NQF

Version Number: 5.6
Meeting Date: December 14, 2017

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 and Review of Meaningful Measures Framework
9:45 AM   MAP Pre-Rulemaking Approach and Voting Instructions
10:00 AM   Overview of the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Program and Opportunity for Public Comment on Measures Under Consideration
10:55 AM   Pre-Rulemaking Input for ESRD QIP
10:55 AM   Break
11:10 AM   Overview of the Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program and Opportunity for Public Comment on Measures Under Consideration
11:20 AM   Pre-Rulemaking Input for PCHQR
11:40 AM   Overview of the Ambulatory Surgery Center Quality Reporting (ASCQR) Program and Opportunity for Public Comment on Measures Under Consideration
11:50 AM   Pre-Rulemaking Input for ASCQR
12:20 PM   Overview of the Hospital Outpatient Quality Reporting Program (HOQR) and Opportunity for Public Comment on Measures Under Consideration
12:30 PM   Pre-Rulemaking Input for HOQR
1:00 PM   Lunch
1:45 PM   Overview of the Hospital Inpatient Quality Reporting (HIQR) Program and Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use) and Opportunity for Public Comment on Measures Under Consideration
1:55 PM   Pre-Rulemaking Input for HIQR
3:00 PM   Overview of Hospital-Acquired Condition (HAC) Reduction Program and Discussion of Future Measures
3:30 PM   Input on Measure Removal Criteria
4:10 PM   Public Comment
4:20 PM   MAP Rural Health Introduction and Presentation
4:40 PM   Summary of Day and Next Steps
5:00 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 Melissa Mariñelarena, Senior Director, NQF

9:15 AM   CMS Opening Remarks and Review of Meaningful Measures Framework
Pierre Yong, CMS

9:45 AM   MAP Pre-Rulemaking Approach and Voting Instructions
Kate McQueston, Project Manager, NQF

10:00 AM   Overview of the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) Program and Opportunity for Public Comment on Measures Under Consideration
10:55 AM   Pre-Rulemaking Input for ESRD QIP
• MUC17-176: Medication Reconciliation for Patients Receiving Care at Dialysis Facilities • MUC17-241: Percentage of Prevalent Patients Waitlisted (PPPW) • MUC17-245: Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR)
Programs under consideration:
  1. Medication Reconciliation for Patients Receiving Care at Dialysis Facilities (MUC ID: MUC17-176)
    • Description: Percentage of patient-months for which medication reconciliation* was performed and documented by an eligible professional.** * “Medication reconciliation” is defined as the process of creating the most accurate list of all home medications that the patient is taking, including name, indication, dosage, frequency, and route, by comparing the most recent medication list in the dialysis medical record to one or more external list(s) of medications obtained from a patient or caregiver (including patient-/caregiver-provided “brown bag” information), pharmacotherapy information network (e.g., Surescripts), hospital, or other provider. ** For the purposes of medication reconciliation, “eligible professional” is defined as: physician, RN, ARNP, PA, pharmacist, or pharmacy technician. (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 measure addresses two priority areas for the ESRD-QIP program, safety and care coordination. The measure addresses a safety issue (medication reconciliation) that is not currently included in the program measure set.
      • Impact on quality of care for patients:This measure encourages dialysis facilities to perform and document medication reconciliation for their patients. Medication reconciliation is a critical safety issue for all patients, but particularly patients with end-stage renal disease (ESRD). Individuals with ESRD frequently require 10 or more medications and take an average of 17-25 doses per day.
    • Preliminary analysis result: Support for Rulemaking


  2. Percentage of Prevalent Patients Waitlisted (PPPW) (MUC ID: MUC17-241)
    • Description: This measure tracks the percentage of patients at each dialysis facility who were on the kidney or kidney-pancreas transplant waiting list. Results are averaged across patients prevalent on the last day of each month during the reporting year. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This fully developed measure addresses an important quality gap for dialysis facilities. This measure should be submitted for NQF endorsement and review.
      • Impact on quality of care for patients:This measure would encourage dialysis facilities to ensure that patients remain healthy, and complete any ongoing testing activities required to remain on the waitlist.
    • Preliminary analysis result: Conditional Support for Rule Making


  3. Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) (MUC ID: MUC17-245)
    • Description: This measure tracks the number of incident patients at the dialysis facility under the age of 75 listed on the kidney or kidney-pancreas transplant waitlist or who received living donor transplants within the first year of initiating dialysis. (Measure Specifications)
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This fully developed measure addresses an important quality gap for dialysis facilities. This measure should be submitted for NQF endorsement and review.
      • Impact on quality of care for patients:This measure would encoruage dialysis facilities to ensure that patients receive support for transplant waitlisting process and to optimize the health and functional status of patients in order to increase their candidacy for transplant waitlisting.
    • Preliminary analysis result: Conditional Support for Rulemaking


10:55 AM   Break
11:10 AM   Overview of the Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting (PCHQR) Program and Opportunity for Public Comment on Measures Under Consideration
11:20 AM   Pre-Rulemaking Input for PCHQR
• MUC17-178: 30-Day Unplanned Readmissions for Cancer Patients
Programs under consideration:
  1. 30-Day Unplanned Readmissions for Cancer Patients (MUC ID: MUC17-178)
    • Description: 30-Day Unplanned Readmissions for Cancer Patients measure is a cancer-specific measure. It provides the rate at which all adult cancer patients covered as Fee-for-Service Medicare beneficiaries have an unplanned readmission within 30 days of discharge from an acute care hospital. The unplanned readmission is defined as a subsequent inpatient admission to a short-term acute care hospital, which occurs within 30 days of the discharge date of an eligible index admission and has an admission type of “emergency” or “urgent.” (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 7
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is fully developed and tested, and has received endorsement from NQF. It fills a current gap in the PPS-Exempt Cancer Hospital Quality Reporting Program by addressing unplanned readmissions of cancer patients.
      • Impact on quality of care for patients:Preventing cancer patient readmissions will improve the quality of care for cancer patients, improve healthoutcome, and reduce unessisary utlization of healthcare resources.
    • Preliminary analysis result: Support for Rulemaking


