing avoidable medical costs, patient morbidity and mortality. Guidelines to prevent SSIs are available here (http://www.cdc.gov/hicpac/SSI/001_SSI.html).
    • Preliminary analysis result: Conditional support, pending NQF annual update


  2. Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (MUC ID: MUC15-395)
    • Description: This measure estimates hospital-level, risk-standardized mortality rates for Medicare fee-for-service (FFS) patients who are 65 years of age or older and discharged from the hospital following a qualifying isolated CABG surgery. (The endorsed specifications of the measure are: The measure estimates a hospital-level, risk-standardized mortality rate (RSMR) for patients 18 years and older discharged from the hospital following a qualifying isolated CABG procedure. Mortality is defined as death from any cause within 30 days of the procedure date of an index CABG admission. The measure was developed using Medicare Fee-for-Service (FFS) patients 65 years and older and was tested in all-payer patients 18 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the mortality outcome.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:CABG is a common surgery with notable variation in mortality. Adding this measure to the VBP measure set could provide an incentive to improve patient safety in this area.
      • Impact on quality of care for patients:Coronary Artery Bypass Graft (CABG) Surgery is one of the most commonly performed surgeries in the United States. However, mortality for CABG surgery varies significantly. The measure developer found a mean rate of 3.2% with a range from 1.5%-7.9%. The developer found a median rate of 3.0% (25th and 75th percentiles are 2.6% and 3.6%, respectively). Adding this measure to the VBP program could help to reduce this variation and drive improvement.
    • Preliminary analysis result: Support


  3. Patient Safety and Adverse Events Composite (MUC ID: MUC15-604)
    • Description: Patient Safety and Adverse Events Composite (Patient Safety Indicator, or PSI90) is a composite measure of 10 individual PSIs, each measuring a different aspect of harm associated with patient safety. Each PSI is reliability-adjusted (smoothed) and indirectly standardized (risk adjusted). The composite is the weighted average of the reliability-adjusted, indirectly standardized, observed-to-expected ratios for component indicators. The final weight for each component is the product of harm weights and volume weights (numerator weights). Harm weights are calculated by multiplying empirical estimates of excess harms associated with the patient safety event by utility weights linked to each of the harms. Excess harms are estimated using statistical models comparing patients with a safety-related event to those without that safety-related event in a CMS Medicare fee-for-service sample that allowed up to one year of follow-up from the discharge date of the hospital stay associated with the index event. Volume weights, the second part of the final weight, are calculated on the basis of the number of safety-related events for the component indicators in the all-payer reference population. The observed to expected ratios (indirect standardization) of the reliability adjusted (smoothed) rates are multiplied by a component weight and the weighted scores are summed to determine the final PSI 90 score. A score of 1 means that the hospital performs as expected, scores greater than one indicate worse performance than expected. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This updated version of PSI 90 addresses a number of concerns raised by the NQF Safety Standing Committee. Three additional PSIs have been added to the measure. Two of the component PSIs were redesigned; specifically PSI 12 with the removal of isolated calf deep vein thromboses (DVT) which have limited clinical relevance and PSI 15 with a greater focus on accidental punctures and lacerations that occur during abdominal/pelvic surgery and those that result in re-operation within one day which reflect events that are more likely preventable. PSIs were better linked to important changes in clinical status with “harm weights” that are based on diagnoses that were assigned after the complication. This is intended to allow the measure to more accurately reflect the impact of the events.
      • Impact on quality of care for patients:The PSI measures were developed to identify harmful healthcare related events that are potentially preventable. Patients that experience a PSI event are hospitalized for two to three times longer, have twp to twenty times higher rates of inpatient mortality and two to eight times higher total hospital charges. The composite measure was constructed to increase the statistical precision by increasing the sample size and to assist consumers, providers, and payers with their decision-making. This updated version would three additional PSIs: PSI09 Postoperative Hemorrhage orHematoma, PSI10 Physiologic and Metabolic Derangement, and PSI11 Postoperative Respiratory Failure .
    • Preliminary analysis result: Support


1:00 pm   Lunch
2:00 pm   Overview of the Hospital Acquired Condition Reduction Program (HACRP)
2:05 pm   Opportunity for Public Comment on Measures Under Consideration for HACRP
2:15 pm   Pre-Rulemaking Input on Hospital Acquired Condition Reduction Program Measure Set
Programs under consideration: Hospital Acquired Condition Reduction Program
  1. American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC ID: MUC15-534)
    • Description: Organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients at least 18 years of age undergoing inpatient colon procedures and/or abdominal hysterectomies as reported through the ACS-NSQIP or CDC NHSN. The measure yields separate SIRs for each procedure. (The endorsed specifications of the measure are: Prototype measure for the facility adjusted Standardized Infection Ratio (SIR) of deep incisional and organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients aged >= 18 years as reported through the ACS National Surgical Quality Improvement Program (ACS-NSQIP) or CDC National Health and Safety Network (NHSN). Prototype also includes a systematic, retrospective sampling of operative procedures in healthcare facilities. This prototype measure is intended for time-limited use and is proposed as a first step toward a more comprehensive SSI measure or set of SSI measures that include additional surgical procedure categories and expanded SSI risk-adjustment by procedure type. This single prototype measure is applied to two operative procedures, colon surgeries and abdominal hysterectomies, and the measure yields separate SIRs for each procedure.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an update to the name of the measure from “reliability adjusted SIR” to “Adjusted Ranking Metric (ARM)”, which provides a better estimate of the hospital’s true SIR relative to other facilities.
      • Impact on quality of care for patients:The continued use of this measure will promote SSI prevention activities, which will lead to an improvement in patient outcomes, reducing avoidable medical costs, patient morbidity and mortality. Guidelines to prevent SSIs are available here (http://www.cdc.gov/hicpac/SSI/001_SSI.html).
    • Preliminary analysis result: Conditional support, pending NQF annual update


  2. Patient Safety and Adverse Events Composite (MUC ID: MUC15-604)
    • Description: Patient Safety and Adverse Events Composite (Patient Safety Indicator, or PSI90) is a composite measure of 10 individual PSIs, each measuring a different aspect of harm associated with patient safety. Each PSI is reliability-adjusted (smoothed) and indirectly standardized (risk adjusted). The composite is the weighted average of the reliability-adjusted, indirectly standardized, observed-to-expected ratios for component indicators. The final weight for each component is the product of harm weights and volume weights (numerator weights). Harm weights are calculated by multiplying empirical estimates of excess harms associated with the patient safety event by utility weights linked to each of the harms. Excess harms are estimated using statistical models comparing patients with a safety-related event to those without that safety-related event in a CMS Medicare fee-for-service sample that allowed up to one year of follow-up from the discharge date of the hospital stay associated with the index event. Volume weights, the second part of the final weight, are calculated on the basis of the number of safety-related events for the component indicators in the all-payer reference population. The observed to expected ratios (indirect standardization) of the reliability adjusted (smoothed) rates are multiplied by a component weight and the weighted scores are summed to determine the final PSI 90 score. A score of 1 means that the hospital performs as expected, scores greater than one indicate worse performance than expected. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This updated version of PSI 90 addresses a number of concerns raised by the NQF Safety Standing Committee. Three additional PSIs have been added to the measure. Two of the component PSIs were redesigned; specifically PSI 12 with the removal of isolated calf deep vein thromboses (DVT) which have limited clinical relevance and PSI 15 with a greater focus on accidental punctures and lacerations that occur during abdominal/pelvic surgery and those that result in re-operation within one day which reflect events that are more likely preventable. PSIs were better linked to important changes in clinical status with “harm weights” that are based on diagnoses that were assigned after the complication. This is intended to allow the measure to more accurately reflect the impact of the events.
      • Impact on quality of care for patients:The PSI measures were developed to identify harmful healthcare related events that are potentially preventable. Patients that experience a PSI event are hospitalized for two to three times longer, have twp to twenty times higher rates of inpatient mortality and two to eight times higher total hospital charges. The composite measure was constructed to increase the statistical precision by increasing the sample size and to assist consumers, providers, and payers with their decision-making. This updated version would three additional PSIs: PSI09 Postoperative Hemorrhage or Hematoma, PSI10 Physiologic and Metabolic Derangement, and PSI11 Postoperative Respiratory Failure.
    • Preliminary analysis result: Support


3:15 pm   Overview of the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
3:20 pm   Opportunity for Public Comment on Measures Under Consideration for PCHQR
3:35 pm   Pre-Rulemaking Input on PPS-Exempt Cancer Hospital Quality Reporting Program Measure Set
Programs under consideration: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program
  1. Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (MUC ID: MUC15-951)
    • Description: Measure estimates risk-adjusted rates of inpatient admissions or emergency department (ED) visits for cancer patients >18 years of age with at least one of the following diagnoses—anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis—within 30 days of hospital outpatient chemotherapy treatment. Two rates are reported. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure fits in a high-priority domain and would align PCHQR with other measure sets that include admissions and readmissions measures, including ASCQR and HRRP.The measure has not been submitted for endorsement to NQF. This measure was conditionally supported by the MAP in 2013 for use in the PCHQR program, pending NQF endorsement.
      • Impact on quality of care for patients:According to research by the measure developer, nearly 20% of chemotherapy patients are affected by potentially preventable adverse events that are so severe they require a hospital admission of ED visit. Incentivizing HODs to better manage chemotherapy complications should reduce burden on patients and lower cost for payers.
    • Preliminary analysis result: Conditional support, pending NQF endorsement


  2. American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (MUC ID: MUC15-534)
    • Description: Organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients at least 18 years of age undergoing inpatient colon procedures and/or abdominal hysterectomies as reported through the ACS-NSQIP or CDC NHSN. The measure yields separate SIRs for each procedure. (The endorsed specifications of the measure are: Prototype measure for the facility adjusted Standardized Infection Ratio (SIR) of deep incisional and organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients aged >= 18 years as reported through the ACS National Surgical Quality Improvement Program (ACS-NSQIP) or CDC National Health and Safety Network (NHSN). Prototype also includes a systematic, retrospective sampling of operative procedures in healthcare facilities. This prototype measure is intended for time-limited use and is proposed as a first step toward a more comprehensive SSI measure or set of SSI measures that include additional surgical procedure categories and expanded SSI risk-adjustment by procedure type. This single prototype measure is applied to two operative procedures, colon surgeries and abdominal hysterectomies, and the measure yields separate SIRs for each procedure.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is an update to the name of the measure from “reliability adjusted SIR” to “Adjusted Ranking Metric (ARM).”
      • Impact on quality of care for patients:The continued use of this measure will promote SSI prevention activities, which will lead to an improvement in patient outcomes, reducing avoidable medical costs, patient morbidity and mortality. Guidelines to prevent SSIs are available here (http://www.cdc.gov/hicpac/SSI/001_SSI.html).
    • Preliminary analysis result: Conditional support, pending NQF annual update


  3. National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (MUC ID: MUC15-533)
    • Description: Standardized infection ratio (SIR) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs). Additional metric added- Adjusted Ranking Metric also known as the “reliability-adjusted SIR.” (The endorsed specifications of the measure are: Standardized infection ratio (SIR) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs)) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would promote alignment between programs assessing general acute care and cancer hospitals (IQR and PCHQR). This measure is included in the MAP Safety Family of Measures. This measure addresses a condition that is a significant cause of morbidity and mortality among hospital patients and is associated with increased healthcare costs. The measure addresses a common condition in the Medicare FFS population that is associated with significant variation in costs and an opportunity for improvement. This measure is fully-specified and tested, but the update has not been reviewed by NQF.
      • Impact on quality of care for patients:The measure is already in the program and will continue to promote multi-drug resistant organism prevention activities, such as CDI. CDC estimated that 107,700 infections occurred in United States acute care hospitals in 2011 (http://www.cdc.gov/hicpac/pubs.html). Adherence to clinical guidelines has resulted in decreased rates of infection.
    • Preliminary analysis result: Conditional support, pending NQF annual update


  4. National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (MUC ID: MUC15-532)
    • Description: Standardized infection ratio (SIR) of hospital-onset unique blood source MRSA Laboratory identified events (LabID events) among all inpatients in the facility (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure promotes alignment between programs, since it is currently in use in the PPS-Exempt Cancer Hospital Quality Reporting Program, Hospital Inpatient Quality Reporting, Hospital Value-Based Purchasing, Inpatient Rehabilitation Facility Quality Reporting, and Long-Term Care Hospital Quality Reporting. This measure is fully-specified and tested, but the update has not been reviewed by NQF.
      • Impact on quality of care for patients:The measure is already in the program and will continue to promote multi-drug resistant organism prevention activities, (http://www.cdc.gov/hicpac/pubs.html) including MRSA, which will help improve patient outcomes including reduction of avoidable costs, morbidity, and mortality.
    • Preliminary analysis result: Conditional support, pending NQF review and endorsement of revised specifications


  5. Oncology: Radiation Dose Limits to Normal Tissues (MUC ID: MUC15-946)
    • Description: Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is currently in the program and is undergoing a substantial change. The update is to expand the denominator to include breast and rectal cancers.
      • Impact on quality of care for patients:The continued use of this measure will promote effective coordination of care for oncology patients by identifying normal tissue dose constraints for those who receive radiation therapy treatments. Even though there is no specific data available, the American College of Radiation Oncology has found that normal dose constraints are not frequently included in the patient chart.
    • Preliminary analysis result: Conditional support, pending NQF endorsement


4:40 pm   Opportunity for Public Comment
4:55 pm   Summary of Day
Erin O'Rourke, Senior Project Manager

5:00 pm   Adjourn


Day 2  
8:30 am   Breakfast
9:00 am   Welcome and Review of Day 1
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair; Ronald Walters, MAP Hospital Workgroup Co-Chair; Melissa Mariñelarena, Senior Director, NQF

9:15 am   Overview of the End-Stage Renal Disease Quality Improvement Program (ESRD-QIP)
9:20 am   Opportunity for Public Comment on Measures Under Consideration for ESRD-QIP
9:30 am   Pre-Rulemaking Input on End-Stage Renal Disease Quality Improvement Program Measure Set
Programs under consideration: End-Stage Renal Disease Quality Incentive Program
  1. Avoidance of Utilization of High Ultrafiltration Rate (= 13 ml/kg/hour) (MUC ID: MUC15-758)
    • Description: Percentage of adult in-center hemodialysis patients in the facility whose average ultrafiltration rate (UFR) is = 13 ml/kg/hour. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This NQF-endorsed measure fills a priority gap in the ESRD-QI program, measuring an intermediate outcome closely associated in the literature with severe adverse events, including elevated mortality. The measure has been tested at the appropriate level, and found to be valid and reliable. The measure is not expected to be burdensome to implement, as the necessary data elements exist already as part of the CROWNWeb repository.
      • Impact on quality of care for patients:Implementation of this measure could encourage providers to slow down and extend dialysis sessions, reducing mortality and other adverse events for patients. A wide variation in facility-level performance suggests potential for improved outcomes for many patients.
    • Preliminary analysis result: Support


