Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Alignment and Coordination of Performance Measures Across Medicare Provider Settings

02/01/2009

We evaluated the extent of alignment and coordination of measures across the six performance measurement programs. By alignment we mean whether the measures included in these programs address the same conditions or procedures. For conditions and procedures that are addressed by more than one program, we then assess whether the programs include similar measures for that condition or procedure, which we refer to as "overlap." This determination was based on measure titles; we did not obtain actual measure specifications to determine whether the measures were exactly the same. We also provide a brief discussion of the range of measures for conditions or procedures that are addressed in multiple programs.

The performance measures reported in the six settings cover 53 different conditions or procedures as well as patient experience in the hospital setting, the presence of health information technology in physician offices, and some health and functional status measures that are not disease/condition specific for skilled nursing facilities and home health.  Of the 249 measures reported in total, 224 (90 percent) are reported only for a single setting.  There are some cases where the same conditions are addressed by the various reporting programs, although identical measures are not being collected across the different settings being measured. Table 4 summarizes the type of conditions, diseases, and procedures that are currently addressed to greater or lesser extents by the various reporting programs.  Only ten conditions are addressed by performance measurement programs for more than one setting. Three conditions/diseases/procedures are included in programs for three settings: acute myocardial infarction, perioperative/surgical care, and urinary incontinence. Seven conditions are included in programs for two settings: back pain, community acquired pneumonia, depression, end stage renal disease, heart failure, pain, and prevention.

 

Table 4. Conditions, Diseases and Procedures Covered By Measures Reported to Medicare (as of November 1, 2008)*
Conditions/Diseases/ Procedures # of Reporting Programs Addressing Condition Hospital Inpatient
(RHQDAPU)
Hospital Outpatient
(HOP QDRP)
Physicians Practitioners
Therapist (PQRI)
Skilled Nursing Facilities Home Health Dialysis Facilities
Acute Myocardial Infarction 3 X X X      
Perioperative /Surgical Care 3 X X X      
Urinary Incontinence 3     X X X  
Back Pain 2   X X      
Community Acquired Bacterial Pneumonia 2 X   X      
Depression 2     X X    
End Stage Renal Disease 2     X     X
Heart Failure 2 X   X      
Pain 2       X X  
Prevention 2     X X    
Abdominal Aortic Aneurysm 1 X          
Acute Bronchitis 1     X      
Acute Leukemia 1     X      
Acute Otitis Externa 1     X      
Asthma 1     X      
Breast Cancer 1     X      
Cataracts 1     X      
Catheter-Associated Blood Stream Infections 1     X      
Chronic Kidney Disease 1     X      
Chronic Lymphotic Leukemia 1     X      
Chronic Obstructive Pulmonary Disease 1     X      
Colon Cancer 1     X      
Coronary Artery Bypass Graft 1     X      
Coronary Artery Disease 1     X      
Delirium 1       X    
Diabetes 1     X      
Diabetic Retinopathy 1     X      
Dsypnea 1         X  
Endarterectomy 1     X      
Falls 1     X      
Glaucoma 1     X      
Hepatitis C 1     X      
Imaging 1   X        
Incontinence (Bowel) 1       X    
Macular Degeneration 1     X      
Multiple Myeloma 1     X      
Myelodyplastic Syndrome 1     X      
Non-Traumatic Chest Pain 1     X      
Osteoarthritis 1     X      
Osteoporosis 1     X      
Otis Media with Effusion 1     X      
Pharyngitis 1     X      
Pneumothorax 1 X          
Pressure Sores 1       X    
Prostate Cancer 1     X      
Rectal Cancer 1     X      
Rheumatoid Arthritis 1     X      
Stroke 1     X      
Syncope 1     X      
Upper Respiratory Infection 1     X      
Urinary Tract Infection 1       X    
Weight Loss (Undesired) 1       X    
Wound Care 1     X      

* Includes measures that will be reported in 2009.

Below we describe the areas of alignment and overlap by condition or type of care. For the nine conditions addressed by more than one performance measurement program, Table 5 list the individual measures by condition and indicates the areas of overlap.