11:40 AM   Overview of the Ambulatory Surgery Center Quality Reporting (ASCQR) Program and Opportunity for Public Comment on Measures Under Consideration
11:50 AM   Pre-Rulemaking Input for ASCQR
• MUC17-233: Hospital Visits following General Surgery Ambulatory Surgical Center Procedures
Programs under consideration:
  1. Hospital Visits following General Surgery Ambulatory Surgical Center Procedures (MUC ID: MUC17-233)
    • Description: The measure assesses ASC general surgery procedure quality using the outcome of hospital visits -- including emergency department (ED) visits, observation stays, and unplanned inpatient admissions -- within 7 days of the procedure performed at an ASC. (Measure Specifications)
    • Public comments received: 10
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This is a fully developed measure that addresses an important health outcome for patients receiving care at ASC general surgery centers. This measure should be sumbitted and reviewed for NQF endorsement.
      • Impact on quality of care for patients:This measure would encourage ASCs to implement strategies to reduce unplanned hospital visits following general surgery procedures.
    • Preliminary analysis result: Conditional Support for Rule Making


12:20 PM   Overview of the Hospital Outpatient Quality Reporting Program (HOQR) and Opportunity for Public Comment on Measures Under Consideration
12:30 PM   Pre-Rulemaking Input for HOQR
• MUC17-223: Lumbar Spine Imaging for Low Back Pain
Programs under consideration:
  1. Lumbar Spine Imaging for Low Back Pain (MUC ID: MUC17-223)
    • Description: This measure calculates the percentage of CT (computed tomography) or MRI (magnetic resonance imaging) studies of the lumbar spine with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy. Antecedent conservative therapy may include: 1. Claim(s) for physical therapy in the 60 days preceding the lumbar spine CT or MRI. 2. Claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the lumbar spine CT or MRI. 3. Claim(s) for evaluation and management in the period > 28 days and < 60 days preceding the lumbar spine CT or MRI. (Measure Specifications; Summary of NQF Endorsement Review)
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure is currently in the Hospital Outpatient Quality Reporting (HOQR) program. The NQF Musculoskeletal Standing Committee agreed that the measure does not meet the validity subcriterion. The measure lost endorsement in 2017.
      • Impact on quality of care for patients:Inappropriate use of imaging is problematic because it subjects patients to unnecessary harms such as radiation exposure and unnecessary treatment, yet it is not associated with improved outcomes. The intent of this measure is to reduce inappropriate imaging for LBP in the absence of “red flags” that can indicate that back pain is caused by a serious, underlying pathology.
    • Preliminary analysis result: Do Not Support for Rulemaking


1:00 PM   Lunch
1:45 PM   Overview of the Hospital Inpatient Quality Reporting (HIQR) Program and Medicare and Medicaid EHR Incentive Program for Hospitals and Critical Access Hospitals (CAHs) (Meaningful Use) and Opportunity for Public Comment on Measures Under Consideration
1:55 PM   Pre-Rulemaking Input for HIQR
• MUC17-210: Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events • MUC17-195: Hospital-Wide All-Cause Risk Standardized Mortality Measure • MUC17-196: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure
Programs under consideration:
  1. Hospital-Wide All-Cause Risk Standardized Mortality Measure (MUC ID: MUC17-195)
    • Description: This measure estimates hospital-level, risk-standardized mortality rate (RSMR) for Medicare fee-for-service (FFS) patients who are between the ages of 65 and 94. Death is defined as death from any cause within 30 days after the index admission date. This is a claims-based version of the Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure. (Measure Specifications)
    • Public comments received: 10
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is fully developed and specified and compliments the existing CMS Hospital-Wide All-Cause Risk-Standardized Readmission Measure (NQF #1789). Testing results should demonstrate reliability and validity at the facility level in the acute care setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to reduce the number of patient deaths (from any cause) within 30 days after admission, including in-hospital deaths.
    • Preliminary analysis result: Conditional Support for Rulemaking


  2. Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure (MUC ID: MUC17-196)
    • Description: This measure estimates hospital-level, risk-standardized mortality rate (RSMR) for Medicare fee-for-service (FFS) patients who are between the ages of 65 and 94. Death is defined as death from any cause within 30 days after the index admission date. The measure is referred to as a hybrid because it will use Medicare fee-for-service (FFS) administrative claims to derive the cohort and outcome, and claims and clinical electronic health record (EHR) data for risk adjustment. (Measure Specifications)
    • Public comments received: 9
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure is fully developed and specified and compliments the existing CMS Hospital-Wide All-Cause Risk-Standardized Readmission Measure (NQF #1789). Testing results should demonstrate reliability and validity at the facility level in the acute care setting. This measure should be submitted to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to reduce the number of patient deaths (from any cause) within 30 days after admission, including in-hospital deaths.
    • Preliminary analysis result: Conditional Support for Rulemaking


  3. Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events (MUC ID: MUC17-210)
    • Description: This measure will assess opioid related adverse respiratory events (ORARE) in the hospital setting. The goal for this measure is to assess the rate at which naloxone is given for opioid related adverse respiratory events that occur in the hospital setting, using a valid method that reliably allows comparison across hospitals. (Measure Specifications)
    • Public comments received: 18
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Currently, this measure has not been tested in enough hospitals to assess measure reliability across hospitals; however, testing results should demonstrate reliability and validity at the facility level in the hospital setting. The developer has indicated that this measure is anticipated for November 2018 submission to NQF for review and endorsement.
      • Impact on quality of care for patients:This measure encourages hospitals to reduce opioid-related adverse respiratory events, a servious reportable event.
    • Preliminary analysis result: Revise and Resubmit


3:00 PM   Overview of Hospital-Acquired Condition (HAC) Reduction Program and Discussion of Future Measures
Reena Duseja, CMS Joseph Clift, CMS

3:30 PM   Input on Measure Removal Criteria
4:10 PM   Public Comment
4:20 PM   MAP Rural Health Introduction and Presentation
Karen Johnson, Senior Director, NQF