  2. ESRD Vaccination: Full-Season Influenza Vaccination (MUC ID: MUC15-761)
    • Description: Percentage of ESRD patients = 6 months of age on October 1 and on chronic dialysis = 30 days in a facility at any point between October 1 and March 31 who either received an influenza vaccination, were offered and declined the vaccination, or were determined to have a medical contraindication. (Measure Specifications)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:MUC-761 is a process measure consistent with CDC clinical guidelines and a necessary precursor to mitigate severe negative outcomes, including hospitalization and death. Influenza is particularly deadly and debilitating in the often immune-compromised ESRD population. While the measure has not been submitted for NQF endorsement, it has been fully tested at the appropriate level and setting, and is closely aligned with similar measures used in other CMS hospital quality programs.
      • Impact on quality of care for patients:CDC estimates indicate influenza is associated with approximately 36,000 deaths and 226,000 every year, and particularly affects immune-compromised individuals, including many ESRD patients. The literature suggests 20% or more of ESRD patients are unvaccinated, and the vaccination is associated with improved mortality.This measure is particularly sensitive to the dual-eligible population, who has higher than average rates of ESRD. This measure addresses a gap in care coordination and preventative services.
    • Preliminary analysis result: Conditional Support, pending NQF endorsement


  3. Measurement of Phosphorus Concentration (MUC ID: MUC15-1136)
    • Description: Percentage of all peritoneal dialysis and hemodialysis patient months with serum or plasma phosphorus measured at least once within the month. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure, NQF#0255, tracks performance of a precursor process that is consistent with clinical guidelines to mitigate patient morbidity and mortality. The measure has been found to be reliable, valid, and not burdensome to calculate. This updated measure has been broadened to include pediatric patients and permit an alternative measurement mechanism, plasma phosphorous.
      • Impact on quality of care for patients:While the performance gap is small (mean performance is at 87%), the minimum performance is 0%, suggesting some facilities are not following this process at all. Moreover, over 500,000 patients were included in the developer’s analysis – even a difference of just a few percent means higher quality of care for tens of thousands of patients.
    • Preliminary analysis result: Support


  4. Proportion of Patients with Hypercalcemia (NQF #1454) (MUC ID: MUC15-1165)
    • Description: Percentage of adult dialysis patients with a 3-month rolling average of total uncorrected calcium (serum or plasma) greater than 10.2 mg/dL (hypercalcemia) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:MUC 1165 is an update to a measure previously in the ESRD QIP, is NQF-endorsed, and measures an outcome that is established in the literature as a correlate of cardiovascular disease and death. The measure has been appropriately tested. The update to the measure removed an incentive to non-measurement, and expanded the possible measurement to either serum or plasma, consistent with scientific consensus.
      • Impact on quality of care for patients:Validity testing showed a correlation between outcomes on this measure and worse mortality outcomes; an analysis of testing data estimated 15% of facilities are performing worse than expected, suggesting a performance gap. Implementing this updated measure is likely to encourage facilities performing below expectations to improve their standard of care, potentially improving patient safety for hundreds of thousands of dialysis patients nationwide.
    • Preliminary analysis result: Support


  5. Standardized Hospitalization Ratio - Modified (MUC ID: MUC15-693)
    • Description: Standardized hospitalization ratio for admissions among ESRD dialysis patients. (Measure Specifications)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:MUC-693 measures a critical outcome in a high-priority domain for the ESRD QIP program. ESRD patients average nearly two hospitalizations per year that burden patients and health systems alike. Hospitalizations are measured in other federal programs under consideration by the MAP Hospital Workgroup, including the OQR and ASCQR programs. MUC-693 is aligned with MUC-1167, a measure of readmissions.
      • Impact on quality of care for patients:There are over 600,000 ESRD cases in the U.S. currently, most of whom are receiving treatment at a dialysis facility. These patients average nearly two hospitalizations per year that burden patients and health systems alike. Reducing those hospitalizations would doubtless improve the general health and well-being of the ESRD population, as well as reduce costs for Medicare, which spends roughly 37% of its total outlay for ESRD patients on hospitalizations.
    • Preliminary analysis result: Conditional Support, pending NQF endorsement


  6. Standardized Mortality Ratio - Modified (MUC ID: MUC15-575)
    • Description: Standardized ratio for death among ESRD dialysis patients. (The endorsed specifications of the measure are: Risk-adjusted standardized hospitalization ratio for admissions for dialysis facility patients.) (Measure Specifications)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:MUC 575 would bolster the ESRD QIP measure set by addressing the high-priority need of Patient Safety with a high-value outcome measure of patient mortality. The measure is an updated version of a previously endorsed measure (NQF #0369), and has been submitted for endorsement maintenance with a decision pending in 2016. Adding a mortality measure would align the ESRD QIP program with IQR without adding a measurement burden, as the measure is calculated using CROWNWeb data and claims data, and has been reported on Dialysis Facility Compare since 2001.
      • Impact on quality of care for patients:MUC 575 measures patient mortality, ultimately the highest-value quality measure. A performance gap is clearly established through testing, where 15% of facilities were shown to perform 30% worse than the national average. As the ESRD QIP program measures performance across nearly 6,000 facilities treating nearly a half-million patients, this measure would drive better care for a large group of particularly vulnerable patients.
    • Preliminary analysis result: Conditional Support, pending NQF endorsement


  7. Standardized Readmission Ratio (SRR) for dialysis facilities (MUC ID: MUC15-1167)
    • Description: The Standardized Readmission Ratio is the ratio of a dialysis facility’s (DF) total Medicare-paid index discharges for its dialysis patients from acute care hospitals (ACHs) that result in an unplanned Medicare-paid ACH readmission within 30 days to the total readmissions expected for the DF, given the discharging ACH, the DF, patient/index hospitalization characteristics, and the US median for DFs. (The endorsed specifications of the measure are: The Standardized Readmission Ratio (SRR) is defined to be the ratio of the number of index discharges from acute care hospitals that resulted in an unplanned readmission to an acute care hospital within 30 days of discharge for Medicare-covered dialysis patients treated at a particular dialysis facility to the number of readmissions that would be expected given the discharging hospitals and the characteristics of the patients as well as the national norm for dialysis facilities. Note that in this document, “hospital” always refers to acute care hospital.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:MUC 1167 is a measure that was previously in the ESRD QIP program, and has been re-submitted to reflect changes to the measure calculation. The updated measure is tested at the ESRD facility level, and testing shows the measure is both valid and reliable. A significant performance gap was established in both measure testing and in national statistics of ESRD patient outcomes.
      • Impact on quality of care for patients:Readmission is a costly adverse event that negatively affects patient quality of life. Over a third of discharges for ESRD patients lead to a readmission, presenting a significant opportunity for improvement. Performance scores are normally distributed with a standard deviation approximately one-third the mean, suggesting many facilities could improve their performance significantly to attain the high standard set by top performing facilities.
    • Preliminary analysis result: Support


10:45 am   Break
11:00 am    Overview of the Hospital Outpatient Quality Reporting Program (HOQR)
11:05 am   Opportunity for Public Comment on Measures Under Consideration for HOQR
11:15 am   Pre-Rulemaking Input on Hospital Outpatient Quality Reporting Program Measure Set
Programs under consideration: Hospital Outpatient Quality Reporting Program
  1. Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (MUC ID: MUC15-951)
    • Description: Measure estimates risk-adjusted rates of inpatient admissions or emergency department (ED) visits for cancer patients >18 years of age with at least one of the following diagnoses—anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis—within 30 days of hospital outpatient chemotherapy treatment. Two rates are reported. (Measure Specifications)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure fits in a high-priority domain and would be the first hospital admissions measure in the OQR set, which would align OQR with other measure sets that include admissions and readmissions measures, including ASCQR and HRRP. This measure would also help expand cancer quality measurement to the Hospital Outpatient setting. The measure has not been submitted for endorsement to NQF. This measure was conditionally supported by the MAP in 2014 for use in the PCHQR program, pending NQF endorsement.
      • Impact on quality of care for patients:According to research by the measure developer, nearly 20% of chemotherapy patients are affected by potentially preventable adverse events that are so severe they require a hospital admission of ED visit. Incentivizing HODs to better manage chemotherapy complications should reduce burden on patients and lower cost for payers.
    • Preliminary analysis result: Conditional Support, pending NQF endorsement.


  2. Risk-standardized hospital visits within 7 days after hospital outpatient surgery (MUC ID: MUC15-982)
    • Description: The measure score is a hospital-level, post-surgical risk-standardized hospital visit (RSHV) ratio, which is a ratio of the predicted to expected number of all-cause, unplanned hospital visits within 7 days of a same-day surgery at a hospital outpatient department (HOPD) among Medicare fee-for-service (FFS) patients aged 65 years and older. (The endorsed specifications of the measure are: Facility-level, post-surgical risk-standardized hospital visit ratio (RSHVR) of the predicted to expected number of all-cause, unplanned hospital visits within 7 days of a same-day surgery at a hospital outpatient department (HOPD) among Medicare fee-for-service (FFS) patients aged 65 years and older.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 6
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses a OQR priority domain by adding the first measure of hospital admissions to the OQR measure set. Adding this measure would align OQR with other CMS programs addressing similar settings including ASCQR. This measure has been fully specified and tested, and is endorsed by the National Quality Forum.
      • Impact on quality of care for patients:This measure directly assesses variations in patient outcomes following surgery at a HOPD. Hospital admissions are costly for payers and burdensome to patients, and there is a broad effort across federal programs to reduce excess admissions. The literature finds significant room for improvement in HOPDs: up to 40% of direct admissions after outpatient surgery are preventable.
    • Preliminary analysis result: Support


12:00 pm   Lunch
1:00 pm   Overview of the Ambulatory Surgical Center Quality Reporting (ASCQR) Program
1:05 pm   Opportunity for Public Comment on Measures Under Consideration for ASCQR
1:15 pm   Pre-Rulemaking Input on Ambulatory Surgical Center Quality Reporting Program Measure Set
Programs under consideration: Ambulatory Surgical Center Quality Reporting Program
  1. Toxic Anterior Segment Syndrome (TASS) Outcome (MUC ID: MUC15-1047)
    • Description: This measure is used to assess the number of ophthalmic anterior segment surgery patients diagnosed with TASS within 2 days of surgery. (Measure Specifications)
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure does not necessarily fill a gap in the program measure set. Moreover, performance on the measure cannot be definitively attributed to the ambulatory surgical center; FDA investigations suggest device manufacturers are responsible for endotoxin contamination that leads to TASS.
      • Impact on quality of care for patients:The measure would add the first outcome measure to Effective Prevention and Treatment, and could improve on the existing cataract surgery measure by basing the results on medical records and physician diagnoses rather than patient self-report.
    • Preliminary analysis result: Do not support


1:50 pm   Overview of the Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program
1:55 pm   Opportunity for Public Comment on Measures Under Consideration for IPFQR
2:05 pm   Pre-Rulemaking Input on Inpatient Psychiatric Facilities Quality Reporting Program Measure Set
Programs under consideration: Inpatient Psychiatric Facility Quality Reporting Program
  1. Substance Use Core Measure Set (SUB)-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (MUC ID: MUC15-1065)
    • Description: Overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. (The endorsed specifications of the measure are: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not included.These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge).) (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Adding this measure set would enhance the substance abuse measures currently in the set by helping to ensure patients are offered treatment. Studies have shown that less than one in 20 patients with a substance abuse disorder are offered treatment.
      • Impact on quality of care for patients:Individuals with serious mental illnesses have high rates of substance abuse disorders which frequently go untreated and can result in poorer outcomes. 40 to 60% of psychiatric inpatients have been found to have substance abuse disorders. Improving care of these disorders could lead to better outcomes and fewer co-morbidities. Additionally, alcohol, drug, and tobacco use are the cause of more than one out of every four deaths in the United States annually. Substance abuse also has severe economic impacts. Annual health care spending on alcohol and drug abuse is approximately $19 billion and $14 billion respectively.
    • Preliminary analysis result: Support


  2. Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an Inpatient Psychiatric Facility (IPF) (MUC ID: MUC15-1082)
    • Description: The measure estimates a facility-level risk-standardized readmission rate for unplanned, all-cause readmission within 30 days of discharge from an Inpatient Psychiatric Facility of adult Medicare fee-for-service (FFS) patients with a principal diagnosis of a psychiatric disorder. The performance period for the measure is 24 months. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Readmissions to IPFs are a common occurrence that negatively impacts patients and drives up the cost of care. An analysis of 2012-2013 claims data shows an opportunity for improvement. The mean observed readmission rate was 20.7% with a range of 16.6%-24.4%. The crude risk-adjusted mean rate was 22.6% with a range of 19.7%-25%. *The stage of development for this MUC was updated to "Fully Developed" on December 3, 2015, after the MUC was publicly released.
      • Impact on quality of care for patients:Implementing this measure could increase the urgency to implement strategies to reduce readmissions such as improved care transitions and ensuring the patient is stabilized before discharge.
    • Preliminary analysis result: Conditional support, pending NQF endorsement


2:40 pm   Opportunity for Public Comment
2:55 pm   Wrap Up
Zehra Shahab, Project Manager

3:00 pm   Adjourn

Appendix A: Measure Information

Measure Index

Ambulatory Surgical Center Quality Reporting Program

End-Stage Renal Disease Quality Incentive Program

Hospital Acquired Condition Reduction Program

Hospital Inpatient Quality Reporting and EHR Incentive Program

Hospital Outpatient Quality Reporting Program

Hospital Value-Based Purchasing Program

Inpatient Psychiatric Facility Quality Reporting Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program


Full Measure Information

Toxic Anterior Segment Syndrome (TASS) Outcome (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC15-1047)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Toxic anterior segment syndrome (TASS), an acute, noninfectious inflammation of the anterior segment of the eye, is a complication of anterior segment eye surgery that typically develops within 24 hours after surgery. Various contaminants, including those from surgical equipment or supplies, have been implicated as causes of TASS. Although most cases of TASS can be treated, the inflammatory response associated with TASS can cause serious damage to intraocular tissues, resulting in vision loss. Prevention requires careful attention to solutions, medications, and ophthalmic devices and to cleaning and sterilization of surgical equipment because of the numerous potential etiologies. Despite a recent focus on prevention, cases of TASS continue to occur, sometimes in clusters. The incidence of TASS is unknown, but frequencies of 1454 cases in approximately 69,000 surgeries (Bodnar et al, J Cataract Refract Surg. 2012 Nov;38(11):1902-10.) and 909 cases in 50,114 surgeries (Cutler et al, J Cataract Refract Surg. 2010 Jul;36(7):1073-80.) have been reported in cross-sectional studies in the literature. With millions of anterior segment surgeries being performed in the United States each year, measurement and public reporting have the potential to serve as an additional tool to drive further preventive efforts.


