public comment measure workbook

IMPAQ International, LLC

Comprehensive ESRD Care (CEC) Model Proposed Quality Measures for Public Comment

Table of Contents

Page # Introduction 3

Measure Summaries by Domain

Technical Expert Panel Recommended CEC Quality Measures 4 Measures that were recommended by a majority of TEP members or that align with CMS priorities. Quality of Life

1. Kidney Disease Quality of Life (KDQOL) 4 Chronic Disease Management

2. Diabetes Care: Eye Exam 5 3. Diabetes Care: Foot Exam 6 4. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes

Care 7

5. Rate of Lower-Extremity Amputation Among Patients with Diabetes 8 6. Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI)

or Left Ventricular Systolic Dysfunction (LVEF <40%) 9

7. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

10

Patient Safety

8. Dialysis Facility Risk-Adjusted Standardized Mortality Ratio 11

Preventive Health

9. Influenza Immunization 12 10. Pneumonia Vaccination Status for Older Adults 13 11. Screening for Clinical Depression and Follow-Up Plan 14 12. Tobacco Use: Screening and Cessation Intervention 15

Care Coordination

13. Standardized Readmission Ratio (SRR) for Dialysis Facilities 16 14. Standardized Hospitalization Ratio for Admissions 17 15. Advance Care Plan 18 16. Documentation of Current Medications in the Medical Record 19

CEC Measure Workbook 2 IMPAQ International, LLC

Measures Under Consideration 20 Measures that received mixed evaluation results from the TEP, but align with CMS priorities.

Quality of Life

1. Functional Status Assessment for Complex Chronic Conditions 20

Chronic Disease Management

2. Diabetes: Hemoglobin A1c Poor Control 21 3. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 22 4. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 23

Patient Safety

5. Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) 24

Care Coordination

6. Medication Reconciliation 25 7. Anemia of Chronic Kidney Disease: Dialysis Facility Standardized Transfusion Ratio 26


Introduction

This workbook includes proposed quality measures for the Comprehensive End Stage Renal Disease Care (CEC) Initiative. The quality measures will be part of an overall quality score used to assess the performance of the ESRD seamless care organizations (ESCOs) and determine the shared savings or losses for each year. This initial CEC measure list includes performance measures that are National Quality Forum (NQF) endorsed or currently in use in other CMS programs that were found to be applicable and relevant to the ESRD population. Subsequent to measure selection and concurrent with public comment, the IMPAQ team will evaluate the feasibility of adapting the technical specifications for ESCO implementation including identifying data sources and implementation or operational issues.

The IMPAQ team seeks comments on each of the measure concepts presented in this CEC Quality Measure Workbook and their applicability to the ESRD population. Reviewers should note that the existing technical measure specifications may need to be adapted to fit the ESRD population and to report each measure at the ESCO level. Once CMS finalizes the set of quality measures for the CEC Model, the IMPAQ team will adapt the technical specifications for ESCO implementation including identifying data sources. This process will be completed in consultation with the measure stewards and NQF, if applicable. Quality measures for the CEC Model will be collected and calculated from a combination of data sources, including CMS claims, patient survey data and clinical medical records and could be reported by dialysis facilities, individual providers and provider groups, and other vendors that are part of an ESCO. The measures are presented in two groups:

1. CEC Quality Measures Recommended by the Technical Expert Panel: measures that were recommended by a majority of TEP members or that align with CMS priorities.

2. Measures Under Consideration: measures that received mixed evaluation results from the TEP, but align with CMS priorities.

The workbook includes detailed information about each of the measures including the numerator, denominator, and a link to the measure specification. Information about the measures is drawn from the CMS Clinical Quality Measures (CQM) Library, or, when not available, the National Quality Forum’s Quality Positioning System. Reviewers should note that the specifications do not yet reflect any adaptations for ESCO implementation; this process will occur subsequent to measure selection.