4:40 PM   Summary of Day and Next Steps
Cristie Upshaw Travis, MAP Hospital Workgroup Co-Chair Ronald Walters, MAP Hospital Workgroup Co-Chair Desmirra Quinnonez, Project Analyst, NQF

5:00 PM   Adjourn

Appendix A: Measure Information

Measure Index

Ambulatory Surgical Center Quality Reporting Program

End-Stage Renal Disease Quality Incentive Program

Hospital Inpatient Quality Reporting and EHR Incentive Program

Hospital Outpatient Quality Reporting Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program


Full Measure Information

Hospital Visits following General Surgery Ambulatory Surgical Center Procedures (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC17-233)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Improving the quality of care provided at ASCs is a key priority in the context of growth in the number of ASCs and procedures performed in this setting. More than 60% of all medical or surgical procedures were performed at ASCs in 2006 -- a three-fold increase since the late 1990s.1 In 2013, more than 3.4 million Fee-for-Service (FFS) Medicare beneficiaries were treated at 5,364 Medicare-certified ASCs, and spending on ASC services by Medicare and its beneficiaries amounted to $3.7 billion.2 The patient population served at ASCs has increased not only in volume but also in age and complexity, which can be partially attributed to improvements in anesthetic care and innovations in minimally invasive surgical techniques.3,4 ASCs have become the preferred setting for the provision of low-risk surgical and medical procedures in the US, as many patients experience shorter wait times, prefer to avoid hospitalization, and are able to return rapidly to work.1 Therefore, in the context of growth in volume and diversity of procedures performed at ASCs, evaluating the quality of care provided at ASCs is increasingly important. In the literature, hospital visit rates following outpatient surgery vary from 0.5-9.0%, based on the type of surgery, outcome measured (admissions alone or admissions and ED visits), and timeframe for measurement after surgery.5-12 These hospital visits can occur due to a range of well-described adverse events, including major adverse events, such as bleeding, wound infection, septicemia, and venous thromboembolism. Patients also frequently report minor adverse events -- for example, uncontrolled pain, nausea, and vomiting -- that may result in unplanned acute care visits following surgery. Several factors make unanticipated hospital visits a priority quality indicator. Because ASC providers are not aware of all post-surgical hospital visits that occur among their patients, reporting this outcome will help to illuminate problems that may not be currently visible. In addition, the outcome of hospital visits is a broad, patient-centered outcome that reflects the full range of reasons leading to hospital use among patients undergoing same-day surgery. Public reporting of this outcome measure will provide ASCs with critical information and incentives to implement strategies to reduce unplanned hospital visits. Given that ASCs vary widely in their focus and the number of procedures that they perform, focusing on general surgery procedures will enable use of a quality measure to make fair comparisons of outcome rates across facilities that perform similar procedures. 1. Cullen KA, Hall MJ, Golosinskiy A, Statistics NCfH. Ambulatory surgery in the United States, 2006. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2009. 2. Medicare Payment Advisory Commission (MedPAC). Report to Congress: Medicare Payment Policy. March 2015; http://www.medpac.gov/docs/default-source/reports/mar2015_entirereport_revised.pdf. 3. Bettelli G. High risk patients in day surgery. Minerva anestesiologica. 2009;75(5):259-268. 4. Fuchs K. Minimally invasive surgery. Endoscopy. 2002;34(2):154-159. 5. Majholm BB. Is day surgery safe? A Danish multicentre study of morbidity after 57,709 day surgery procedures. Acta anaesthesiologica Scandinavica. 2012;56(3):323-331. 6. Whippey A, Kostandoff G, Paul J, Ma J, Thabane L, Ma HK. Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2013;60(7):675-683. 7. 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. Arch Surg. 2004;139(1):67-72. 8. 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. 2002;14(5):349-353. 9. Hollingsworth JMJM. Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery. The Journal of urology. 2012;188(4):1274-1278. 10. Bain J, Kelly H, Snadden D, Staines H. Day surgery in Scotland: patient satisfaction and outcomes. Quality in Health Care. 1999;8(2):86-91. 11. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery--a prospective study. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 1998;45(7):612-619. 12. Aldwinckle R, Montgomery J. Unplanned admission rates and postdischarge complications in patients over the age of 70 following day case surgery. Anaesthesia. 2004;59(1):57-59.


Medication Reconciliation for Patients Receiving Care at Dialysis Facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC17-176)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Medication management is a critical safety issue for all patients, but especially so for patients with ESRD, who often require 10 or more medications and take an average of 17-25 doses per day, have numerous comorbid conditions, have multiple healthcare providers and prescribers, and undergo frequent medication regimen changes(1,2,3,4). Medication-related problems (MRPs) contribute significantly to the approximately $40 billion in public and private funds spent annually on ESRD care in the United States(5,6), and it is believed that medication management practices focusing on medication documentation, review, and reconciliation could systematically identify and resolve MRPs, improve ESRD patient outcomes, and reduce total costs of care. As most hemodialysis patients are seen at least thrice weekly and peritoneal dialysis patients monthly, the dialysis facility has been suggested as a reasonable locale for medication therapy management(7).