Avoidance of Utilization of High Ultrafiltration Rate (= 13 ml/kg/hour) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-758)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The measure focus is evidence-based, demonstrated as follows: • Health outcome: a rationale supports the relationship of the health outcome to processes or structures of care. Applies to patient-reported outcomes (PRO), including health-related quality of life/functional status, symptom/symptom burden, experience with care, health-related behavior. • Intermediate clinical outcome: a systematic assessment and grading of the quantity, quality, and consistency of the body of evidence that the measured intermediate clinical outcome leads to a desired health outcome. • Process: a systematic assessment and grading of the quantity, quality, and consistency of the body of evidence 4 that the measured process leads to a desired health outcome. • Structure: a systematic assessment and grading of the quantity, quality, and consistency of the body of evidence that the measured structure leads to a desired health outcome. • Efficiency: evidence not required for the resource use component.

Summary of NQF Endorsement Review




ESRD Vaccination: Full-Season Influenza Vaccination (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-761)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Influenza vaccination is universally recommended for all people aged 6 months and older. According to the CDC, seasonal influenza, which occurs between October and March/April of the following year, is associated with approximately 36,000 deaths and 226,000 hospitalizations annually. While overall rates of influenza infection are highest among children, rates of serious illness and mortality are highest among adults aged 65 years or older and children aged two years or younger as well as among immunocompromised patients, which include ESRD patients. The proposed influenza vaccination measure is a facility-level measure that applies to all dialysis patients. At the end of 2012 there were 413,725 patients being dialyzed, of whom 114,083 were new (incident) to dialysis.


Measurement of Phosphorus Concentration (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1136)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Consistent monitoring of phosphorus levels helps ensure regulation of patient morbidity and mortality, including stabilization of bone density, decreased bone pain, fracture prevention and decreased rates of arteriosclerosis and related conditions (e.g., stroke, heart attack). Routine blood tests will also aid in detection of and monitoring for abnormal states phosphorus balance in this especially vulnerable population. Among the 6,073 facilities that have at least one eligible patient, we generated the following statistics of their performance scores (based on the patient month) using the January – December 2013 CROWNWeb clinical data: mean (SD)=87% (18%); min=0%; max=100%; 25th percentile=86%; 50th percentile=92%; 75th percentile=96%. A description of the data is included in questions 1.1-1.7 under “Scientific Acceptability”. Disparity analyses were performed among the entire eligible adult population (n=518,127) to examine the difference in performance scores by sex, race, ethnicity, and age. In particular, for each facility, the percent of patient-months by demographic group (sex, race, ethnicity, age) was calculated. Then, the facilities were divided into quintiles (Q1-Q5) based on the percentage of patient-months in the particular demographic category (i.e., a facility with percentage of females similar to the national median will be included in quintile 3). The top 20% of facilities in terms of rank, based on the percentages of females, were classified as Q5, while the bottom 20% of facilities were classified as Q1. Average (mean) performance for the measure was calculated for each quintile, and the means were examined for trend across quintiles (Q1-Q5). The Cochran-Armitage test for trend was performed to assess disparities in performance scores. All the results for each group across quintiles were statistically significant (p<0.0001), which imply that there are statistically significant changes in performance scores depending on sex, race, ethnicity, and age. While these differences are statistically significant, we did not determine them to be clinically meaningful differences. The mean performance scores for percent of patient-months with a phosphorus measurement in each quintile, by demographic group, are presented below. Facility Level Quintiles by Population Group (Quintile 1-5): Female(Q1=85.6%; Q2=88.0%; Q3=87.6%; Q4=88.3%; Q5=84.5%; P<0.0001) White (Q1=86.4%; Q2=85.5%; Q3=87.2%; Q4=87.3%; Q5=87.6%; P<0.0001) Black (Q1=86.9%; Q2=87.4%; Q3=87.1%; Q4=86.0%; Q5=86.7%; P<0.0001) Hispanic (Q1=85.2%; Q2=89.1%; Q3=87.6%; Q4=86.1%; Q5=86.8%; P<0.0001) Age>=65 (Q1=83.2%; Q2=88.0%; Q3=87.6%; Q4=87.4%; Q5=87.9%; P<0.0001) (note: age <18 was too small to calculate quintiles). In healthy individuals, the kidney occupies an integral, multi-faceted role in the maintenance of calcium-phosphorus homeostasis. It follows that abnormalities of calcium-phosphorus regulation are exceedingly common in patients with advanced chronic kidney disease, which, indeed, most data indicate that only 25-35% of dialysis patients are able to maintain calcium in the suggested target range of 8.4-9.5 mg/dL (KDOQI 2003). Numerous studies have demonstrated the impact of prolonged calcium-phosphorus dysregulation on patient morbidity and mortality (KDOQI 2003), which can lead to progressive bone weakness, bone pain and increased susceptibility to fractures, and severe arteriosclerosis that can precipitate strokes, heart attacks, and other adverse cardiac events. Unfortunately, overt symptoms can often remain unmanifested in many but the most extreme disordered states of calcium-phosphorus dysregulation, which is why routine blood tests are necessary to detect and monitor abnormal states of calcium and phosphorus balance in this especially vulnerable population. National Kidney Foundation. 2003. "K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease," American Journal of Kidney Disease, 42 (Suppl 3): S17. Found at: http://www.kidney.org/professionals/kdoqi/guidelines_bone/index.htm

Summary of NQF Endorsement Review




Proportion of Patients with Hypercalcemia (NQF #1454) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1165)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
In 2011, total Medicare costs for the ESRD program were $34.3 billion, a 5.4% increase from 2010 [14]. Abnormalities in serum levels of calcium and phosphorus, which are markers of mineral and bone disorder, are common among ESRD patients. Numerous studies have demonstrated the association of prolonged calcium and phosphorus dysregulation on patient morbidity and mortality [2,1]. In March 2010, the C- TEP recommended that a quality measure (CPM) for the upper limit of total serum calcium be calculated as the proportion of patients (calculated as patient months) with 3-month rolling average of total serum calcium greater than 10.2 mg/dL. This recommendation is consistent with the value indicated by a TEP held in 2006 and with the 2003 KDOQI guidelines [1]. The TEP in 2013 also reviewed the measures and recommended no changes to the current threshold. Since 10.2 mg/dl is the considered the upper limit of the normal range in the majority of clinical laboratories, this measure is also consistent with the published KDIGO guidelines [2]. Review of the currently available literature and evidence indicates that observational cohort studies show a consistent adverse association of hypercalcemia with cardiovascular events and all-cause mortality [3-7]. Clinical data demonstrate the association of increased serum calcium with vascular [8,9] and valvular calcifications [10]. The basic science also supports a pathological role of high calcium in promoting soft tissue and vascular calcification [11-13]. Although there are no interventional studies demonstrating the benefit of correcting hypercalcemia, there was unanimous agreement among the 2010 C-TEP members that calcium concentrations >10.2 mg/dL place the patient at increased risk of poor outcomes. Current guidelines indicate that clinical decision should be based on trends rather than single laboratory values [2]. Therefore, it was unanimously agreed to use a three-month rolling average for the reporting period. 1c.4. Citations for data demonstrating high priority provided in 1a.3 1) National Kidney Foundation: K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. American Journal of Kidney Disease 2003 42:S1-S202 (suppl 3). 2) Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group: KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney International 2009 76 (Suppl 113): S1-S130. 3) Block GA, Klassen PS, Lazarus JM, et al. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. Journal of the American Society of Nephrology : JASN 2004 15:2208-18. 4) Young EW, Albert JM, Satayathum S, et al. Predictors and consequences of altered mineral metabolism: the Dialysis Outcomes and Practice Patterns Study. Kidney international 2005 67:1179-87. 5) Kalantar-Zadeh K, Kuwae N, Regidor DL, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney international 2006 70:771-80. 6) Kimata N, Albert JM, Akiba T, et al. Association of mineral metabolism factors with all-cause and cardiovascular mortality in hemodialysis patients: the Japan dialysis outcomes and practice patterns study. Hemodialysis international. International Symposium on Home Hemodialysis 2007 11:340-8. 7) Tentori F, Blayney MJ, Albert JM, et al. Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). American journal of kidney diseases : the official journal of the National Kidney Foundation 2008 52:519-30. 8) Chertow G.M., Raggi P., Chasan-Taber S., Bommer J., Holzer H., Burke S.K. Determinants of progressive vascular calcification in haemodialysis patients. Nephrology Dialysis Transplantation 2004 19 (6), pp. 1489-1496. 9) Dhingra R, Sullivan LM, Fox CS, Wang TJ, D´Agostino RB Sr, Gaziano JM, Vasan RS: Relations of serum phosphorus and calcium levels to the incidence of cardiovascular disease in the community. Arch Intern Med 2007 167: 879–885. 10) Wang AY, Lam CW, Wang M, Chan IH, Lui SF, Sanderson JE. Is valvular calcification a part of the missing link between residual kidney function and cardiac hypertrophy in peritoneal dialysis patients? Clinical journal of the American Society of Nephrology 2009 4:1629-36. 11) Ketteler M, Schlieper G, Floege J. Calcification and cardiovascular health: new insights into an old phenomenon. Hypertension 2006 47:1027–1034. 12) Giachelli CM. Vascular calcification mechanisms. Journal of the American Society of Nephrology : JASN 2004 15:2959–2964. 13) Yang H, Curinga G, Giachelli CM. Elevated extracellular calcium levels induce smooth muscle cell matrix mineralization in vitro. Kidney Int. 2004;66(6):2293–2299. 14) U S Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2013.

Summary of NQF Endorsement Review




Standardized Hospitalization Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-693)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
1b.1. Rationale Hospitalization rates are an important indicator of patient morbidity and quality of life. On average, dialysis patients are admitted to the hospital twice a year and spend an average of 11 days in the hospital per year (USRDS, 2014). Hospitalizations account for approximately 37 percent of total Medicare expenditures for ESRD patients. Measures of the frequency of hospitalization have the potential to help efforts to control escalating medical costs, and to play an important role in identifying potential problems and helping facilities provide cost-effective health care. 1c.4. Citations 1) U S Renal Data System, USRDS 2014 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014. 2) Wheeler J, Hirth R, Meyer K, Messana JM. Exploring preventable hospitalizations of dialysis patients. J Am Soc Nephrol 22, 2011. [3] Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Physician visits and 30-day hospital readmissions in patients receiving hemodialysis. J Am Soc Nephrol 25, 2014 (published online before print). [4] Arora P, Kausz AT, Obrador GT, Ruthazer R, Khan S, Jenuleson CS, Meyer KB, Pereira BJ. Hospital utilization among chronic dialysis patients. J Am Soc Nephrol 11: 740 –746, 2000. [5] Piraino B. Staphylococcus aureus infections in dialysis patients: focus on prevention. ASAIO J 46(6): S13-S17, 2000. [6] Dalrymple LS, Johansen KL, Romano PS, Chertow GM, Mu Y, Ishida JH, Grimes B, Kaysen GA, Nguyen DV. Comparison of hospitalization rates among for-profit and nonprofit dialysis facilities. Clin J Am Soc Nephrol 9, 2014 (published online before print).


Standardized Mortality Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-575)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
There is evidence indicating that mortality among black ESRD patients is lower than mortality for white ESRD patients, mortality for Hispanic ESRD patients is lower than mortality for non-Hispanic ESRD patients, and mortality for female ESRD patients is lower than mortality for male ESRD patients (see references below). Without a race adjustment, identical SMRs for one facility with predominantly white patients and one facility with predominantly black patients, for example, would give the false impression that quality of care at the two facilities was equivalent, when in fact adjusted mortality at the facility with more black patients would be lower if performance was identical. The SMR is adjusted for all three of these patient characteristics to avoid masking disparities in care across groups. To examine sociodemographic disparities we included quintiles of socioeconomic status (defined for each patient as the median zipcode code household income). This had little effect on the resulting expected deaths counts from the model. See the section on risk adjustment for further details. References: J Kalbfleisch, R Wolfe, S Bell, R Sun, J Messana, T Shearon, V Ashby, R Padilla, M Zhang, M Turenne, J Pearson, C Dahlerus, Y Li, 2015, “Risk Adjustment and the Assessment of Disparities in Dialysis Mortality Outcomes” accepted for publication by JASN; Powe, NR. Reverse race and ethnic disparities in survival increase with severity of chronic kidney disease: What does this mean? Clin J Am Soc Nephrol 1: 905–906, 2006; Cowie CC, Port FK, Rust KF, Harris MI: Differences in survival between black and white patients with diabetic end-stage renal disease. Diabetes Care 17: 681–687, 1994).