Comprehensive ESRD Care (CEC) Model

Public Comment Measure Summaries TEP Recommended CEC Quality Measures

Kidney Disease Quality of Life (KDQOL) Administration

Survey Tool Kidney Disease Quality of Life (KDQOL)

NQF Number: N/A

Measure Criteria Overview Self-reported survey that assesses health-related quality of life (physical and mental functioning) of ESRD patients receiving dialysis. The survey population includes patients currently dialyzing in-center and home hemodialysis and peritoneal dialysis patients (aged 18 years and older) minus exclusions. Includes: peritoneal dialysis, in-center hemodialysis, home hemodialysis.

Exclusions Under age 18.

Unable to complete due to cognitive impairment, dementia or active psychosis.

Non-English speaking/reading (no native language translation or interpreter available).

Patients under the facility’s care for less than 3 months.

Patients who refuse to complete the questionnaire.

Data Source Patient Survey

Measure Steward RAND Corporation

Quality Domain Quality of Life

Other Quality Programs Using Measure

Part 494 Conditions for Coverage for End-Stage Renal Disease Facilities: Interpretive Guidance

Specification Source

http://www.rand.org/health/surveys_tools/kdqol.html


Diabetes Care: Eye Exam

Measure Diabetes Care: Eye Exam

NQF Number: 0055

Measure Criteria Description Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period.

Numerator Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: A retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period.

Denominator Patients 18-75 with diabetes with a visit during the measurement period.

Exclusions Patients with a diagnosis of gestational diabetes during the measurement period.

Data Source EHR/paper medical record

Measure Steward National Committee for Quality Assurance (NCQA)

Quality Domain Chronic Disease Management


Meaningful Use Stage 2, Physician Quality Reporting System


http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html Will be modified as needed for paper medical records.


Diabetes Care: Foot Exam

Measure Diabetes Care: Foot Exam

NQF Number: 0056

Measure Criteria Description Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period.

Numerator Patients who received visual, pulse and sensory foot examinations during the measurement period.

Denominator Patients 18-75 with diabetes with a visit during the measurement period.

Exclusions Patients with a diagnosis of gestational diabetes, or who had a bilateral foot/leg amputation performed during the measurement period.









Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

Measure Diabetic Retinopathy: Communication with the Physician

Managing Ongoing Diabetes Care

NQF Number: 0089

Measure Criteria Description Percentage of patients aged 18 years and older with a

diagnosis of diabetic retinopathy who had a dilated macular or

fundus exam performed with documented communication to

the physician who manages the ongoing care of the patient

with diabetes mellitus regarding the findings of the macular or

fundus exam at least once within 12 months.

Numerator Patients with documentation, at least once within 12 months,

of the findings of the dilated macular or fundus exam via

communication to the physician who manages the patient’s

diabetic care.

Denominator All patients aged 18 years and older with a diagnosis of

diabetic retinopathy who had a dilated macular or fundus

exam performed.

Exclusions None


Measure Steward AMA-PCPI


Other Quality

Programs Using

Measure


Specification

Source

http://cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html

Will be modified as needed for paper medical records.


Rate of Lower-Extremity Amputation Among Patients With Diabetes (PQI 16)

Measure Rate of Lower-Extremity Amputation Among Patients

With Diabetes (PQI 16)

NQF Number: 0285

Measure Criteria Description The number of discharges for lower-extremity amputation

among patients with diabetes per 100,000 population age 18

years and older in a Metro Area or county in a one year time

period.

Numerator All discharges of age 18 years and older with an ICD-9-CM

procedure code for lower-extremity amputation and

diagnosis code of diabetes in any field.

Denominator Population age 18 years and older in Metro Area or

county.

Discharges in the numerator are assigned to the

denominator based on the Metro Area or county of the

patient residence, not the Metro Area or county where

the hospital discharge occurred.

Exclusions Transfer from a hospital (different facility).

Transfer from a skilled Nursing Facility (SNF) or

Intermediate Care Facility (ICF).

Transfer from another health care facility.

MDC 14 (pregnancy, childbirth, and puerperium) with any

diagnosis of trauma.