Summary of NQF Endorsement Review




Percentage of Prevalent Patients Waitlisted (PPPW) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC17-241)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
A measure focusing on the waitlisting process is appropriate for improving access to kidney transplantation for several reasons. First, waitlisting is a necessary step prior to potential receipt of a deceased donor kidney. Second, dialysis facilities exert substantial control over the process of waitlisting. This includes proper education of dialysis patients on the option for transplant, referral of appropriate patients to a transplant center for evaluation, assisting patients with completion of the transplant evaluation process, and optimizing the health and functional status of patients in order to increase their candidacy for transplant waitlisting. These types of activities are included as part of the conditions for coverage for Medicare certification of ESRD dialysis facilities. In addition, dialysis facilities can also help maintain patients on the wait list through assistance with ongoing evaluation activities and by optimizing health and functional status. Finally, wide regional variations in waitlisting rates highlight substantial room for improvement for this process measure [1,2,3]. This measure focuses specifically on the prevalent dialysis population, examining waitlisting status monthly for each patient. This allows evaluation and encouragement of ongoing waitlisting of patients beyond the first year of dialysis initiation who have not yet been listed. Patients may not be ready, either psychologically or due to their health status, to consider transplantation early after initiation of dialysis and many choose to undergo evaluation for transplantation only after years on dialysis. In addition, as this measure assesses monthly waitlisting status of patients, it also evaluates and encourages maintenance of patients on the waitlist. This is an important area to which dialysis facilities can contribute through ensuring patients remain healthy, and complete any ongoing testing activities required to remain on the waitlist. 1. Ashby VB, Kalbfleisch JD, Wolfe RA, et al. Geographic variability in access to primary kidney transplantation in the United States, 1996-2005. American Journal of Transplantation 2007; 7 (5 Part 2):1412-1423. Abstract: This article focuses on geographic variability in patient access to kidney transplantation in the United States. It examines geographic differences and trends in access rates to kidney transplantation, in the component rates of wait-listing, and of living and deceased donor transplantation. Using data from Centers for Medicare and Medicaid Services and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients, we studied 700,000+ patients under 75, who began chronic dialysis treatment, received their first living donor kidney transplant, or were placed on the waiting list pre-emptively. Relative rates of wait-listing and transplantation by State were calculated using Cox regression models, adjusted for patient demographics. There were geographic differences in access to the kidney waiting list and to a kidney transplant. Adjusted wait-list rates ranged from 37% lower to 64% higher than the national average. The living donor rate ranged from 57% lower to 166% higher, while the deceased donor transplant rate ranged from 60% lower to 150% higher than the national average. In general, States with higher wait-listing rates tended to have lower transplantation rates and States with lower wait-listing rates had higher transplant rates. Six States demonstrated both high wait-listing and deceased donor transplantation rates while six others, plus D.C. and Puerto Rico, were below the national average for both parameters. 2. Satayathum S, Pisoni RL, McCullough KP, et al. Kidney transplantation and wait-listing rates from the international Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Intl 2005 Jul; 68 (1):330-337. Abstract: BACKGROUND: The international Dialysis Outcomes and Practice Patterns Study (DOPPS I and II) allows description of variations in kidney transplantation and wait-listing from nationally representative samples of 18- to 65-year-old hemodialysis patients. The present study examines the health status and socioeconomic characteristics of United States patients, the role of for-profit versus not-for-profit status of dialysis facilities, and the likelihood of transplant wait-listing and transplantation rates. METHODS: Analyses of transplantation rates were based on 5267 randomly selected DOPPS I patients in dialysis units in the United States, Europe, and Japan who received chronic hemodialysis therapy for at least 90 days in 2000. Left-truncated Cox regression was used to assess time to kidney transplantation. Logistic regression determined the odds of being transplant wait-listed for a cross-section of 1323 hemodialysis patients in the United States in 2000. Furthermore, kidney transplant wait-listing was determined in 12 countries from cross-sectional samples of DOPPS II hemodialysis patients in 2002 to 2003 (N= 4274). RESULTS: Transplantation rates varied widely, from very low in Japan to 25-fold higher in the United States and 75-fold higher in Spain (both P values <0.0001). Factors associated with higher rates of transplantation included younger age, nonblack race, less comorbidity, fewer years on dialysis, higher income, and higher education levels. The likelihood of being wait-listed showed wide variation internationally and by United States region but not by for-profit dialysis unit status within the United States. CONCLUSION: DOPPS I and II confirmed large variations in kidney transplantation rates by country, even after adjusting for differences in case mix. Facility size and, in the United States, profit status, were not associated with varying transplantation rates. International results consistently showed higher transplantation rates for younger, healthier, better-educated, and higher income patients. 3. Patzer RE, Plantinga L, Krisher J, Pastan SO. Dialysis facility and network factors associated with low kidney transplantation rates among United States dialysis facilities. Am J Transplant. 2014 Jul; 14(7):1562-72. Abstract: Variability in transplant rates between different dialysis units has been noted, yet little is known about facility-level factors associated with low standardized transplant ratios (STRs) across the United States End-stage Renal Disease (ESRD) Network regions. We analyzed Centers for Medicare & Medicaid Services Dialysis Facility Report data from 2007 to 2010 to examine facility-level factors associated with low STRs using multivariable mixed models. Among 4098 dialysis facilities treating 305 698 patients, there was wide variability in facility-level STRs across the 18 ESRD Networks. Four-year average STRs ranged from 0.69 (95% confidence interval [CI]: 0.64-0.73) in Network 6 (Southeastern Kidney Council) to 1.61 (95% CI: 1.47-1.76) in Network 1 (New England). Factors significantly associated with a lower Standardized Transplantation Ratio(STR) (p < 0.0001) included for-profit status, facilities with higher percentage black patients, patients with no health insurance and patients with diabetes. A greater number of facility staff, more transplant centers per 10 000 ESRD patients and a higher percentage of patients who were employed or utilized peritoneal dialysis were associated with higher STRs. The lowest performing dialysis facilities were in the Southeastern United States. Understanding the modifiable facility-level factors associated with low transplant rates may inform interventions to improve access to transplantation.


Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC17-245)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
A measure focusing on the waitlisting process is appropriate for improving access to kidney transplantation for several reasons. First, waitlisting is a necessary step prior to potential receipt of a deceased donor kidney (receipt of a living donor kidney is also accounted for in the measure). Second, dialysis facilities exert substantial control over the process of waitlisting. This includes proper education of dialysis patients on the option for transplant, referral of appropriate patients to a transplant center for evaluation, assisting patients with completion of the transplant evaluation process, and optimizing the health and functional status of patients in order to increase their candidacy for transplant waitlisting. These types of activities are included as part of the conditions for coverage for Medicare certification of ESRD dialysis facilities. Finally, wide regional variations in waitlisting rates highlight substantial room for improvement for this process measure [1,2,3]. This measure additionally focuses specifically on the population of patients incident to dialysis, examining for waitlist or living donor transplant events occurring within a year of dialysis initiation. This will evaluate and encourage rapid attention from dialysis facilities to waitlisting of patients to ensure early access to transplantation. 1. Ashby VB, Kalbfleisch JD, Wolfe RA, et al. Geographic variability in access to primary kidney transplantation in the United States, 1996-2005. American Journal of Transplantation 2007; 7 (5 Part 2):1412-1423. Abstract: This article focuses on geographic variability in patient access to kidney transplantation in the United States. It examines geographic differences and trends in access rates to kidney transplantation, in the component rates of wait-listing, and of living and deceased donor transplantation. Using data from Centers for Medicare and Medicaid Services and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients, we studied 700,000+ patients under 75, who began chronic dialysis treatment, received their first living donor kidney transplant, or were placed on the waiting list pre-emptively. Relative rates of wait-listing and transplantation by State were calculated using Cox regression models, adjusted for patient demographics. There were geographic differences in access to the kidney waiting list and to a kidney transplant. Adjusted wait-list rates ranged from 37% lower to 64% higher than the national average. The living donor rate ranged from 57% lower to 166% higher, while the deceased donor transplant rate ranged from 60% lower to 150% higher than the national average. In general, States with higher wait-listing rates tended to have lower transplantation rates and States with lower wait-listing rates had higher transplant rates. Six States demonstrated both high wait-listing and deceased donor transplantation rates while six others, plus D.C. and Puerto Rico, were below the national average for both parameters. 2. Satayathum S, Pisoni RL, McCullough KP, et al. Kidney transplantation and wait-listing rates from the international Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Intl 2005 Jul; 68 (1):330-337. Abstract: BACKGROUND: The international Dialysis Outcomes and Practice Patterns Study (DOPPS I and II) allows description of variations in kidney transplantation and wait-listing from nationally representative samples of 18- to 65-year-old hemodialysis patients. The present study examines the health status and socioeconomic characteristics of United States patients, the role of for-profit versus not-for-profit status of dialysis facilities, and the likelihood of transplant wait-listing and transplantation rates. METHODS: Analyses of transplantation rates were based on 5267 randomly selected DOPPS I patients in dialysis units in the United States, Europe, and Japan who received chronic hemodialysis therapy for at least 90 days in 2000. Left-truncated Cox regression was used to assess time to kidney transplantation. Logistic regression determined the odds of being transplant wait-listed for a cross-section of 1323 hemodialysis patients in the United States in 2000. Furthermore, kidney transplant wait-listing was determined in 12 countries from cross-sectional samples of DOPPS II hemodialysis patients in 2002 to 2003 (N= 4274). RESULTS: Transplantation rates varied widely, from very low in Japan to 25-fold higher in the United States and 75-fold higher in Spain (both P values <0.0001). Factors associated with higher rates of transplantation included younger age, nonblack race, less comorbidity, fewer years on dialysis, higher income, and higher education levels. The likelihood of being wait-listed showed wide variation internationally and by United States region but not by for-profit dialysis unit status within the United States. CONCLUSION: DOPPS I and II confirmed large variations in kidney transplantation rates by country, even after adjusting for differences in case mix. Facility size and, in the United States, profit status, were not associated with varying transplantation rates. International results consistently showed higher transplantation rates for younger, healthier, better-educated, and higher income patients. 3. Patzer RE, Plantinga L, Krisher J, Pastan SO. Dialysis facility and network factors associated with low kidney transplantation rates among United States dialysis facilities. Am J Transplant. 2014 Jul; 14(7):1562-72. Abstract: Variability in transplant rates between different dialysis units has been noted, yet little is known about facility-level factors associated with low standardized transplant ratios (STRs) across the United States End-stage Renal Disease (ESRD) Network regions. We analyzed Centers for Medicare & Medicaid Services Dialysis Facility Report data from 2007 to 2010 to examine facility-level factors associated with low STRs using multivariable mixed models. Among 4098 dialysis facilities treating 305 698 patients, there was wide variability in facility-level STRs across the 18 ESRD Networks. Four-year average STRs ranged from 0.69 (95% confidence interval [CI]: 0.64-0.73) in Network 6 (Southeastern Kidney Council) to 1.61 (95% CI: 1.47-1.76) in Network 1 (New England). Factors significantly associated with a lower STR (p < 0.0001) included for-profit status, facilities with higher percentage black patients, patients with no health insurance and patients with diabetes. A greater number of facility staff, more transplant centers per 10 000 ESRD patients and a higher percentage of patients who were employed or utilized peritoneal dialysis were associated with higher STRs. The lowest performing dialysis facilities were in the Southeastern United States. Understanding the modifiable facility-level factors associated with low transplant rates may inform interventions to improve access to transplantation.


Hospital-Wide All-Cause Risk Standardized Mortality Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC17-195)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Hospital-wide mortality has been the focus of several previous quality reporting initiatives in the U.S. and other countries. Prior efforts have met with some success and various challenges. Through our environmental scan and literature review, we identified multiple hospital-wide mortality measures reported at the state-level, and several at the health-system level. There is no hospital-wide mortality measure reported at the national-level in the United States.


Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC17-196)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Hospital-wide mortality has been the focus of several previous quality reporting initiatives in the U.S. and other countries. Prior efforts have met with some success and various challenges. Through our environmental scan and literature review, we identified multiple hospital-wide mortality measures reported at the state-level, and several at the health-system level. There is no hospital-wide mortality measure reported at the national-level in the United States.


Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC17-210)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Opiates are critical for the management of pain in hospitalized patients. However, known side effects can lead to serious adverse effects if opiate-treated patients are not properly managed. Many types of opioid related adverse respiratory events (respiratory depression, respiratory arrest, cardiopulmonary arrest, etc.) can potentially be measured electronically. Additionally, naloxone is a strong surrogate to serious adverse events after opiate administration in hospitals, and surveillance and care in administration can reduce adverse events1. Citations: 1 Lee LA, Caplan RA, Stephens LS, et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122(3):659-665. 2 Jha A, Pronovost P. Toward a safer health care system: The critical need to improve measurement. JAMA. May 3, 2016; 315(17):1831-1832. 3 Makary MA, Daniel M. Medical Error-the third leading cause of death in the US. BMJ. 2016; 353; i2139: 1-5; Available at: http://www.bmj.com/content/bmj/353/bmj.i2139.full.pdf


Lumbar Spine Imaging for Low Back Pain (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC17-223)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The specifications for OP-8 are based primarily on the American College of Radiology’s Appropriateness Criteria® for low back pain. The 2015 publication of this Criteria® states that presentation of acute, subacute, or chronic uncomplicated low back pain or radiculopathy with no red flags and no prior management does not warrant imaging (using a CT or MRI). The Appropriateness Criteria® then details symptoms or diagnoses for which imaging may be appropriate, most of which are captured as measure exclusions for OP-8.

Summary of NQF Endorsement Review




30-Day Unplanned Readmissions for Cancer Patients (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC17-178)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Cancer is the second leading cause of death in the United States, with nearly 600,000 cancer-related deaths expected this year.1 It is now the leading cause of death among adults aged 40 to 79 years as well and in 21 states.2 It is estimated roughly 1.7 million Americans will be diagnosed with cancer in 2016, and nearly 14.5 million Americans with a history of cancer were alive in 2014. Cancer disproportionately affects older Americans, with 86% of all cancers diagnosed in people 50 years of age and older.1 Oncology care contributes greatly to Medicare spending and accounted for an estimated $125 billion in healthcare spending in 2010. This figure is projected to rise to between $173 billion and $207 billion by 2020.3 Given the current and projected increases in cancer prevalence and costs of care, it is essential that healthcare providers look for opportunities to lower the costs of cancer care. Reducing readmissions after hospital discharge has been proposed as an effective means of lowering healthcare costs and improving the outcomes of care. Research suggests that between 9% and 48% of all hospital readmissions are preventable, owing to inadequate treatment during the patient’s original (index) admission or after discharge.4 Jencks, et al. estimated that unplanned readmissions cost the Medicare program $17.4 billion in 2004.5 Unnecessary hospital readmissions negatively impact cancer patients by compromising their quality of life, by placing them at risk for health-acquired infections, and by increasing the costs of their care. Furthermore, unplanned readmissions during treatment can delay treatment completion and, potentially, worsen patient prognosis. Preventing these readmissions improves the quality of care for cancer patients. Numerous studies have examined all-cause readmissions and readmissions for specific conditions, such as orthopedic surgery. Existing studies in cancer have largely focused on post-operative readmissions, reporting readmission rates between 6.5% and 25%. Patient factors, including age, comorbidities, cancer stage, and socioeconomic status, were identified as risk factors in these patients. Surgical complications, surgery duration, and hospital length of stay also increased readmission risk in these studies. Finally, hospital factors (e.g., hospital size) and practice patterns, such as inadequate discharge planning, comorbidity management, and follow-up care, were associated with preventable readmissions.6-17 Moya, et al. observed a 20% readmission rate in hematopoietic cell transplantation (HCT) recipients along with an extended length of stay during the readmission (25 ± 21 days). Infections (some associated with the graft), graft failure, coagulation disorders, and a second neoplasm were the most frequent causes of readmission.18 Bejanyan, et al. examined readmissions in patients with myeloablative allogeneic HCT and observed a 39% readmission rate in these patients. Infections, fever, gastrointestinal complications, and graft-versus-host disease (GVHD) were the most frequent reasons for readmission.19 Less is known about other readmissions in medical cancer admissions, though Ji, et al. noted that surgical patients were most often readmitted for surgical complications while medical patients were typically readmitted for the same condition treated during the index admission.6 Together, these studies suggest that certain readmissions in cancer patients are preventable and should be routinely measured for purposes of quality improvement and accountability. All-cause and disease-specific unplanned readmissions rates have been adopted by the Centers for Medicare & Medicaid Services (CMS) as key indicators of inpatient quality care. Additionally, Medicare began reducing payments to hospitals with excess readmissions in October 2012, as mandated in the Patient Protection and Affordable Care Act of 2010. Benbassat, et al. concluded that global readmission rates are not useful indicators of healthcare quality and, instead, recommended measuring readmissions at the condition level.4 Readmission rates have been developed for pneumonia, acute myocardial infarction, and heart failure. However, cancer has lagged behind these conditions in the development of validated readmission rates. In 2012, the Comprehensive Cancer Center Consortium for Quality Improvement, or C4QI (a group of eighteen academic medical centers that collaborate to measure and improve the quality of cancer in their centers), began development of a cancer-specific unplanned readmissions measure: 30-Day Unplanned Readmissions for Cancer Patients. The Alliance of Dedicated Cancer Centers, or ADCC (an organization of eleven comprehensive cancer centers that are reimbursed differently by Medicare), identified this ongoing work as a potential accountability measure for the PCHQR. Both groups recognize the importance of measuring unplanned readmissions as an indicator of the quality of hospital-based oncology care and have designed the 30-Day Unplanned Readmissions for Cancer Patients measure accordingly.5,6 This measure is intended to reflect the unique clinical aspects of oncology patients and to yield readmission rates that more accurately reflect the quality of cancer care delivery, when compared with broader readmissions measures. Likewise, this measure addresses cancer measurement gaps in existing readmissions measures, such as the Hospital-Wide All-Cause Unplanned Readmission Measure (HWR), stewarded by CMS. The 30-Day Unplanned Readmissions for Cancer Patients measure can be used by individual hospitals to inform local quality improvement efforts. Through adoption in public reporting programs (e.g., PCHQR), it can increase transparency around the quality of care delivered to patients with cancer. 1. American Cancer Society. Cancer facts and figures 2016. 2016. Available at: http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf. 2. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016;66(1):7-30. 3. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103(2):117-128. 4. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care: advantages and limitations. Arch Intern Med. 2000;160(8):1074-1081. 5. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. 6. Ji H, Abushomar H, Chen XK, Qian C, Gerson D. All-cause readmission to acute care for cancer patients. Healthc Q. 2012;15(3):14-16. 7. Rochefort MM, Tomlinson JS. Unexpected readmissions after major cancer surgery: an evaluation of readmissions as a quality-of-care indicator. Surg Oncol Clin N Am. 2012;21(3):397-405, viii. 8. Manzano JG, Luo R, Elting LS, George M, Suarez-Almazor ME. Patterns and predictors of unplanned hospitalization in a population-based cohort of elderly patients with GI cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2014;32(31):3527-3533. 9. Dickinson H, Carico C, Nuno M, et al. Unplanned readmissions and survival following brain tumor surgery. J Neurosurg. 2015;122(1):61-68. 10. Fernandez FG, Khullar O, Force SD, et al. Hospital readmission is associated with poor survival after esophagectomy for esophageal cancer. Ann Thorac Surg. 2015;99(1):292-297. 11. Manzano JG, Gadiraju S, Hiremath A, Lin HY, Farroni J, Halm J. Unplanned 30-Day Readmissions in a General Internal Medicine Hospitalist Service at a Comprehensive Cancer Center. J Oncol Pract. 2015;11(5):410-415. 12. Saunders ND, Nichols SD, Antiporda MA, et al. Examination of unplanned 30-day readmissions to a comprehensive cancer hospital. J Oncol Pract. 2015;11(2):e177-181. 13. Shah SP, Xu T, Hooker CM, et al. Why are patients being readmitted after surgery for esophageal cancer? J Thorac Cardiovasc Surg. 2015;149(5):1384-1389; discussion 1389-1391. 14. Valero-Elizondo J, Kim Y, Prescott JD, et al. Incidence and Risk Factors Associated with Readmission After Surgical Treatment for Adrenocortical Carcinoma. J Gastrointest Surg. 2015;19(12):2154-2161. 15. Uppal S, Penn C, Del Carmen MG, Rauh-Hain JA, Reynolds RK, Rice LW. Readmissions after major gynecologic oncology surgery. Gynecol Oncol. 2016;141(2):287-292. 16. Wilbur MB, Mannschreck DB, Angarita AM, et al. Unplanned 30-day hospital readmission as a quality measure in gynecologic oncology. Gynecol Oncol. 2016;143(3):604-610. 17. Nakayama JM, Ou JP, Friedman C, Smolkin ME, Duska LR. The Risk Factors of Readmission in Postoperative Gynecologic Oncology Patients at a Single Institution. Int J Gynecol Cancer. 2015;25(9):1697-1703. 18. Moya R, Espigado I, Parody R, Carmona M, Marquez F, De Blas JM. Evaluation of readmissions in hematopoietic stem cell transplant recipients. Transplant Proc. 2006;38(8):2591-2592. 19. Bejanyan N, Bolwell BJ, Lazaryan A, et al. Risk factors for 30-day hospital readmission following myeloablative allogeneic hematopoietic cell transplantation (allo-HCT). Biol Blood Marrow Transplant. 2012;18(6):874-880.