Standardized Readmission Ratio (SRR) for dialysis facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1167)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Unplanned readmission rates are an important indicator of patient morbidity and quality of life. On average, dialysis patients are admitted to the hospital nearly twice a year and hospitalizations account for approximately 38 percent of total Medicare expenditures for dialysis patients (U.S. Renal Data System, 2012). In 2010, more than 30% of dialysis patient discharges from an all-cause hospitalization were followed by an unplanned readmission within 30 days (U.S. Renal Data System, 2012). Measures of the frequency of unplanned readmissions, such as SRR, help efforts to control escalating medical costs, play an important role in providing cost-effective health care, and support coordination of care across inpatient and outpatient settings: discharge planning, transition, and follow-up care. Studies have shown that pre- and post-discharge interventions may reduce admission and unplanned readmission rates. A variety of studies on non-ESRD populations that evaluated post-discharge interventions (Dunn 1994; Bostrom 1996; Dudas 2001; Azevedo 2002; Coleman 2004; Coleman 2006; Balaban 2008; Braun 2009) or a combination of pre- and post-discharge interventions (Naylor 1994; McDonald 2001; Creason 2001; Ahmed 2004; Anderson 2005; Jack 2009; Koehler 2009; Parry 2009) have indicated a reduction in the risk of unplanned readmissions to various degrees. In addition, a recent study in the ESRD population found that certain postdischarge assessments and changes in treatment at the dialysis facility may be associated with a reduced risk of readmission (Chan 2009). Altogether, these studies support the potential for modifying unplanned readmission rates with interventions performed prior to and immediately following patient discharge. Ahmed A, Thornton P, Perry GJ, Allman RM, DeLong JF. Impact of atrial fibrillation on mortality and readmission in older adults hospitalized with heart failure. Eur J Heart Fail. 2004;6(4):421–426. Anderson MA, Clarke MM, Helms LB, Foreman MD. Hospital readmission from home health care before and after prospective payment. J Nurs Scholarsh. 2005;37(1):73–79. Azevedo A, Pimenta J, Dias P, Bettencourt P, Ferreira A, Cerqueira-Gomes M. Effect of a heart failure clinic on survival and hospital readmission in patients discharged from acute hospital care. Eur J Heart Fail. 2002 Jun;4(3):353–359. Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23(8):1228–1233. Bostrom J, Caldwell J, McGuire K, Everson D. Telephone follow-up after discharge from the hospital: Does it make a difference? Appl Nurs Res. 1996;9:47–52. Braun E, Baidusi A, Alroy G, Azzam ZS. Telephone follow-up improves patients satisfaction following hospital discharge. Eur J Internal Med. 2009;20:221–225. Chan K, Lazarus M, Wingard R, et al. “Association between repeat hospitalization and early intervention in dialysis patients following hospital discharge.” Kidney International (2009) 76:331-41. Coleman E, Parry C, Chalmers S, et al. The care transitions intervention. Arch Internal Med. 2006;166:1822–1828. Creason H. Congestive heart failure telemanagement clinic. Lippencotts Case Management: Managing the Process of Patient Care. 2001 Jul-Aug;6(4):146-56. Dudas V, Bookwalter T, Kerr KM et al. The impact of follow-up telephone calls to patients after hospitalization. American Journal of Medicine. 2001; 111(9B):26S-30S Dunn JM, Elliot TB, Lavy JA et al. Outpatient clinic review after arterial reconstruction: is it necessary? Annals of the Royal College of Surgeons of England. 1994 Sep;76(5):304-6. Jack B, Chetty V, Anthony D, et al. “A reengineered hospital discharge program to decrease rehospitalizaton.” Annals of Internal Medicine (2009) 150:178-88. Koehler BE, Richter KM, Youngblood L et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine. 2009 Apr;4(4):211-8. McDonald, MD. The hospitalist movement: wise or wishful thinking? Nurse management. 2001 Mar;32(3):30-1. Naylor M, Brooten D, Jones R et al. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine. 1994 Jun 15;120(12):999-1006. Parry C, Min SH, Chugh A et al. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Services Quarterly. 2009;28(2-3):84-99.

Summary of NQF Endorsement Review




American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-534)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

Summary of NQF Endorsement Review




Patient Safety and Adverse Events Composite (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-604)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Each measure used within the PSI 90 composite is an outcome measure that has been shown to be largely preventable through improved structures and processes of care. Each measure has an evidence review form as part of the NQF endorsement process. The literature to support each measure is updated on a schedule basis.

Summary of NQF Endorsement Review




Adult Local Current Smoking Prevalence (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1013)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Tobacco use and exposure to secondhand smoke caused more than 400,000 in the U.S. in each year between 2000 and 2004, according to the CDC. These deaths represent more than 5 million years of potential life lost (YPLL).1 At the state level, the median annual number of lives lost per state was 5,534, though there was a great deal of variation by state.2 National Cost of Tobacco Use The Centers for Disease Control and Prevention (CDC) estimates that, in the U.S. in each year from 2001 through 2004, an average of $96 billion was spent on health care due to smoking.1 A 2007 study calculates the cost of smoking to the U.S. Medicaid system, concluding that the projected lifetime costs of smoking to Medicaid, for a single cohort—current 24-year-old smokers—is nearly $1 billion. 1. Centers for Disease Control and Prevention (CDC). Smoking attributable mortality, years of potential life lost, and productivity losses--United States, 2000-2004. MMWR Morb Mortal Wkly Rep. 2008 Nov 14;57(45):1226-8. 2. Centers for Disease Control and Prevention (CDC). State-specific smoking-attributable mortality and years of potential life lost--United States, 2000-2004. MMWR Morb Mortal Wkly Rep. 2009 Jan 23;58(2):29-33. Erratum in: MMWR Morb Mortal Wkly Rep. 2009 Feb 6;58(4):91. 3. Trogdon J, Pais J. Saving Lives, Saving Money II: Tobacco-Free States Spend Less on Medicaid. A Policy Report of the American Legacy Foundation. 2007. 4. Centers for Disease Control and

Summary of NQF Endorsement Review




American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-534)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

Summary of NQF Endorsement Review




Aortic Aneurysm Procedure Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-835)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf


Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-836)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf


Excess Days in Acute Care after Hospitalization for Pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-391)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Pneumonia results in approximately 1.2 million hospital admissions each year and accounts for more than $10 billion annually in hospital expenditures. Approximately 20% of pneumonia patients were rehospitalized within thirty days, representing the second-highest proportion of all rehospitalizations at 6.3% (Jencks et al., 2009). Acute care utilization after discharge (return to the emergency department, observation stay and readmission), for any reason, is disruptive to patients and caregivers, costly to the healthcare system, and puts patients at additional risk of hospital-acquired infections and complications. Although some readmissions are unavoidable, they may also result from poor quality of care or inadequate transitional care. Numerous studies have found an association between quality of inpatient or transitional care and early (typically 30-day) readmission rates for a wide range of conditions including pneumonia (Frankl et al., 1991; Corrigan et al., 1992; Oddone et al., 1996; Ashton et al., 1997; Benbassat et al., 2000; Courtney et al., 2003; Halfon et al., 2006; Dean et al., 2006). Several studies also have reported on the relationship between inpatient admissions and other types of hospital care including ED visits and observation stays. Two recent studies conducted in patients of all ages have shown that 9.5% of patients return to the ED within 30 days of hospital discharge and that about 12% of these patients are discharged from the ED and are not captured by current CMS readmissions measures (Rising et al., 2013; Vashi et al., 2013). Rising rates of observation stays among Medicare beneficiaries have gained the attention of patients, providers, and policymakers (Feng et al., 2012; Rising et al., 2013; Vashi et al., 2013). A report from the Office of the Inspector General (OIG) notes the potential relationship between hospital use of observation stays as an alternative to short-stay inpatient hospitalizations as a response to changing hospital payment incentives (Wright, 2013). Thus, in the context of the publicly reported CMS 30-day readmission measures, the increasing use of ED visits and observation stays has raised concerns that current readmission measures do not capture the full range of unplanned acute care in the post-discharge period. References: Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence. Med Care. Oct 1997;35(10):1044-1059. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Archives of Internal Medicine. Apr 24 2000;160(8):1074-1081. Corrigan JM, Martin JB. Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res. Apr 1992;27(1):81-101. Courtney EDJ, Ankrett S, McCollum PT. 28-Day emergency surgical re-admission rates as a clinical indicator of performance. Ann R Coll Surg Engl. Mar 2003;85(2):75-78. Dean NC, Bateman KA, Donnelly SM, Silver MP, Snow GL, Hale D. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 2006;130(3):794-799 Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health affairs (Project Hope). Jun 2012;31(6):1251-1259. Frankl SE, Breeling JL, Goldman L. Preventability of emergent hospital readmission. Am J Med. Jun 1991;90(6):667-674. Halfon P, Eggli Y, Pr, et al. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Medical Care. Nov 2006;44(11):972-981. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28. Oddone EZ, Weinberger M, Horner M, et al. Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions. Journal of General Internal Medicine. 1996;11(10):597-607. Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Annals of Emergency Medicine. Vashi AA, Fox JP, Carr BG, et al. Use of hospital-based acute care among patients recently discharged from the hospital. JAMA : the journal of the American Medical Association. Jan 23 2013;309(4):364-371. Wright S. Hospitals’ Use of Observation Stays and Short Inpatient Stays for Medicare Beneficiaries. Washington, DC: OIG;2013


Hospital 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-294)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Post-stroke mortality rates have been shown to be influenced by critical aspects of care at the hospital such as response to complications, speediness of delivery of care, organization of care, and appropriate imaging [Smith et al., 2006; Reeves et al., 2009; Lingsma et al., 2008; Hong et al., 2008; Fonarow et al., 2014]. This research demonstrates the relationship between hospital organizational factors and performance on the stroke mortality measure, and supports the ability of hospitals to impact these rates.


Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-378)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Medicare spending is estimated to have been $525.0 billion in 2010 with annual growth rates projected to be 6.3% for 2013 through 2020 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary[1]. Further projections anticipate an exhaustion of Medicare‘s Hospital Insurance Trust Fund (Part A) by 2024 [2]. The growth in spending is unsustainable and highlights the need to understand the value of care Medicare buys with every dollar spent. Given the urgency of the state of the Medicare Hospital Insurance Trust Fund and the fact that Medicare pays for 40-50% of hospitalizations nationally [3], hospital costs are a natural venue in which to deconstruct payments for Medicare patients. Yet payments to hospitals are difficult to interpret in isolation. Some high payment hospitals may have better clinical outcomes when compared with low payment hospitals; other high payment hospitals may not. For this reason, the value of hospital care is more clearly assessed when pairing hospital payments with hospital quality. A measure of payments for Medicare patients to hospitals that is aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure will reflect differences in the management of care for patients with pneumonia both during hospitalization and immediately post-discharge. Pneumonia is a condition with substantial range in costs of care and for which there are well-established publicly reported quality measures and is therefore an ideal condition for assessing relative value for an episode-of-care that begins with an acute hospitalization. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care. 1. Ash AS, Byrne-Logan S. How Well Do Models Work? Predicting Health Care Costs. Proceedings of the Section on Statistics in Epidemiology. American Statistical Association. 1998. 2. Medpac. Report to the Congress: Medicare Payment Policy 9/17/12 2012. 3. National Hospital Discharge Survey. http://www.cdc.gov/nchs/nhds.htm. Accessed 08/07/2012.

Summary of NQF Endorsement Review




Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Claims and Clinical Electronic Health Record (EHR) Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1135)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Post-stroke mortality rates have been shown to be influenced by critical aspects of care at the hospital such as response to complications, speediness of delivery of care, organization of care, and appropriate imaging [Smith et al., 2006; Reeves et al., 2009; Lingsma et al., 2008; Hong et al., 2008; Fonarow et al., 2014]. This research demonstrates the relationship between hospital organizational factors and performance on the stroke mortality measure, and supports the ability of hospitals to impact these rates. The hybrid measure addresses a limitation of the claims-only measure by incorporating clinical data collected at the time of admission to assess the condition of the patient before care has been administered.


Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Electronic Health Record (EHR)-Extracted Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1033)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Post-stroke mortality rates have been shown to be influenced by critical aspects of care at the hospital such as response to complications, speediness of delivery of care, organization of care, and appropriate imaging [Smith et al., 2006; Reeves et al., 2009; Lingsma et al., 2008; Hong et al., 2008; Fonarow et al., 2014]. This research demonstrates the relationship between hospital organizational factors and performance on the stroke mortality measure, and supports the ability of hospitals to impact these rates. The hybrid measure addresses a limitation of the claims-only measure by incorporating clinical data collected at the time of admission to assess the condition of the patient before care has been administered.


INR Monitoring for Individuals on Warfarin after Hospital Discharge (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1015)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
An analysis of the Food and Drug Administration’s (FDA) Adverse Drug Event Reporting System found that warfarin ranked seventh overall in drugs identified to cause death, disability, or other serious adverse outcomes (Moore, Cohen, & Furberg, 2007). Evidence suggests that low INR (INR < 2) is associated with an increased risk of stroke and high INR (INR > 3) is associated with increased risk of bleeding (Reynolds, 2004). A study by White et al. (2007) found that patients with poor INR control suffered higher rates of mortality and major bleeding when compared to those with good or moderate INR control. Patients in the transition period from hospital to home are at particular risk for adverse events from medication errors in general, and for warfarin in particular, as they move from a tightly controlled environment to one with limited supervision and support (Forster et al., 2005). A timely INR test shortly after hospital discharge is expected to lead to the stabilization of the patient’s warfarin regimen and avoidance of non-therapeutic INR levels and, therefore, result in fewer warfarin-related bleeding, thromboembolic events, and lower mortality. The 2012 American College of Chest Physicians guidelines for antithrombotic therapy and prevention of thrombosis recommend INR monitoring within 1-2 weeks for patients with a sub-therapeutic or supra-therapeutic INR (Holbrook et al., 2012). Three recent studies have been published on INR monitoring after hospital discharge and/or INR monitoring after an out-of-range value. In a population-based sample of Canadian patients on warfarin (Van Walraven et al., 2007), hospitalization was associated with less time in the therapeutic range, more time with INR <1.5, and more time with INR >=5.0. Qualls et al. (2013) compared patients with heart failure with and without at least one INR test within 45 days of discharge and found that those who had been tested had lower risks of mortality and myocardial infarction one year after discharge. Finally, in a study of patients in VA anticoagulation clinics (Rose et al., 2011), longer follow-up intervals for repeat tests after both INR values above and below the therapeutic range were found to be associated with worse control of anticoagulation among ambulatory patients at the clinic level. Food and Drug Administration. (2011). Warfarin (Coumadin) product labeling. Reference ID 3022954. Retrieved Oct. 16, 2013, from http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/009218s107lbl.pdf Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2005). Adverse drug events occurring following hospital discharge. Journal of General Internal Medicine, 20(4), 317–323. Holbrook, A., Schulman, S., Witt, D. M., Vandvik, P. O., Fish, J., Kovacs, M. J., ... & Guyatt, G. H. (2012). Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. CHEST Journal, 141(2_suppl), e152S-e184S. Moore, T. J., Cohen, M. R., & Furberg, C. D. (2007). Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Archives of Internal Medicine, 167(16), 1752-1759. Qualls, L. G., Greiner, M. A., Eapen, Z. J., Fonarow, G. C., Mills, R. M., Klaskala, W., . . . Curtis, L. H. (2013). Postdischarge international normalized ratio testing and long-term clinical outcomes of patients with heart failure receiving warfarin: Findings from the ADHERE registry linked to Medicare claims. Clinical Cardiology, 36(12), 757-765. Reynolds, M. W., Fahrbach, K., Hauch, O., Wygant, G., Estok, R., Cella, C., & Nalysnyk, L. (2004). Warfarin anticoagulation and outcomes in patients with atrial fibrillation: a systematic review and metaanalysis. CHEST Journal, 126(6), 1938-1945. Rose, A. J., Ozonoff, A., Henault, L. E., & Hylek, E. M. (2008). Warfarin for atrial fibrillation in community-based practise. Journal of Thrombosis and Haemostasis, 6(10), 1647-1654. Van Walraven, C., Austin, P. C., Oake, N., Wells, P., Mamdani, M., Forster, A. J. (2007). The effect of hospitalization on oral anticoagulation control: A population-based study. Thrombosis Research 119(6), 705–714. White, H. D., M. Gruber, Feyzi, J., Kaatz, S., Tse, H. F., Husted, S., et al. (2007). Comparison of outcomes among patients randomized to warfarin therapy according to anticoagulant control: results from SPORTIF III and V. Archives of Internal Medicine, 167(3), 239-245.