Data Source Claims

Measure

Steward

Agency for Healthcare Research and Quality (AHRQ)


Other Quality

Programs Using

Measure

None

Specification

Source

AHRQ Prevention Quality Indicator Set

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V45/TechSpecs/P

QI%2016%20Lower-Extremity%20Amputation%20Diabetes%20Rate.pdf


Coronary Artery Disease: Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left

Ventricular Systolic Dysfunction (LVEF <40%)

Measure Coronary Artery Disease: Beta-Blocker Therapy – Prior

Myocardial Infarction or Left Ventricular Dysfunction NQF Number: 0070

Measure Criteria Description Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who also have a prior myocardial infarction (MI) or a current or prior LVEF <40% who were prescribed beta-blocker therapy.

Numerator Patients who were prescribed beta-blocker therapy.

Denominator All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period.

Exclusions None









Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Measure Heart Failure (HF): Angiotensin-Converting Enzyme (ACE)

Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

NQF Number: 0081

Measure Criteria Description Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.

Numerator Patients who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.

Denominator All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%.

Exclusions None









Dialysis Facility Risk-Adjusted Standardized Mortality Ratio

Measure Name Dialysis Facility Risk-Adjusted Standardized Mortality Ratio

NQF Number: 0369

Measure Criteria Description Risk-adjusted standardized mortality ratio for dialysis facility patients.

Numerator Number of deaths among eligible patients at the facility during the time period.

Denominator Number of deaths that would be expected among eligible dialysis patients at the facility during the time period, given the mortality rate is at the national average and the patient mix at the facility.

Exclusions N/A

Data Source Claims

Measure Steward Centers for Medicare and Medicaid Services (CMS)

Quality Domain Patient Safety


None


http://www.dialysisreports.org/pdf/esrd/public/SMRdocumentation.pdf


Influenza Immunization

Measure Name Influenza Immunization

NQF Number: 0041

Measure Criteria Description Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

Numerator Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization.

Denominator All patients aged 6 months and older seen for a visit between October 1 and March 31.

Exclusions Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons).

Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons).

Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons).



Quality Domain Preventive Health


Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality Reporting System




Pneumonia Vaccination Status for Older Adults

Measure Pneumonia Vaccination Status for Older Adults

NQF Number: 0043

Measure Criteria Description Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

Numerator Patients who have ever received a pneumococcal vaccination.

Denominator Patients 65 years of age and older with a visit during the measurement period.

Exclusions None









Screening for Clinical Depression and Follow-Up Plan

Measure Name Screening for Clinical Depression and Follow-Up Plan

NQF Number: 0418

Measure Criteria Description Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.

Numerator Patients who were screened for clinical depression on the date of the encounter using an age appropriate standardized tool and if positive, a follow-up plan is documented on the date of the positive screen.

Denominator All patients aged 12 and older at the beginning of the measurement period with at least one eligible encounter during the measurement period.

Exclusions A patient is not eligible if one or more of the following conditions exist:

Patient refuses to participate.

Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.

Situations where the patient’s motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools. For example: certain court appointed cases.

Patient was referred with a diagnosis of depression.

Patient has been participating in ongoing treatment with screening of clinical depression in a preceding reporting period

Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example: cases such as delirium or severe cognitive impairment, where depression cannot be accurately assessed through use of nationally recognized standardized depression assessment tools.









Tobacco Use: Screening and Cessation Intervention

Measure Name Tobacco Use: Screening and Cessation Intervention

NQF Number: 0028

Measure Criteria Description Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.

Numerator Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user.

Denominator All patients 18 years and older.

Exclusions Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy)





Medicare Shared Savings Program, Meaningful Use Stage 1 & Meaningful Use Stage 2, Physician Quality Reporting System, UDS




Standardized Readmission Ratio (SRR) for Dialysis Facilities

Measure Standardized Readmission Ratio (SRR) for Dialysis Facilities

NQF Number: N/A

Measure Criteria Description The ratio of the number of index discharges from acute care hospitals that resulted in an unplanned readmission to an acute care hospital within 30 days of discharge for Medicare-covered dialysis patients treated at a particular dialysis facility to the number of readmissions that would be expected given the discharging hospitals and the characteristics of the patients as well as the national norm for dialysis facilities. Note that in this document, “hospital” always refers to acute care hospital.