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 April 2017.

Program Index


Full Program Summaries

Ambulatory Surgical Center Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Ambulatory Surgical Center Quality Reporting Program (ASCQR) 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:

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Making Care Safer a. 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 a. 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. At a minimum, the following requirements will be considered in selecting measures for ASCQR 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 presentation organized according to concepts.

End-Stage Renal Disease Quality Incentive Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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 ESRD 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 QIP. 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.
  4. Access to Transplantation: Obtaining a transplant is an extended process for dialysis patients, including education, referral, waitlisting, transplantation, and follow-up care. The care and information available from dialysis facilities are integral to the process. Complicating the issue of attribution are the role of transplant facilities in setting criteria and making decisions about transplant candidates and the limited availability of donor organs. Measures for the ESRD QIP must balance the role of the facility and other providers with the need to make transplants accessible to as many candidate recipients as possible.

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 presentation organized according to concepts.

Hospital Acquired Condition Reduction Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: Section 3008 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the HospitalAcquired Condition Reduction Program (HACRP). Created under Section 1886(p) of the Social Security Act (the Act), the HACRP provides an incentive for hospitals to reduce the number of HACs. Effective Fiscal Year (FY) 2014 and beyond, the HACRP 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.” The Total HAC Score is the sum of the two weighted domain scores, with Domain 1 weighted at 15% and Domain 2 weighted at 85%.

High Priority Domains for Future Measure Consideration:

For FY 2017 federal rulemaking, CMS may propose the adoption, removal, and/or suspensionof measures for fiscal years 2018 and beyond of the HACRP. CMS identified the following topics as areas within the NQS priority of “Making Care Safer” for future measure consideration:

Making Care Safer:

  1. Measures that address adverse drug events during the inpatient stay
  2. Measures that address ventilator-associated events
  3. Additional surgical site infection locations that are not already covered within an existing measure in the program
  4. Outcome risk-adjusted measures that capture outcomes from hospital-acquired conditions and are risk-adjusted to account for patient and/or facility differences (e.g., multiple comorbidities, patient care location)
  5. Measures that address diagnostic errors such as harm from receiving improper tests or treatment, harm from not receiving proper tests or treatment, harm from failure to diagnose, or harm from improper diagnosis
  6. Measure that address causes of hospital harm such as an all-cause harm measure or a measure that encompasses multiple harms

Measure Requirements:

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

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

Hospital Inpatient Quality Reporting and EHR Incentive Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Hospital Inpatient Quality Reporting (HIQR) Program was established by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and expanded by the Deficit Reduction Act 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 that fail to meet the requirements of the HIQR will result in a reduction of one-fourth to their fiscal year IPPS annual payment update (the annual payment update includes inflation in costs of goods and services used by hospitals in treating Medicare patients). Hospitals that choose to not participate in the program receive a reduction by that same amount. Hospitals not included in the HIQR, such as critical access hospitals and hospitals located in Puerto Rico and the U.S. Territories, are permitted to participate in voluntary quality reporting. Performance of quality measures are publicly reported on the CMS Hospital Compare website. The American Recovery and Reinvestment Act of 2009 amended Titles XVIII and XIX of the Social Security Act to authorize incentive payments to eligible hospitals (EHs) and critical access hospitals (CAHs) that 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 Programs. All EHR Incentive Program requirements related to eCQM reporting will be addressed in IPPS rulemaking including, but not limited to, new program requirements, reporting requirements, reporting and submission periods, reporting methods, alignment efforts between the HIQR and the Medicare EHR Incentive Program for EHs and CAHs, 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.