Summary of NQF Endorsement Review




IQI-22: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1083)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The evidence supporting VBAC is robust and well-summarized in the ACOG and AAFP guidelines.


National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-531)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Numerous individual studies and systematic reviews provide strong evidence that measurement of antimicrobial use and data-driven interventions by antimicrobial stewardship programs (ASPs) lead to more judicious use of antibiotics, reduced antimicrobial resistance, and other favorable healthcare outcomes (Feazel 2014; Davey 2006; Davey 2013; Kaki 2011). Antimicrobial use measurement enables ASPs to understand prescribing practices, focus efforts on improvement, and determine the impact of their activities (Pollack, 2014). Although standardized metrics have been developed to measure antibiotic use, differences in measurement, limited uptake, and variation among facilities has impeded the ability to compare antibiotic use among hospitals. The measure will serve as a quantitative guide for hospital and health system ASPs, enabling them to benchmark antibiotic use in their facilities and patient care locations against nationally aggregated data. The measure focuses on antibiotic agents that have been shown to be high value targets for antimicrobial stewardship programs activities such as protocols for use or post-prescription reviews to determine need for de-escalation, dose-optimization or oral conversion. Knowledge about antibiotic use patterns of these agents is a primary means to prioritize and evaluate antimicrobial stewardship efforts.


Patient Safety and Adverse Events Composite (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-604)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Each measure used within the PSI 90 composite is an outcome measure that has been shown to be largely preventable through improved structures and processes of care. Each measure has an evidence review form as part of the NQF endorsement process. The literature to support each measure is updated on a schedule basis.

Summary of NQF Endorsement Review




Spinal Fusion Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-837)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf


Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-838)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., .Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf


Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-951)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Cancer patients receiving chemotherapy have much higher rates of admissions and ED use than other patients. A study of 2007 commercial claims data for more than 14 million patients found that cancer patients average one admission per year; 40 percent of those admissions were chemotherapy related (Kolodziej et al. 2011). The authors also found that cancer patients average approximately two ED visits per year, about half of which were chemotherapy related. Common complications of chemotherapy treatment include nausea, emesis, anemia, neutropenic fever, diarrhea, dehydration, and pain (Burton et al. 2007; Crawford et al. 2004; Groopman and Itri 2000; Osoba et al. 1997; Richardson and Dobish 2007; Stein et al. 2010). Chemotherapy-related admissions and ED visits may be due to outpatient chemotherapy patients having unmet needs and gaps in care, which, if addressed, could reduce admissions and ED visits and increase patients’ quality of life (Hassett et al. 2006; Mayer et al. 2011; McKenzie et al. 2011). Although it is extremely unlikely that all admissions and ED visits related to chemotherapy can be avoided by prevention and treatment of side effects and complications, there is evidence and consensus among providers on ways to prevent and treat each of the symptoms included in the numerator of this measure. Measurement of admissions and ED visits for patients receiving outpatient chemotherapy should encourage reporting facilities to take steps to prevent and improve management of side effects and complications from treatment. Poor performance on the measure would reflect high resource use and significant consequences for patient/society due to poor quality; admissions and ED visits are costly to payers and reduce quality of life for patients. Burton, A.W., G.J. Fanciullo, R.D. Beasley, and M.J. Fisch. “Chronic Pain in the Cancer Survivor: A New Frontier”. Pain Medicine, vol. 8, 2007, pp. 189–198. Crawford, J.C., D.C. Dale, and G.H. Lyman. “Chemotherapy-Induced Neutropenia.” Cancer, vol. 15, 2004, pp. 228–237. Groopman, J.E., and L.M. Itri. “Chemotherapy-Induced Anemia in Adults: Incidence and Treatment.” Journal of the National Cancer Institute, vol. 91, 2000, pp. 1616–1634. Hassett, M.J., J. O’Malley, J.R. Pakes, J.P. Newhouse, and C.C. Earle. “Frequency and Cost of Chemotherapy-Related Serious Adverse Effects in a Population Sample of Women with Breast Cancer.” Journal of the National Cancer Institute, vol. 98, no. 16, 2006, pp. 1108–1117. Kolodziej, M., J.R. Hoverman, J.S. Garey, J. Espirito, S. Sheth, A. Ginsburg, M.A. Neubauer, D. Patt, B. Brooks, C. White, M. Sitarik, R. Anderson, and R. Beveridge. “Benchmarks for Value in Cancer Care: An Analysis of a Large Commercial Population.” Journal of Oncology Practice, vol. 7, 2011, pp. 301–306. Mayer, D.K., D. Travers, A. Wyss, A. Leak, A. Waller. “Why Do Patients with Cancer Visit Emergency Departments? Results of a 2008 Population Study in North Carolina.” Journal of Clinical Oncology, vol. 26, no. 19, 2011, pp. 2683–2688. McKenzie, H., L. Hayes, K. White, K. Cox, J. Fethney, M. Boughton, and J. Dunn. “Chemotherapy Outpatients’ Unplanned Presentations to Hospital: A Retrospective Study.” Support Care Cancer, vol. 19, 2011, pp. 963–969. Osoba, D., B. Zee, D. Warr, J. Latreilee, L. Kaizer, and J. Pater. “Effect of Postchemotherapy Nausea and Vomiting on Health-Related Quality of Life.” Support Care Cancer, vol. 5, 1997, pp. 307–313. Richardson, G., and R. Dobish. “Chemotherapy Induced Diarrhea.” Journal of Oncology Pharmacy Practice, vol. 13, no.4, 2007, pp. 181–98. Stein, A., W. Voigt, and K. Jordan. “Chemotherapy-Induced Diarrhea: Pathophysiology, Frequency, and Guideline-Based Management.” Therapeutic Advances Medical Oncology, vol. 2, 2010, pp. 51–63.


Risk-standardized hospital visits within 7 days after hospital outpatient surgery (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-982)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Nearly 70% of all surgeries in the US are now performed in the outpatient setting with most performed as same-day surgeries at HOPDs.[1] While most outpatient surgery is safe, there are well-described and potentially preventable adverse events that occur after outpatient surgery, such as uncontrolled pain, urinary retention, infection, bleeding, and venous thromboembolism, which can result in unanticipated hospital visits. Similarly, direct admissions after surgery that are primarily caused by non-clinical patient considerations, such as lack of transport home upon discharge, or hospital logical issues, such as delayed start of surgery, are common causes of unanticipated yet preventable hospital admissions following same-day surgery. Hospital utilization following same-day surgery is an important and accepted patient-centered outcome reported in the literature. National estimates of hospital visit rates following surgery vary from 0.5-9.0% based on the type of surgery, outcome measured (admissions alone or admissions and emergency department [ED] visits), and timeframe for measurement after surgery.[2-9] Furthermore, hospital visit rates vary among HOPDs,[7] suggesting variation in surgical and discharge care quality. However, providers (HOPDs and surgeons) are often unaware of their patients’ hospital visits after surgery since patients often present to the ED or to different hospitals.[10] Therefore, a quality measure of hospital visits following outpatient same-day surgery can improve transparency, inform patients and providers, and foster quality improvement. The literature suggests 1.3-13.6% of outpatient surgeries at HOPDs result in an inpatient admission with the admission rate varying by type of surgery and HOPD case mix.[3,7-9,11-21] Of these admissions, 40-60% are reported to be due to adverse effects of the surgery, anesthesia, or due to other suspected medical problems such as chest pain.[3,7-9,11-21] A smaller proportion of admissions are due to non-clinical reasons such as lack of transport home or logistical issues such as delayed start of surgery.[3,7-9,11-19] When specifically assessed, up to 40% of direct admissions after outpatient surgery have been found to be preventable.[19] Major and minor adverse events, such as uncontrolled pain, urinary retention, infection, bleeding, and venous thromboembolism, are well documented to occur post-discharge and result in unanticipated hospital visits.[12,13,22] Some hospital visits post-discharge are for scheduled follow-up care provided after surgery (e.g., visits for rehabilitation). We remove these ‘planned’ hospital visits from the outcome. We limit the outcome of hospital visits to 7 days since existing literature suggests the vast majority of adverse events after surgery occur within the first 7 days following the surgery.[4,12] We observed in our own data the highest rates of hospital visits occurring within 7 days of surgery. References: 1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. National health statistics reports. Jan 28 2009(11):1-25. 2. Majholm B, Engbaek J, Bartholdy J, et al. Is day surgery safe? A Danish multicentre study of morbidity after 57,709 day surgery procedures. Acta anaesthesiologica Scandinavica. Mar 2012;56(3):323-331. 3. Linares-Gil MJ, Pelegri-Isanta MD, Pi-Siqués F, Amat-Rafols S, Esteva-Ollé MT, Gomar C. Unanticipated admissions following ambulatory surgery. Ambulatory Surgery. 12// 1997;5(4):183-188. 4. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Archives of surgery (Chicago, Ill. : 1960). Jan 2004;139(1):67-72. 5. Coley KC, Williams BA, DaPos SV, Chen C, Smith RB. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. Journal of clinical anesthesia. Aug 2002;14(5):349-353. 6. Hollingsworth JM, Saigal CS, Lai JC, Dunn RL, Strope SA, Hollenbeck BK. Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery. The Journal of urology. Oct 2012;188(4):1274-1278. 7. Bain J, Kelly H, Snadden D, Staines H. Day surgery in Scotland: patient satisfaction and outcomes. Quality in health care : QHC. Jun 1999;8(2):86-91. 8. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery--a prospective study. Canadian journal of anaesthesia = Journal canadien d'anesthesie. Jul 1998;45(7):612-619. 9. Aldwinckle RJ, Montgomery JE. Unplanned admission rates and postdischarge complications in patients over the age of 70 following day case surgery. Anaesthesia. Jan 2004;59(1):57-59. 10. Mezei G, Chung F. Return hospital visits and hospital readmissions after ambulatory surgery. Annals of surgery. Nov 1999;230(5):721-727. 11. Margovsky A. Unplanned admissions in day-case surgery as a clinical indicator for quality assurance. The Australian and New Zealand journal of surgery. Mar 2000;70(3):216-220. 12. Mattila K, Toivonen J, Janhunen L, Rosenberg PH, Hynynen M. Postdischarge symptoms after ambulatory surgery: first-week incidence, intensity, and risk factors. Anesthesia and analgesia. Dec 2005;101(6):1643-1650. 13. Minatti WR, Flavio B, Pablo C, Raúl R, Guillermo P, Miguel S. Postdischarge unplanned admission in ambulatory surgery—a prospective study. Ambulatory Surgery. 1// 2006;12(3):107-112. 14. Morales R, Esteve N, Casas I, Blanco C. Why are ambulatory surgical patients admitted to hospital?: Prospective study. Ambulatory Surgery. 3/15/ 2002;9(4):197-205. 15. Ogg T, Hitchock M, Penn S. Day surgery admissions and complications. Ambulatory Surgery. 1998;6:101-106. 16. Mingus ML, Bodian CA, Bradford CN, Eisenkraft JB. Prolonged surgery increases the likelihood of admission of scheduled ambulatory surgery patients. Journal of clinical anesthesia. Sep 1997;9(6):446-450. 17. Laeeque R, Samad A, Raja AJ. Day care surgery at a university hospital--who is responsible after discharge. JPMA. The Journal of the Pakistan Medical Association. Dec 2001;51(12):422-427. 18. Crew JP, Turner KJ, Millar J, Cranston DW. Is day case surgery in urology associated with high admission rates? Annals of the Royal College of Surgeons of England. Nov 1997;79(6):416-419. 19. Awan FN, Zulkifli MS, McCormack O, et al. Factors involved in unplanned admissions from general surgical day-care in a modern protected facility. Irish medical journal. May 2013;106(5):153-154. 20. Rudkin GE, Bacon AK, Burrow B, et al. Review of efficiencies and patient satisfaction in Australian and New Zealand day surgery units: a pilot study. Anaesthesia and intensive care. Feb 1996;24(1):74-78. 21. Paez A, Redondo E, Linares A, Rios E, Vallejo J, Sanchez-Castilla M. Adverse events and readmissions after day-case urological surgery. International braz j urol : official journal of the Brazilian Society of Urology. May-Jun 2007;33(3):330-338. 22. Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesthesia and analgesia. Feb 1997;84(2):319-324.

Summary of NQF Endorsement Review

Developer response:

Committee Response:



  • Endorsement Committee Recommendation: Standing Committee Recommendation for Endorsement: Y-18; N-1




  • American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-534)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

    Summary of NQF Endorsement Review




    Cellulitis Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1143)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf


    Gastrointestinal Intestinal (GI) Hemorrhage Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1144)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf


    Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-395)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    It is envisioned that this measure will provide hospitals with procedure-specific information to help improve patient safety and quality of care, thus reducing mortality rates. CABG is a priority area for outcomes measure development because it is a common procedure associated with considerable morbidity, mortality, and health care spending. In 2007, there were 114,028 hospitalizations for CABG surgery and 137,721 hospitalizations for combined surgeries for CABG and valve procedures (“CABG plus valve” surgeries) among Medicare FFS patients in the U.S. [1] CABG surgeries are costly procedures that account for the majority of major cardiac surgeries performed nationally. In fiscal year 2009, isolated CABG surgeries accounted for almost half (47.6%) of all cardiac surgery hospital admissions in Massachusetts. [2] In 2008, the average Medicare payment was $30,546 for CABG without valve and $47,669 for CABG plus valve surgeries. [3] Mortality rates following CABG surgery vary widely across hospitals. Our mean RSMR is 3.2% with a range from 1.5%-7.9%. The median risk-standardized rate is 3.0% (25th and 75th percentiles are 2.6% and 3.6%, respectively). Similarly, published data also demonstrate variation in mortality rates. 1. Drye E, Krumholz H, Vellanky S, Wang Y. Probing New Conditions and Procedures for New Measure Development: Yale New Haven Health Systems Corporation; Center for Outcomes Research and Evaluation.; 2009:1-7. 2. Massachusetts Data Analysis Center. Adult Coronary Artery Bypass Graft Surgery in the Commonwealth of Massachusetts: Hospital and Surgeons Risk-Standardized 30-Day Mortality Rates. In: Health MDoP, ed. Boston2009:77. 3. Pennsylvania Health Care Cost Containment Council. Cardiac Surgery in Pennsylvania 2008-2009. Harrisburg2011:60. 4. American New York State Department of Health. Adult Cardiac Surgery in New York State 2006-20082010:54.

