This measure is a re-specified version of the measure, “Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)” (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (“provider”) and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.
Category: Quality Measures
Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer
Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging.
Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate
Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.
Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)
The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items – to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.
Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)
The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.
Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.
Multimodal Pain Management
Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain management.
Functional Status Change for Patients with Neck Impairments
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.
Back Pain After Lumbar Surgery
For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.
Leg Pain After Lumbar Surgery
For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.