Measure Requirements:

CMS applies criteria for measures that may be considered for potential adoption in the HIQR program. At a minimum, the following criteria will be considered in selecting measures for HIQR 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 underSection 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, createdin 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 thata performance gap exists and that measure implementation can lead to improvement indesired outcomes, costs, or resource utilization.
  5. Measure must be fully developed, tested, and validated in an 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 presentation organized according to concepts.

Hospital Outpatient Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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 presentation organized according to concepts.

Hospital Readmissions Reduction Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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 Secretaryto establish readmission measures for applicable conditions and to calculate an excess readmissionratio 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 FY 2017 HRRP program currentlyinclude measures for acute myocardial infarction, heart failure, pneumonia, chronic obstructivepulmonary disease, elective total knee and total hip arthroplasty, and coronaryartery bypass graft surgery. 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 continuesto 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. At a minimum, the following criteria and requirements must be met for consideration in the HRRP:

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

Hospital Value-Based Purchasing Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Hospital Value-Based Purchasing (HVBP) Program was established by Section 3001(a) of the Affordable Care Act, under which value-based incentive payments are made each 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. In addition, 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 HVBP Program based on the statutory requirements, including specification under the Hospital Inpatient Quality Reporting (HIQR) Program and posting dates on the Hospital Compare website.

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. Making Care Affordable:
    1. Measures that effectuate changes in efficiency and reward value over volume.

Measure Requirements:

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

  1. Measure must adhere to CMS statutory requirements, including specification under the Hospital IQR Program and posting dates on the Hospital Compare website.
    • 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)
    • 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 may not require reporting to a proprietary registry.
  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 acute inpatient setting.
  5. 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.
  6. Measure must promote alignment across HHS and CMS programs.
  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 presentation organized according to concepts.

Inpatient Psychiatric Facility Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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 16 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) 2017 and beyond.

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. 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
  4. 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. At a minimum, the following criteria will be considered in selecting measures for IPFQR implementation: Measure must adhere to CMS statutory requirements. 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 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 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. The measure assesses meaningful performance differences between facilities. The measure addresses an aspect of care affecting a significant proportion of IPF patients. Measure must be fully developed, tested, and validated in the acute inpatient setting. Measure must address a NQS priority/CMS strategy goal, with preference for measures addressing the high priority domains for future measure consideration. Measure must promote alignment across HHS and CMS programs. 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 presentation organized according to concepts.

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

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 programfor hospitals described in section 1886(d)(1)(B)(v) of the Act (referred to as a “PPS-Exempt Cancer Hospital” or PCHQR). 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 voluntaryquality reporting program, in which data will be publicly reported on a CMS website. In the FY 2012 IPPSrule, five NQF endorsed measures were adopted and finalized for the FY 2014 reporting period, which was the first year of the PCHQR. In the FY 2013 IPPS rule, one additional measure wasadopted. Twelve new measures were adopted in the FY 2014 IPPS rule and one measure was adopted in theFY 2015 IPPS rule. Data collection for the FY 2017 and FY 2018 reporting periods is underway.

High Priority Domains for Future Measure Consideration:

CMS identified the following categories as high-priority for future measure consideration:

  1. Communication and Care Coordination
    • Measures regarding care coordination with other facilities and outpatient settings, such as hospice care.
    • Measures of the patient’s functional status, quality of life, and end of life.
  2. Making Care Affordable
    • 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
    • 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 forprogram implementation: Measure is responsive to specific program goals and statutory requirements. Measures are required to reflect consensus among stakeholders, and to the extent feasible, be endorsed by the national consensus entity with a contract underSection 1890(a) of the Social Security Act; currently the National Quality Forum(NQF) 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 Measure specifications must be publicly available. Measure steward will provide CMS with technical assistance and clarifications on the measure as needed. Promote alignment with specific program attributes and across CMS and HHSprograms. 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. 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 ortreatment, limiting access to care). Measures must be fully developed and tested, preferably in the PCHenvironment. Measures must be feasible to implement across PCHs, e.g., calculation, and reporting. 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. CMS has the resources to operationalize and maintain the measure.

Current Measures: NQF staff have compiled the program's measures in a presentation 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.

Ambulatory Surgical Center Quality Reporting Program

End-Stage Renal Disease Quality Incentive Program

Hospital Inpatient Quality Reporting and EHR Incentive Program

Hospital Outpatient Quality Reporting Program

Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program


Full Comments (Listed by Measure)

Medication Reconciliation for Patients Receiving Care at Dialysis Facilities (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC17-176)
30-Day Unplanned Readmissions for Cancer Patients (Program: Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program; MUC ID: MUC17-178)
Hospital-Wide All-Cause Risk Standardized Mortality Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC17-195)
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC17-196)
Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events (Program: Hospital Inpatient Quality Reporting and EHR Incentive Program; MUC ID: MUC17-210)
Lumbar Spine Imaging for Low Back Pain (Program: Hospital Outpatient Quality Reporting Program; MUC ID: MUC17-223)
Hospital Visits following General Surgery Ambulatory Surgical Center Procedures (Program: Ambulatory Surgical Center Quality Reporting Program; MUC ID: MUC17-233)
Percentage of Prevalent Patients Waitlisted (PPPW) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC17-241)
Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) (Program: End-Stage Renal Disease Quality Incentive Program; MUC ID: MUC17-245)

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Appendix E: Instructions for Joining the Meeting Remotely

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