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-378)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Medicare spending is estimated to have been $525.0 billion in 2010 with annual growth rates projected to be 6.3% for 2013 through 2020 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary[1]. Further projections anticipate an exhaustion of Medicare‘s Hospital Insurance Trust Fund (Part A) by 2024 [2]. The growth in spending is unsustainable and highlights the need to understand the value of care Medicare buys with every dollar spent. Given the urgency of the state of the Medicare Hospital Insurance Trust Fund and the fact that Medicare pays for 40-50% of hospitalizations nationally [3], hospital costs are a natural venue in which to deconstruct payments for Medicare patients. Yet payments to hospitals are difficult to interpret in isolation. Some high payment hospitals may have better clinical outcomes when compared with low payment hospitals; other high payment hospitals may not. For this reason, the value of hospital care is more clearly assessed when pairing hospital payments with hospital quality. A measure of payments for Medicare patients to hospitals that is aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure will reflect differences in the management of care for patients with pneumonia both during hospitalization and immediately post-discharge. Pneumonia is a condition with substantial range in costs of care and for which there are well-established publicly reported quality measures and is therefore an ideal condition for assessing relative value for an episode-of-care that begins with an acute hospitalization. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care. 1. Ash AS, Byrne-Logan S. How Well Do Models Work? Predicting Health Care Costs. Proceedings of the Section on Statistics in Epidemiology. American Statistical Association. 1998. 2. Medpac. Report to the Congress: Medicare Payment Policy 9/17/12 2012. 3. National Hospital Discharge Survey. http://www.cdc.gov/nchs/nhds.htm. Accessed 08/07/2012.

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for Acute Myocardial Infarction (AMI) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-369)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    In 2012 total Medicare expenditures were $574.2 billion, representing 3.6% of gross domestic product (GDP). Current estimates suggest that Medicare spending will increase to 5.6% of GDP by 2035 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary [1]. The growth in Medicare spending is unsustainable and highlights the need to create incentives for high value care. A critical first step in moving toward high value care is to define an approach to calculate costs that is transparent to consumers and fair to providers. AMI is a condition with a substantial range in costs of care and for which there are well-established publicly reported quality measures; therefore, it is an ideal condition for assessing relative value for an episode of care that begins with an acute hospitalization. A measure of payments for Medicare patients during an episode of care for AMI aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure, which uses standardized payments, reflects differences in the management of care for patients with AMI both during hospitalization and immediately post-discharge. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care. References: 1. Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2013 Annual Report, May 31, 2013. 2. Andrews RM, Elixhauser, A. The National Hospital Bill: Growth Trends and 2005 Update on the Most Expensive Conditions by Payer. Agency for Healthcare Research and Quality. 2007.

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for heart failure (HF) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-322)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Medicare spending is estimated to have been $525.0 billion in 2010 with annual growth rates projected to be 6.3% for 2013 through 2020 due to both an increase in the Medicare population as well as Medicare spending on each beneficiary [1]. Further projections anticipate an exhaustion of Medicare‘s Hospital Insurance Trust Fund (Part A) by 2024 [2]. The growth in spending is unsustainable and highlights the need to understand the value of care Medicare buys with every dollar spent. Given the urgency of the state of the Medicare Hospital Insurance Trust Fund and the fact that Medicare pays for 40-50% of hospitalizations nationally [3], hospital costs are a natural venue in which to deconstruct payments for Medicare patients. Yet payments to hospitals are difficult to interpret in isolation. Some high payment hospitals may have better clinical outcomes when compared with low payment hospitals; other high payment hospitals may not. For this reason, the value of hospital care is more clearly assessed when pairing hospital payments with hospital quality. A measure of payments for Medicare patients to hospitals that is aligned with current quality of care measures will facilitate profiling hospital value (payments and quality). This measure will reflect differences in the management of care for patients with heart failure both during hospitalization and immediately post-discharge. Heart failure is a condition with substantial range in costs of care and for which there are well-established publicly reported quality measures and is therefore an ideal condition for assessing relative value for an episode-of-care that begins with an acute hospitalization. By focusing on one specific condition, value assessments may provide actionable feedback to hospitals and incentivize targeted improvements in care. 1. Ash AS, Byrne-Logan S. How Well Do Models Work? Predicting Health Care Costs. Proceedings of the Section on Statistics in Epidemiology. American Statistical Association. 1998. 2. Medpac. Report to the Congress: Medicare Payment Policy 9/17/12 2012. 3. National Hospital Discharge Survey. http://www.cdc.gov/nchs/nhds.htm. Accessed 08/07/2012.

    Summary of NQF Endorsement Review




    Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-295)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Due to their frequency and cost, THA and TKA are priority areas for outcome measure development. More than one third of the US population 65 years and older suffers from osteoarthritis [1]. Between 2009 and 2012, there were 337,419 THA procedures and 750,569 TKA procedures for Medicare fee-for-service patients 65 years and older [2]. Estimates place the annual insurer cost of osteoarthritis in the US at $149 billion, with Medicare direct payments to hospitals for THA/TKA exceeding $15 billion annually [3]. Further, there are conflicting data regarding costs after total joint arthroplasty, with evidence to support both increased [4] and decreased costs [5] following arthroplasty, suggesting there is great variation in the costs of a full episode of care for THA and TKA. The goal of hospital-level resource use measurement is to capture the full spectrum of care in order to incentivize collaboration and shared responsibility for improving patients’ health and reducing the burden of their disease. Variation in the cost of a THA or TKA episode of care is often related to the quality of care, where complications and readmissions increase the total payment for post-surgical care. Given the well-documented variation in readmission and complication rates following THA and TKA, there is expected variation in total episode of care costs for the procedures [6]. Birkmeyer et al. found that the average 30-day cost increased by $2,436 among hospitals with the highest quintile of complication rates, compared to the lowest quintile following THA [7]. The same study also found that rehabilitation costs accounted for 50% of “excess” payments among those undergoing THA. Miller et al. found that a major driver of differences in episode payments for THA was that hospitals within Accountable Care Organizations (ACO) had smaller payments for post-discharge care compared to non-ACO hospitals [8]. Taken together, these studies suggest that much of the variation in total episode costs arises in the post-acute setting. Health systems have taken notice of opportunities to improve value by encouraging collaboration of care between hospitals and post-acute providers. [10]. Transparency regarding the variation of episode of care payments triggered by THA and TKA helps to guide health systems and providers towards improvement in the value of care. 1. Centers for Disease Control and Prevention (CDC). Osteoarthritis. 2011; http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Accessed August 13, 2013. 2. Suter LG, Grady JN, Lin Z, et al. 2013 Measure Updates and Specifications: Elective Primary Total Hip Arthroplasty (THA) And/Or Total Knee Arthroplasty (TKA) All-Cause Unplanned 30-Day Risk-Standardized Readmission Measure (Version 2.0). March 2013. 3. Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health affairs (Project Hope). Nov 2011;30(11):2107-2115. 4. Bozic KJ, Stacey B, Berger A, Sadosky A, Oster G. Resource utilization and costs before and after total joint arthroplasty. BMC health services research. 2012;12:73. 5. Hawker GA, Badley EM, Croxford R, et al. A population-based nested case-control study of the costs of hip and knee replacement surgery. Med Care. 2009;47(7):732-741. 6. Suter LG, et al., Medicare Hospital Quality Chartbook 2013: Performance Report on Outcome Measures, 2013. 7. Birkmeyer JD, Gust C, Dimick JB, Birkmeyer NJ, Skinner JS. Hospital quality and the cost of inpatient surgery in the United States. Annals of surgery. 2012;255(1):1-5. 8. Miller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the effects of accountable care organizations for inpatient surgery. JAMA surgery. Jun 2013;148(6):549-554. 9. CMS. Bundled Payments for Care Improvement (BPCI) Initiative: General Information. http:/ / innovation.cms.gov/initiatives/bundled?payments/ [accessed Jan 7, 2014] 10. Miller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the effects of accountable care organizations for inpatient surgery. JAMA surgery. Jun 2013;148(6):549-554.


    Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1145)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Episode-based performance measurement allows meaningful comparisons between providers based on resource use for certain clinical conditions or procedures, as noted in the NQF report for the “Episode Grouper Evaluation Criteria” project (available at http://www.qualityforum.org/Publications/2014/09/Evaluating_Episode_Groupers__A_Report_from_the_National_Quality_Forum.aspx) and in various peer-reviewed articles (e.g., Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., & Damberg, S. L. (2009). Episode-Based Performance Measurement and Payment: Making It a Reality. Health Affairs, 28(5), 1406-1417. doi:10.1377/hlthaff.28.5.1406). While reliability analyses have been conducted on similar performance measures, we plan to conduct our own reliability analysis for this specific measure and propose a minimum number of cases for reporting. The analysis will likely mirror the 2012 MSPB reliability analysis: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/MSPBReliabilityAnalysis-Jul-18-12.pdf


    Patient Safety and Adverse Events Composite (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-604)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Each measure used within the PSI 90 composite is an outcome measure that has been shown to be largely preventable through improved structures and processes of care. Each measure has an evidence review form as part of the NQF endorsement process. The literature to support each measure is updated on a schedule basis.

    Summary of NQF Endorsement Review




    Substance Use Core Measure Set (SUB)-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1065)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    In a study on the provision of evidence-based care and preventive services provided in hospitals for 30 different medical conditions, quality varied substantially according to diagnosis. Adherence to recommended practices for treatment of substance use ranked last, with only 10% of patients receiving proper care (McGlynn 2003, Gentilello 2005). Currently, less than one in twenty patients with an addiction is referred for treatment (Gentilello 1999). Unfortunately, many physicians mistakenly believe that substance use problems are largely confined to the young. They are significantly less likely to recognize an alcohol problem in an older patient than in a younger one. (Curtis 1989) As a result, these problems usually go undetected, resulting in harmful, expensive, and sometimes even catastrophic consequences. This is demonstrated by the fact that few older adults who need substance use treatment actually receive it. In 2005, persons 65 years and older made up only 11,344 out of 1.8 million substance use treatment episodes recorded.(SAMHSA 2007) Citations: • Gentilello LM, Ebel BE, Wickizer TM, Salkever DS Rivera FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: A cost benefit analysis. Ann Surg. 2005 Apr;241(4):541-50. • Gentilello LM, Villaveces A, Ries RR, Nason KS, Daranciang E, Donovan DM Copass M, Jurkovich GJ Rivara FP. Detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff. J Trauma. 1999 Dec;47(6):1131-5; discussion 1135-9. • McGlynn, EA, Asch SM, Adams J, Keesey J, et al. The New England Journal of Medicine. Boston: Jun 26, 2003. Vol. 348, Iss.26; pg. 2635, 11pgs. • Curtis, J.R.; Geller, G.; Stokes, E.J. ; et al. Characteristics, diagnosis, and treatment of alcoholism in elderly patients. J Am Geriatr Soc 37:310-316, 1989. • SAMHSA. Office of Applied Studies. Older adults in substance abuse treatment: 2005. The DASIS Report. Rockville MD, November 8, 2007.

    Summary of NQF Endorsement Review




    Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an Inpatient Psychiatric Facility (IPF) (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1082)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Patient Volume Analysis of calendar year 2013 IPF claims data showed that 308,915 Medicare beneficiaries had 471,349 IPF stays. This group of patients is particularly vulnerable. Sixty-six percent of discharges are for patients under 65 indicating Medicare eligibility due to disability; 56% of discharges also have dual eligibility with Medicaid indicating they have limited financial resources. Twenty-nine percent of Medicare beneficiaries who used IPF services in 2013 had more than one stay. For CY 2012 and CY 2013, approximately one-third of all admissions for a principal psychiatric disorder (ICD-9 codes 290-319) were to short-stay acute care hospitals (including critical access hospitals). However, of the 1669 short-stay acute care hospitals with psychiatric admissions, only 39% had 25 or more psychiatric admissions. Forty percent of the psychiatric admissions to short-stay acute care hospitals were to hospitals that also had IPF units. The HWR measure for short-stay acute care hospitals includes some of these diagnoses (i.e., dementia, substance use, and screening/history of mental health and substance use). Consequences of Readmissions Readmission is considered an adverse event because it indicates deterioration in health status after discharge from the IPF that requires an acute level of care. In addition to patient burden, readmissions impacts cost. A MedPAC report indicated that Medicare payments to IPFs averaged nearly $10,000 per discharge (MedPAC, 2014) MedPAC analyses also showed that spending for Medicare beneficiaries who use IPF services is substantially higher than for all fee-for-service beneficiaries, due in part to the IPF stays (MedPAC, 2010). Performance Variation There is variation in 30-day all-cause readmission rates across IPFs, which is noted in Item 44: Evidence of performance gap. Evidence of Effective Interventions to Reduce Readmissions Some individual studies and systematic reviews have supported the positive effect of the following interventions in reducing psychiatric readmissions: • Follow-up within 7 days of discharge (Mark, 2013) • Stabilizing condition prior to discharge (Durbin, 2007) • Transition/discharge practices (Vigod, 2013; Steffen, 2009) • Intensive case management (Dieterich, 2010) Citations: *Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. The Cochrane database of systematic reviews. 2010(10):Cd007906. *Durbin J, Lin E, Layne C, Teed M. Is readmission a valid indicator of the quality of inpatient psychiatric care? J. Behav. Health Serv. Res. 2007;34(2):137-150. *Mark T, Tomic KS, Kowlessar N, Chu BC, Vandivort-Warren R, Smith S. Hospital readmission among medicaid patients with an index hospitalization for mental and/or substance use disorder. J. Behav. Health Serv. Res. 2013;40(2):207-221. *MedPAC. Chapter 6: Inpatient Psychiatric Care in Medicare: Trends and Issues. June 2010 Report to Congress: Aligning Incentives in Medicare. Washington, DC: MedPAC; 2010:161-187. * MedPAC. Inpatient Psychiatric Facility Services Payment System. Washington, DC: MedPAC; October 2014. *Steffen S, Kosters M, Becker T, Puschner B. Discharge planning in mental health care: a systematic review of the recent literature. Acta Psychiatr. Scand. 2009;120(1):1-9. *Vigod SN, Kurdyak PA, Dennis CL, et al. Transitional interventions to reduce early psychiatric readmissions in adults: systematic review. Br. J. Psychiatry. 2013;202(3):187-194.


    Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-951)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Cancer patients receiving chemotherapy have much higher rates of admissions and ED use than other patients. A study of 2007 commercial claims data for more than 14 million patients found that cancer patients average one admission per year; 40 percent of those admissions were chemotherapy related (Kolodziej et al. 2011). The authors also found that cancer patients average approximately two ED visits per year, about half of which were chemotherapy related. Common complications of chemotherapy treatment include nausea, emesis, anemia, neutropenic fever, diarrhea, dehydration, and pain (Burton et al. 2007; Crawford et al. 2004; Groopman and Itri 2000; Osoba et al. 1997; Richardson and Dobish 2007; Stein et al. 2010). Chemotherapy-related admissions and ED visits may be due to outpatient chemotherapy patients having unmet needs and gaps in care, which, if addressed, could reduce admissions and ED visits and increase patients’ quality of life (Hassett et al. 2006; Mayer et al. 2011; McKenzie et al. 2011). Although it is extremely unlikely that all admissions and ED visits related to chemotherapy can be avoided by prevention and treatment of side effects and complications, there is evidence and consensus among providers on ways to prevent and treat each of the symptoms included in the numerator of this measure. Measurement of admissions and ED visits for patients receiving outpatient chemotherapy should encourage reporting facilities to take steps to prevent and improve management of side effects and complications from treatment. Poor performance on the measure would reflect high resource use and significant consequences for patient/society due to poor quality; admissions and ED visits are costly to payers and reduce quality of life for patients. Burton, A.W., G.J. Fanciullo, R.D. Beasley, and M.J. Fisch. “Chronic Pain in the Cancer Survivor: A New Frontier”. Pain Medicine, vol. 8, 2007, pp. 189–198. Crawford, J.C., D.C. Dale, and G.H. Lyman. “Chemotherapy-Induced Neutropenia.” Cancer, vol. 15, 2004, pp. 228–237. Groopman, J.E., and L.M. Itri. “Chemotherapy-Induced Anemia in Adults: Incidence and Treatment.” Journal of the National Cancer Institute, vol. 91, 2000, pp. 1616–1634. Hassett, M.J., J. O’Malley, J.R. Pakes, J.P. Newhouse, and C.C. Earle. “Frequency and Cost of Chemotherapy-Related Serious Adverse Effects in a Population Sample of Women with Breast Cancer.” Journal of the National Cancer Institute, vol. 98, no. 16, 2006, pp. 1108–1117. Kolodziej, M., J.R. Hoverman, J.S. Garey, J. Espirito, S. Sheth, A. Ginsburg, M.A. Neubauer, D. Patt, B. Brooks, C. White, M. Sitarik, R. Anderson, and R. Beveridge. “Benchmarks for Value in Cancer Care: An Analysis of a Large Commercial Population.” Journal of Oncology Practice, vol. 7, 2011, pp. 301–306. Mayer, D.K., D. Travers, A. Wyss, A. Leak, A. Waller. “Why Do Patients with Cancer Visit Emergency Departments? Results of a 2008 Population Study in North Carolina.” Journal of Clinical Oncology, vol. 26, no. 19, 2011, pp. 2683–2688. McKenzie, H., L. Hayes, K. White, K. Cox, J. Fethney, M. Boughton, and J. Dunn. “Chemotherapy Outpatients’ Unplanned Presentations to Hospital: A Retrospective Study.” Support Care Cancer, vol. 19, 2011, pp. 963–969. Osoba, D., B. Zee, D. Warr, J. Latreilee, L. Kaizer, and J. Pater. “Effect of Postchemotherapy Nausea and Vomiting on Health-Related Quality of Life.” Support Care Cancer, vol. 5, 1997, pp. 307–313. Richardson, G., and R. Dobish. “Chemotherapy Induced Diarrhea.” Journal of Oncology Pharmacy Practice, vol. 13, no.4, 2007, pp. 181–98. Stein, A., W. Voigt, and K. Jordan. “Chemotherapy-Induced Diarrhea: Pathophysiology, Frequency, and Guideline-Based Management.” Therapeutic Advances Medical Oncology, vol. 2, 2010, pp. 51–63.


    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-534)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Affects large numbers, Frequently performed procedures, A leading cause of morbidity/mortality, High resource use, Severity of illness, Patient/societal consequences of poor quality. SSIs estimated to account for 20% of all HAIs[1] 290,485 estimated SSIs/yr[2] Estimated 8,205 deaths associated with SSIs each year[1] Estimated 11% of all deaths occurring in intensive care units are associated with SSIs[1] $34,670 medical cost/SSI[2] Total >$10 billion attributable to SSI in U.S. each year[2] Estimated additional 7-10 days of hospitalization for each SSI per patient[1] [1] Klevens RM, Edwards JR, et al. Estimating healthcare-associated infection and deaths in U.S. hospitals, 2002. Public Health Reports 2007; 122:160-166. [2] Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf accessed April 12, 2010.

    Summary of NQF Endorsement Review




    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-533)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Clostridium difficile is responsible for a spectrum of C. difficile infections (CDI), including uncomplicated diarrhea, pseudomembranous colitis, and toxic megacolon, which can, in some instances lead to sepsis and even death. In recent years, a previously unrecognized strain of C. difficile, with increased virulence and high levels of antimicrobial resistance, has resulted in outbreaks in healthcare facilities in the United States. Additionally, CDI has become more common in the community setting, with increased risk in those with history of recent inpatient stay in a healthcare facility. Significant increases in cost of inpatient care have been seen in cases of CDI.

    Summary of NQF Endorsement Review




    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-532)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    Clinical guidelines for the management of multidrug resistant organisms (MDROs), including MRSA, have been published. Adherence to the recommendations in the guidelines can result in decreased rates of MDRO transmission and infection. Decreasing rates of infection will result in a lower SIR, which indicates improving performance.

    Summary of NQF Endorsement Review




    Oncology: Radiation Dose Limits to Normal Tissues (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-946)

    Measure Specifications

    Preliminary Analysis of Measure

    Rationale for measure provided by HHS
    This measure is rated as moderate by the measure developer. The quality of the body of evidence supporting the guideline recommendation is summarized according to the National Comprehensive Cancer Network (NCCN) categories of evidence and consensus as being based on "lower-level evidence". Lower-level evidence is later described as evidence that may include non-randomized trials; case series; or when other data are lacking, the clinical experience of expert physicians. Although there is no explicit statement regarding the overall consistency of results across studies in the guidelines supporting the measure, the recommendation received uniform NCCN consensus that the intervention is appropriate. The description of the evidence review in the guideline did not address the overall quantity of studies in the body of evidence. However, 330 articles are cited in NCCN´s pancreatic adenocarcinoma guideline. 408 and 172 articles are cited in NCCN´S non small cell lung cancer and small cell lung cancer guidelines, respectively. A panel of experts with members from each of the NCCN Member Institutions develops the NCCN Guidelines. Specialties that must be included on a particular panel are identified before that panel is convened but also evolve as the standard of care changes over time. This multidisciplinary representation varies from panel to panel. The NCCN Guidelines Panel Chairs are charged with ensuring that representatives of all treatment strategies are included. Many of the panels also include a patient representative, especially when issues of long-term care and patient preference are paramount in the panel´s considerations.

    Summary of NQF Endorsement Review





    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

    Ambulatory Surgical Center Quality Reporting 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: The Ambulatory Surgical Center (ASC) Quality Reporting Program was established under the authority provided by Section 109(b) of the Medicare Improvements and Extension Act of 2006, Division B, Title I of the Tax Relief and Health Care Act (TRHCA) of 2006. The statute provides the authority for requiring ASCs paid under the ASC fee schedule (ASCFS) to report on process, structure, outcomes, patient experience of care, efficiency, and costs of care measures. ASCs receive a 2.0 percentage point payment penalty to their ASCFS annual payment update for not meeting program requirements. CMS implemented this program so that payment determinations were effective beginning with the Calendar Year (CY) 2014 payment update.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Making Care Safer
      1. Measures of infection rates
    2. Person and Family Engagement
      1. Measures that improve experience of care for patients, caregivers, and families.
      2. Measures to promote patient self-management.
    3. Best Practice of Healthy Living
      1. Measures to increase appropriate use of screening and prevention services.
      2. Measures which will improve the quality of care for patients with multiple chronic conditions.
      3. Measures to improve behavioral health access and quality of care.
    4. Effective Prevention and Treatment
      1. Surgical outcome measures
    5. Communication/Care Coordination
      1. Measures to embed best practice to manage transitions across practice settings.
      2. Measures to enable effective health care system navigation.
      3. To reduce unexpected hospital/emergency visits and admissions.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the ASCQR program.
    At a minimum, the following requirements will be considered in selecting measures for ASCQR Program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
    3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    4. Measure must be field tested for the ASC clinical setting.
    5. Measure that is clinically useful.
    6. Reporting of measure limits data collection and submission burden since many ASCs are small facilities with limited staffing.
    7. Measure must supply sufficient case numbers for differentiation of ASC performance.
    8. Measure must promote alignment across HHS and CMS programs.
    9. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    End-Stage Renal Disease Quality Incentive 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: For more than 30 years, monitoring the quality of care provided to end-stage renal disease (ESRD) patients by dialysis facilities has been an important component of the Medicare ESRD payment system. The ESRD quality incentive program (QIP) is the most recent step in fostering improved patient outcomes by establishing incentives for dialysis facilities to meet or exceed performance standards established by CMS. The ESRD QIP is authorized by section 1881(h) of the Social Security Act, which was added by section 153(c) of Medicare Improvements for Patients and Providers (MIPPA) Act (the Act). CMS established the ESRD QIP for Payment Year (PY) 2012, the initial year of the program in which payment reductions were applied, in two rules published in the Federal Register on August 12, 2010, and January 5, 2011 (75 FR 49030 and 76 FR 628, respectively). Subsequently, CMS published rules in the Federal Register detailing the QIP requirements for PY 2013 through FY 2016. Most recently, CMS published a rule on November 6, 2014 in the Federal Register (79 FR 66119), providing the QIP requirements for PY2017 and PY 2018, with the intention of providing an additional year between finalization of the rule and implementation in future rules.

    Section 1881(h) of the Act requires the Secretary to establish an ESRD QIP by (i) selecting measures; (ii) establishing the performance standards that apply to the individual measures; (iii) specifying a performance period with respect to a year; (iv) developing a methodology for assessing the total performance of each facility based on the performance standards with respect to the measures for a performance period; and (v) applying an appropriate payment reduction to facilities that do not meet or exceed the established Total Performance Score (TPS).

    High Priority Domains for Future Measure Consideration: CMS identified the following 3 domains as high-priority for future measure consideration:

    1. Care Coordination: ESRD patients constitute a vulnerable population that depends on a large quantity and variety medication and frequent utilization of multiple providers, suggesting medication reconciliation is a critical issue. Dialysis facilities also play a substantial role in preparing dialysis patients for kidney transplants, and coordination of dialysis-related services among transient patients has consequences for a non-trivial proportion of the ESRD dialysis population.
    2. Safety: ESRD patients are frequently immune-compromised, and experience high rates of blood stream infections, vascular access-related infections, and mortality. Additionally, some medications provided to treat ESRD patients may cause harmful side effects such as heart disease and a dynamic bone disease. Recently, oral-only medications were excluded from the bundle payment, increasing need for quality measures that protect against overutilization of oral-only medications.
    3. Patient- and Caregiver-Centered Experience of Care: Sustaining and recovering patient quality of life was among the original goals of the Medicare ESRD program. This includes such issues as physical function, independence, and cognition. Quality of Life measures should also consider the life goals of the particular patient where feasible, to the point of including Patient-Reported Outcomes.

    Measure Requirements:

    1. Measures for anemia management reflecting FDA labeling, as well as measures for dialysis adequacy.
    2. Measure(s) of patient satisfaction, to the extent feasible.
    3. Measures of iron management, bone mineral metabolism, and vascular access, to the extent feasible.
    4. Measures should be NQF endorsed, save where due consideration is given to endorsed measures of the same specified area or medical topic.
    5. Must include measures considering unique treatment needs of children and young adults.
    6. May incorporate Medicare claims and/or CROWNWeb data, alternative data sources will be considered dependent upon available infrastructure.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Acquired Condition Reduction 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 3008 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Hospital-Acquired Condition (HAC) Reduction Program (HAC Reduction Program). Created under Section 1886(p) of the Social Security Act (the Act), the HAC Reduction Program provides an incentive for hospitals to reduce the number of HACs. Effective Fiscal Year (FY) 2014 and beyond, the HAC Reduction Program requires the Secretary to make payment adjustments to applicable hospitals that rank in the top quartile of all subsection (d) hospitals relative to a national average of HACs acquired during an applicable hospital stay. HACs include a condition identified in subsection 1886(d)(4)(D)(iv) of the Act and any other condition determined appropriate by the Secretary. Section 1886(p)(6)(C) of the Act requires the HAC information be posted on the Hospital Compare website.

    CMS finalized in the FY 2014 IPPS/LTCH PPS final rule that hospitals will be scored using a Total HAC Score based on measures categorized into two (2) domains of care, each with a different set of measures. Domain 1 consists of Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), and Domain 2 consists of Hospital Associated Infections (HAI) as collected by the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Both domains of the HAC Reduction Program are categorized under the National Quality Strategy (NQS) priority of “Making Care Safer”. Measures in each domain are assigned points so that each domain has a score. In the FY 2016 IPPS/LTCH PPS proposed rule, we are proposing that the weighting of the domain scores be changed as follows for the FY 2017 program: (1) Domain 1 weight would be decreased from 25% to 15%; and (2) Domain 2 weight would be increased from 75% to 85%. The Total HAC Score is the sum of the two weighted domain scores.

    High Priority Domains for Future Measure Consideration: For FY 2017 federal rulemaking, CMS may propose the adoption, removal, and/or suspension of measures for fiscal years 2018 and beyond of the HAC Reduction Program. CMS identified the following topics as areas within the NQS priority of “Making Care Safer” for future measure consideration:

    1. Making Care Safer:
      1. Adverse Drug Events
      2. Ventilator Associated Events
      3. Additional Surgical Site Infection Locations
      4. Outcome Risk-Adjusted Measures

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HAC Reduction Program. At a minimum, the following requirements must be met for consideration in the HAC Reduction Program:

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Inpatient Quality Reporting and EHR Incentive 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: The Hospital Inpatient Quality Reporting (IQR) Program was established by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and later amended by the Deficit Reduction Act (DRA) of 2005. The program requires hospitals paid under the Inpatient Prospective Payment System (IPPS) to report on process, structure, outcomes, patient perspectives on care, efficiency, and costs of care measures. Hospitals receive a quarter of the applicable percentage point of the annual market basket (the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients) payment update. Hospitals who choose non-participation in the program receive a reduction by that same amount. Performance of quality measures are publicly reported on the CMS Hospital Compare website.

    The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5) amended Titles XVIII and XIX of the Social Security Act (the Act) to authorize incentive payments to eligible hospitals (EHs) and Critical Access Hospitals (CAHs) and other groups eligible to participate in the EHR Incentive Program, to promote the adoption and meaningful use of certified electronic health record (EHR) technology (CEHRT). EHs and CAHs are required to report on electronically specified clinical quality measures (eCQMs) using CEHRT in order to qualify for incentive payments under the Medicare and Medicaid EHR Incentive. All EHR Incentive Program requirements related to eCQM reporting will be addressed in IQR Program rulemaking including, but not limited to, new program requirements, reporting requirements, reporting and submission periods, reporting methods, and information regarding the eCQMs.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Patient and Family Engagement:
      1. Measures that foster the engagement of patients and families as partners in their care.
    2. Best Practices of Healthy Living:
      1. Measures that promote best practices to enable healthy living.
    3. Making Care Affordable:
      1. Measures that effectuate changes in efficiency and reward value over volume.