Numerator Each facility’s observed number of hospital discharges that are followed by an unplanned hospital readmission within 30 days of discharge.

Denominator The expected number of unplanned readmissions in each facility, which is derived from a model that accounts for patient characteristics and discharging acute care hospitals.

Exclusions Hospital discharges that:

End in death.

Result in a patient dying within 30 days with no readmission.

Are against medical advice.

Include a primary diagnosis for cancer, mental health or rehabilitation.

Occur after a patient’s 12th admission in the calendar year.

Are from a PPS-exempt cancer hospital.

Result in a transfer to another hospital on the same day.

Data Source Claims


Quality Domain Care Coordination


None


CMS Communication/Measure Information Form

IMPAQ International, LLC

Standardized Hospitalization Ratio for Admissions

Measure Standardized Hospitalization Ratio for Admissions NQF Number: 1463

Measure Criteria Description Risk-adjusted standardized hospitalization ratio for admissions for dialysis facility patients.

Numerator Number of inpatient hospital admissions among eligible patients at the facility during the reporting period.

Denominator Number of hospital admissions that would be expected among eligible patients at the facility during the reporting period, given the patient mix at the facility.

Exclusions None

Data Source Claims




None


http://www.dialysisreports.org/pdf/esrd/public-measures/SHR_Measures_Specifications_forWeb_July12_508.pdf


Advance Care Plan

Measure Advance Care Plan

NQF Number: 0326

Measure Criteria Description Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Numerator Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Denominator All patients aged 65 years and older.

Exclusions None

Data Source Claims, Electronic Clinical Data




Physician Quality Reporting System


http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_indclaimsregistry_measurespec_supportingdocs_12192012.zip


Documentation of Current Medications in the Medical Record

Measure Documentation of Current Medications in the Medical

Record NQF Number: 0419

Measure Criteria Description Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

Numerator Eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the counters, herbals, vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route.

Denominator All visits occurring during the 12 month reporting period for patients aged 18 years and older on the date of the encounter where one or more CPT or HCPCS codes are reported on the claims submission for that encounter.

Exclusions Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.









Comprehensive ESRD Care (CEC) Model Public Comment Measure Summaries

Measures Under Consideration

Functional Status Assessment for Complex Chronic Conditions

Measure Functional Status Assessment for Complex Chronic Conditions

NQF Number: TBD

Measure Criteria Description Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments.

Numerator Patients with patient reported functional status assessment results (e.g., VR-12, VR-36, MLHF-Q, KCCQ, PROMIS-10 Global Health, PROMIS-29) present in the EHR at least two weeks before or during the initial encounter and the follow-up encounter during the measurement year.

Denominator Adults aged 65 years and older who had two outpatient encounters during the measurement year and an active diagnosis of heart failure.

Exclusions Patients with severe cognitive impairment or patients with an active diagnosis of cancer.


Measure Steward CMS

Quality Domain Quality of Life






Diabetes Care: Hemoglobin A1c Poor Control

Measure Diabetes Care: Hemoglobin A1c Poor Control

NQF Number: 0059

Measure Criteria Description Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

Numerator Patients whose most recent HbA1c level (performed during the measurement period) is > 9.0%.

Denominator Patients 18-75 years of age with diabetes with a visit during the measurement period.

Exclusions Patients with a diagnosis of gestational diabetes during the measurement period.

Data Source EHR/patient medical record




Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality

Reporting System




Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic

Measure Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic

NQF Number: 0068

Measure Criteria Description Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period.

Numerator Patients who have documentation of use of aspirin or another antithrombotic during the measurement period.

Denominator Patients 18 years of age and older with a visit during the measurement period, and an active diagnosis of ischemic vascular disease (IVD) or who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period.

Exclusions N/A





Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality

Reporting System




Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Measure Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

NQF Number: 0083

Measure Criteria Description Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.

Numerator Patients who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.

Denominator All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%.