    CMS identified the following topics/areas as high-priority for future measure consideration:

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the IQR program. At a minimum, the following criteria will be considered in selecting measures for IQR program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act; currently the National Quality Forum (NQF)
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must be claims-based or an electronically specified clinical quality measure (eCQM).
      1. A Measure Authoring Tool (MAT) number must be provided for all eCQMs, created in the HQMF format
      2. eCQMs must undergo reliability and validity testing including review of the logic and value sets by the CMS partners, including, but not limited to, MITRE and the National Library of Medicine
      3. eCQMs must have successfully passed feasibility testing
    3. Measure may not require reporting to a proprietary registry.
    4. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    5. Measure must be fully developed, tested, and validated in the acute inpatient setting.
    6. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains and/or measurement gaps for future measure consideration.
    7. Measure must promote alignment across HHS and CMS programs.
    8. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Outpatient Quality Reporting 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: The Hospital Outpatient Quality Reporting (OQR) Program was established by Section 109 of the Tax Relief and Health Care Act (TRHCA) of 2006. The program requires subsection (d) hospitals providing outpatient services paid under the Outpatient Prospective Payment System (OPPS) to report on process, structure, outcomes, efficiency, costs of care, and patient experience of care. Hospitals receive a 2.0 percentage point reduction of their annual payment update (APU) under the Outpatient Prospective Payment System (OPPS) for non-participation in the program. Performance on quality measures is publicly reported on the CMS Hospital Compare website.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Making Care Safer:
      1. Measures that address processes and outcomes designed to reduce risk in the delivery of health care, e.g., emergency department overcrowding and wait times.
    2. Best Practices of Healthy Living:
      1. Measures that focus on primary prevention of disease or general screening for early detection of disease unrelated to a current or prior condition.
    3. Patient and Family Engagement:
      1. Measures that address engaging both the person and their family in their care.
      2. Measures that address cultural sensitivity, patient decision-making support or care that reflects patient preferences.
    4. Communication/Care Coordination:
      1. Measures to embed best practices to manage transitions across practice settings.
      2. Measures to enable effective health care system navigation.
      3. Measures to reduce unexpected hospital/emergency visits and admissions.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HOQR program. At a minimum, the following criteria will be considered in selecting measures for HOQR program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
    3. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    4. Measure must be fully developed, tested, and validated in the hospital outpatient setting.
    5. Measure must promote alignment across HHS and CMS programs.
    6. Feasibility of Implementation: An evaluation of feasibility is based on factors including, but not limited to
      1. The level of burden associated with validating measure data, both for CMS and for the end user.
      2. Whether the identified CMS system for data collection is prepared to accommodate the proposed measure(s) and timeline for collection.
      3. The availability and practicability of measure specifications, e.g., measure specifications in the public domain.
      4. The level of burden the data collection system or methodology poses for an end user.
    7. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Readmissions Reduction 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 3025 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Hospital Readmissions Reduction Program (HRRP). Codified under Section 1886(q) of the Social Security Act (the Act), the HRRP provides an incentive for hospitals to reduce the number of excess readmissions that occur in their settings. Effective Fiscal Year (FY) 2012 and beyond, the HRRP requires the Secretary to establish readmission measures for applicable conditions and to calculate an excess readmission ratio for each applicable condition, which will be used to determine a payment adjustment to those hospitals with excess readmissions. A readmission is defined as an admission to an acute care hospital within 30 days of a discharge from the same or another acute care hospital. A hospital’s excess readmission ratio measures a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition. Applicable conditions in the HRRP program currently include measures for acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, and elective total knee and total hip arthroplasty. Readmission following coronary artery bypass graft surgery has been finalized as an applicable condition beginning with the FY 2017 payment determination. Planned readmissions are excluded from the excess readmission calculation.

    High Priority Domains for Future Measure Consideration: For FY 2017 federal rulemaking, CMS may propose the adoption, removal, refinement, and or suspension of measures for fiscal year 2018 and subsequent years of the HRRP. CMS continues to emphasize the importance of the NQS priority of “Communication/Care Coordination” for this program.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the HRRP program. At a minimum, the following criteria and requirements must be met for consideration in the HRRP program:

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Hospital Value-Based Purchasing 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: The Hospital Value-Based Purchasing (VBP) Program was established by Section 3001(a) of the Affordable Care Act, under which value-based incentive payments are made in a fiscal year to hospitals meeting performance standards established for a performance period for such fiscal year. The Secretary shall select measures, other than measures of readmissions, for purposes of the Program. However, measures of five conditions (acute myocardial infarction, pneumonia, heart failure, surgeries, and healthcare-associated infections), the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and efficiency measures must be included. Measures are eligible for adoption in the Hospital VBP Program based on the statutory requirements, including specification under the Hospital IQR Program and posting dates on the Hospital Compare Web site.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Patient and Family Engagement:
      1. Measures that foster the engagement of patients and families as partners in their care.
    2. Best Practices of Healthy Living:
      1. Measures that promote best practices to enable healthy living.
    3. Making Care Affordable:
      1. Measures that effectuate changes in efficiency and reward value over volume.

    CMS identified the following topics/areas as high-priority for future measure consideration:

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Inpatient Psychiatric Facility Quality Reporting 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: The Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program was established by Section 1886(s)(4) of the Social Security Act, as added by sections 3401(f)(4) and 10322(a) of the Patient Protection and Affordable Care Act (the Affordable Care Act). Under current regulations, the program requires participating inpatient psychiatric facilities (IPFs) to report on 10 quality measures or face a 2.0 percentage point reduction to their annual update. Reporting on these measures apply to payment determinations for Fiscal Year (FY) 2016 and beyond. The reporting period for the FY 2016 payment determination was CY 2014, with the exception of the Follow-Up After Hospitalization for Mental Illness measure which was July 1, 2013 – June 30, 2014. Four measures were added for the FY 2017 payment determination, two with reporting periods of October 1, 2015 - March 31, 2016 and two with reporting periods of CY 2015.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Patient and Family Engagement
      1. Patient experience of care
    2. Effective Prevention and Treatment
      1. Inpatient psychiatric treatment and quality of care of geriatric patients and other adults, adolescents, and children
      2. Quality of prescribing for antipsychotics and antidepressants
    3. Communication/Care Coordination
      1. Readmissions and re-hospitalizations
    4. Best Practices of Healthy Living
      1. Screening and treatment for non-psychiatric comorbid conditions for which patients with mental or substance use disorders are at higher risk
      2. Access to care
    5. Making Care Affordable
      1. Measures which effectuate changes in efficiency and that reward value over volume.

    Measure Requirements: CMS applies criteria for measures that may be considered for potential adoption in the IPFQR program. At a minimum, the following criteria will be considered in selecting measures for IPFQR program implementation:

    1. Measure must adhere to CMS statutory requirements.
      1. Measures are required to reflect consensus among affected parties, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure must address an important condition/topic for which there is analytic evidence that a performance gap exists and that measure implementation can lead to improvement in desired outcomes, costs, or resource utilization.
    3. The measure assesses meaningful performance differences between facilities.
    4. The measure addresses an aspect of care affecting a significant proportion of IPF patients.
    5. Measure must be fully developed, tested, and validated in the acute inpatient setting.
    6. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration.
    7. Measure must promote alignment across HHS and CMS programs.
    8. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

    Prospective Payment System-Exempt Cancer Hospital Quality Reporting 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 3005 of the Affordable Care Act added new subsections (a)(1)(W) and (k) to section 1866 of the Social Security Act (the Act). Section 1866(k) of the Act establishes a quality reporting program for hospitals described in section 1886(d)(1)(B)(v) of the Act (referred to as a “PPS-Exempt Cancer Hospital” or “PCH”). Section 1866(k)(1) of the Act states that, for FY 2014 and each subsequent fiscal year, a PCH shall submit data to the Secretary in accordance with section 1866(k)(2) of the Act with respect to such a fiscal year. In FY 2014 and each subsequent fiscal year, each hospital described in section 1886(d)(1)(B)(v) of the Act shall submit data to the Secretary on quality measures (QMs) specified under section 1866(k)(3) of the Act in a form and manner, and at a time, specified by the Secretary.

    The program requires PCHs to submit data for selected QMs to CMS. PCHQR is a voluntary quality reporting program, in which data will be publicly reported on a CMS website. In the FY 2012 IPPS rule, five NQF endorsed measures were adopted and finalized for the FY 2014 reporting period, which was the first year of the PCHQR program. In the FY 2013 IPPS rule, one additional measure was adopted. Twelve new measures were adopted in the FY 2014 IPPS rule and one measure was adopted in the FY 2015 IPPS rule. Data collection for the FY 2016 and FY 2017 reporting periods is underway. We published the FY 2014 measure rates on HospitalCompare.gov on October 1, 2014 after a 30-day preview period.

    High Priority Domains for Future Measure Consideration: CMS identified the following categories as high-priority for future measure consideration:

    1. Communication and Care Coordination
      1. Measures regarding care coordination with other facilities and outpatient settings, such as hospice care.
      2. Measures of the patient’s functional status, quality of life, and end of life.
    2. Making Care Affordable
      1. Measures related to efficiency, appropriateness, and utilization (over/under-utilization) of cancer treatment modalities such as chemotherapy, radiation therapy, and imaging treatments.
    3. Person and Family Engagement
      1. Measures related to patient-centered care planning, shared decision-making, and quality of life outcomes.

    Measure Requirements: The following requirements will be considered by CMS when selecting measures for program implementation:

    1. Measure is responsive to specific program goals and statutory requirements.
      1. Measures are required to reflect consensus among stakeholders, and to the extent feasible, be endorsed by the national consensus entity with a contract under Section 1890(a) of the Social Security Act; currently the National Quality Forum (NQF)
      2. The Secretary may select a measure in an area or topic in which a feasible and practical measure has not been endorsed, by the entity with a contract under Section 1890(a) of the Social Security Act, as long as endorsed measures have been given due consideration
    2. Measure specifications must be publicly available.
    3. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed.
    4. Promote alignment with specific program attributes and across CMS and HHS programs. Measure alignment should support the measurement across the patient’s episode of care, demonstrated by assessment of the person’s trajectory across providers and settings.
    5. Potential use of the measure in a program does not result in negative unintended consequences (e.g., inappropriate reduced lengths of stay, overuse or inappropriate use of care or treatment, limiting access to care).
    6. Measures must be fully developed and tested, preferably in the PCH environment.
    7. Measures must be feasible to implement across PCHs, e.g., calculation, and reporting.
    8. Measure addresses an important condition/topic with a performance gap and has a strong scientific evidence base to demonstrate that the measure when implemented can lead to the desired outcomes and/or more appropriate costs.
    9. CMS has the resources to operationalize and maintain the measure.

    Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.


    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

    Ambulatory Surgical Center Quality Reporting Program

    End-Stage Renal Disease Quality Incentive Program

    Hospital Acquired Condition Reduction Program

    Hospital Inpatient Quality Reporting and EHR Incentive Program

    Hospital Outpatient Quality Reporting Program

    Hospital Value-Based Purchasing Program

    Inpatient Psychiatric Facility Quality Reporting Program

    Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program


    Full Comments (Listed by Measure)

    General
    Adult Local Current Smoking Prevalence (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1013)
    INR Monitoring for Individuals on Warfarin after Hospital Discharge (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1015)
    Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Electronic Health Record (EHR)-Extracted Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1033)
    Toxic Anterior Segment Syndrome (TASS) Outcome (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC15-1047)
    Substance Use Core Measure Set (SUB)-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1065)
    Thirty-day all-cause unplanned readmission following psychiatric hospitalization in an Inpatient Psychiatric Facility (IPF) (Program: Inpatient Psychiatric Facility Quality Reporting Program; MUC ID: MUC15-1082)
    IQI-22: Vaginal Birth After Cesarean (VBAC) Delivery Rate, Uncomplicated (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1083)
    Hybrid 30-Day Risk-Standardized Acute Ischemic Stroke Mortality Measure with Claims and Clinical Electronic Health Record (EHR) Risk Adjustment Variables (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-1135)
    Measurement of Phosphorus Concentration (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1136)
    Cellulitis Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1143)
    Gastrointestinal Intestinal (GI) Hemorrhage Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1144)
    Kidney/Urinary Tract Infection Clinical Episode-Based Payment Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-1145)
    Proportion of Patients with Hypercalcemia (NQF #1454) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1165)
    Standardized Readmission Ratio (SRR) for dialysis facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-1167)
    Hospital 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-294)
    Hospital-level, risk-standardized payment associated with an episode of care for primary elective total hip and/or total knee arthroplasty (THA/TKA) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-295)
    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for heart failure (HF) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-322)
    Hospital-level, risk-standardized payment associated with a 30-day episode-of-care for Acute Myocardial Infarction (AMI) (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-369)
    Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-378)
    Hospital-level, risk-standardized 30-day episode-of-care payment measure for pneumonia (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-378)
    Excess Days in Acute Care after Hospitalization for Pneumonia (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-391)
    Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-395)
    National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-531)
    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-532)
    National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-533)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-534)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-534)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-534)
    American College of Surgeons-Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-534)
    Standardized Mortality Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-575)
    Patient Safety and Adverse Events Composite (Program: Hospital Acquired Condition Reduction Program; MUC ID: MUC15-604)
    Patient Safety and Adverse Events Composite (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-604)
    Patient Safety and Adverse Events Composite (Program: Hospital Value-Based Purchasing Program; MUC ID: MUC15-604)
    Standardized Hospitalization Ratio - Modified (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-693)
    Avoidance of Utilization of High Ultrafiltration Rate (= 13 ml/kg/hour) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-758)
    ESRD Vaccination: Full-Season Influenza Vaccination (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC15-761)
    Aortic Aneurysm Procedure Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-835)
    Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-836)
    Spinal Fusion Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-837)
    Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Clinical Episode-Based Payment Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC15-838)
    Oncology: Radiation Dose Limits to Normal Tissues (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-946)
    Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-951)
    Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC15-951)
    Risk-standardized hospital visits within 7 days after hospital outpatient surgery (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC15-982)

    Appendix D: Instructions and Help

    If you have any problems navigating the discussion guide, please contact us at: maphospital@qualityforum.org. 

    Navigating the Discussion Guide

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    Appendix E: Instructions for Joining the Meeting Remotely

    Remote Participation Instructions:

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