Exclusions None









Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)

Measure Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)

NQF Number: 1789

Measure Criteria Description This measure estimates the hospital-level, risk-standardized rate of unplanned, all-cause readmission after admission for any eligible condition within 30 days of hospital discharge (RSRR) for patients aged 18 and older. The measure reports a single summary RSRR, derived from the volume-weighted results of five different models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology, each of which will be described in greater detail below. The measure also indicates the hospital standardized risk ratios (SRR) for each of these five specialty cohorts. We developed the measure for patients 65 years and older using Medicare fee-for-service (FFS) claims and subsequently tested and specified the measure for patients aged 18 years and older using all-payer data. We used the California Patient Discharge Data (CPDD), a large database of patient hospital admissions, for our all-payer data.

Numerator The outcome for this measure is unplanned all-cause 30-day readmission. We defined a readmission as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an eligible index admission. All readmissions are counted as outcomes except those that are considered planned.

Denominator This claims-based measure can be used in either of two patient cohorts: (1) admissions to acute care facilities for patients aged 65 years or older or (2) admissions to acute care facilities for patients aged 18 years or older. We have tested the measure in both age groups.

Exclusion Admissions for patients without 30 days of post-discharge data.

Admissions for patients lacking a complete enrollment history for the 12 months prior to admission.

Admissions for patients discharged against medical advice (AMA).

Admissions for patients to a PPS-exempt cancer hospital.

Admissions for patients with medical treatment of cancer.

Admissions for primary psychiatric disease.

Admissions for “rehabilitation care; fitting of prostheses and adjustment devices.”

Additionally, in the all-payer testing, excluded obstetric admissions because the measure was developed among patients aged 65 years or older (approximately 500,000).

Data Source Claims

Measure Steward Centers for Medicare & Medicaid Services (CMS)

Quality Domain Patient Safety


Medicare Shared Savings Program, Hospital Inpatient Quality Reporting


National Quality Forum, Quality Positioning System


Medication Reconciliation

Measure Medication Reconciliation

NQF Number: 0097

Measure Criteria Description Percentage of patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days of discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist who had reconciliation of the discharge medications with the current medication list in the outpatient medical record documented. This measure is reported as two rates stratified by age group: 18-64 and 65+.

Numerator Patients who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.* *The medical record must indicate that the physician, prescribing practitioner, registered nurse, or clinical pharmacist is aware of the inpatient facility discharge medications and will reconcile the list with the current medications list in the medical record.

Denominator All patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care. This measure is reported as two rates with age-specific denominators: 18-64 and 65+.

Exclusions N/A

Data Source Claims, Medical Record




Medicare Shared Savings Program, Physician Quality Reporting System


National Quality Forum, Quality Positioning System; http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf


Anemia of Chronic Kidney Disease: Dialysis Facility Standardized Transfusion Ratio

Measure Anemia of Chronic Kidney Disease: Dialysis Facility Standardized Transfusion Ratio

NQF Number: N/A

Measure Criteria Description Dialysis Facility Standardized Transfusion Ratio: Description: Risk adjusted facility level transfusion ratio (STrR) for all adult dialysis patients. STrR is a ratio of number of observed eligible red blood cell transfusion events occurring in patients dialyzing at a facility to the number of eligible transfusions that would be expected from a predictive model that accounts for patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window.

Numerator Number of observed red blood cell transfusion events (defined as transfer of one or more units of blood or blood products as described in the following code set into recipient’s blood stream) among patients dialyzing at the facility during the inclusion episodes of the reporting period.

Denominator Number of eligible red blood cell transfusion events that would be expected among patients at a facility during the inclusion episodes of the reporting period, given the patient mix at the facility.

Exclusions All transfusions associated with transplant hospitalization are excluded. Patients are excluded if they have a Medicare claim for hemolytic and aplastic anemia, solid organ cancer (breast, prostate, lung, digestive tract and others), lymphoma, carcinoma in situ, coagulation disorders, multiple myeloma, myelodysplastic syndrome and myelofibrosis, leukemia, head and neck cancer, other cancers (connective tissue, skin, and others), metastatic cancer, sickle cell anemia within one year of their patient at risk time.

Data Source Claims




None


CMS Communication/Measure Information Form

public comment measure workbook

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