  • Acute myocardial infarction measures are included in the RHQDAPU (9 measures), HOP QDRP (5 measures) and PQRI (1 measure) reporting programs. An "aspirin at arrival" measure is included in all three reporting efforts, while fibrinolytic medication received within 30 minutes of hospital arrival is included in RHQDAPU and HOP QDRP.27 RHQDAPU includes a measure of the receipt of PCI within 120 minute of arrival, while HOP QDRP has a measure examining the median time to transfer for PCI. The remaining measures in the programs do not overlap. Of the 15 measures in the three programs, ten focus on either the care received upon arrival of the patient to the hospital or the time it took the patient to receive recommended care, four address prescriptions or counseling received at discharge from the hospital and one is a longer-term patient outcome.
  • Perioperative /Surgical care measures are included in the RHQDAPU (11 measures), HOP QDRP (2 measures), and PQRI (6 measures) reporting programs. Measures related to the timing of the ordering and the selection of prophylactic antibiotics for surgical patients are included in all three programs, while measures on the discontinuation of these prophylactic antibiotics are included only in RHQDAPU and PQRI. A measure on the ordering of venous thromboembolism prophylaxis is included in both RHQDAPU and PQRI; a measure on the actual administration is included only in RHQDAPU. RHQDAPU also includes measures for appropriate hair removal and post-operative serum glucose control for cardiac patients and several surgical outcome measures.
Table 5. Measures for Conditions Addressed by Multiple Reporting Programs (as of November 1, 2008)*
Measure Hospital Inpatient(RHQDAPU) Hospital Outpatient (HOP QDRP) Physicians Practitioners Therapist (PQRI) Skilled Nursing Facilities Home Health Dialysis Facilities
Conditions Addressed by Three Reporting Programs
Acute Myocardial Infarction (AMI)
Aspirin at arrival (For HOP QDRP, applies to emergency department transfers) X X X      
Aspirin prescribed at discharge X          
ACE-I or ARB for LVSD X          
Adult smoking cessation advice/counseling X          
Beta blocker at arrival X          
Beta blocker prescribed at discharge X          
Fibrinolytic medication received within 30 minutes of hospital arrival (For HOP QDRP, applies to emergency department transfers) X X        
Emergency department transfer: median time to fibrinolysis   X        
PCI received within 120 minutes of hospital arrival X          
Emergency department transfer: median time to transfer for primary PCI   X        
Emergency department transfer: median time to electrocardiogram   X        
30-day AMI mortality X          
Perioperative/Surgical Care
Timing of antibiotic prophylaxis-ordering physician     X      
Timing of administration of prophylactic antibiotic for surgical patients X X X      
Prophylactic antibiotic selection for surgical patients X X X      
Prophylactic antibiotics discontinued within 24 hours after surgery end time: (For PQRI separated into cardiac and non-cardiac procedures) X   X

(2 measures)

     
Surgery patients with recommended venous thromboembolism prophylaxis ordered X   X      
Surgery patients with recommended venous thromboembolism prophylaxis received within 24 hours prior to or after surgery X          
Cardiac patients with controlled 6 am post-operative serum glucose X          
Surgery patients with appropriate hair removal X          
Surgery patients on a beta blocker prior to arrival who received a beta blocker during the perioperative period X          
Death among surgical patients with treatable serious complications X          
Postoperative wound dehiscence X          
Mortality for selected surgical procedures (composite) X          
Urinary Incontinence (UI)
Assessment of presence or absence of UI in women aged 65 years and older     X      
Characterization of UI in women aged 65 years and older     X      
Plan of care for women aged 65 years and older     X      
Improvement in urinary incontinence         X  
Residents who have had a catheter inserted and left in their bladder       X    
Conditions Addressed by Two Reporting Programs
Community Acquired Bacterial Pneumonia (PN)
Oxygenation assessment     X      
Blood culture performed in the emergency department before the first antibiotic received in hospital X          
Appropriate initial antibiotic selection X   X      
Initial antibiotic received within 4 hours X          
Assessed and given pneumococcal vaccination X          
Assessed and given influenza vaccination X          
Vital signs     X      
Assessment of mental status     X      
Adult smoking cessation advice/counseling X          
30-day PN mortality X          
Depression
Antidepressant medication during acute phase for patients with new episode of major depression     X      
Patients who have major depression disorder who meet DSM IV criteria     X      
Assessed for suicide risk     X      
Residents who are more depressed or anxious       X    
ESRD
Plan of care for inadequate peritoneal dialysis     X      
Vascular access for patients undergoing hemodialysis     X      
Influenza vaccination     X      
Plan of care for inadequate hemodialysis     X      
Adequacy of hemodialysis (pediatric)     X      
Influenza vaccination (pediatric)     X      
Anemia control           X
Hemodialysis adequacy           X
Patient survival           X
Heart Failure - (HF)
Left ventricular function assessment X          
ACE-I or ARB for LVSD X   X      
Beta blocker therapy for LVSD     X      
Adult smoking cessation advice/counseling X          
Discharge instructions X          
30-day HF mortality X          
30-day HF readmission X          
Pain
Improvement in pain interfering with activity         X  
Residents who had moderate to severe pain       X    
Prevention/Screening
Medication reconciliation after discharge from inpatient setting     X      
Advance care plan     X      
Influenza vaccination for patients > 50 (for SNF measure: residents during flu season)     X X    
Pneumonia vaccination for patients > 65 (for SNF measure: residents assessed and given vaccination)     X X    
Screening mammography     X      
Colorectal cancer screening     X      
Inquiry regarding tobacco use     X      
Advising smokers to quit     X      
Universal weight screening and follow-up     X      
Universal documentation and verification of current medications in the medical record     X      
Pain assessment prior to initiation of patient treatment     X      
Screening for clinical depression     X      
Screening and brief counseling for alcohol abuse     X      
Endoscopy and polyp surveillance     X      
Elder maltreatment screen with follow-up plan     X      
* Includes measures that will be reported in 2009.

* Includes measures that will be reported in 2009.

  • Urinary incontinence measures are included in the PQRI (3 measures), HHQI (1 measure), and NHQI (1 measure) reporting programs. NHQI includes a second measure that addresses both urinary and bowel incontinence.  None of the measures in the three programs overlap. The PQRI measures focus on the identifying and characterizing urinary incontinence, and putting in place a treatment plan. The SNF NHQI measure focuses on the use of use of catheters being inserted and left in the bladder of residents with urinary incontinence. The HHQI measure focuses on improvement in urinary incontinence.
  • Pneumonia measures are included in RHQDAPU (7 measures) and PQRI (4 measures) reporting programs. Both programs include measures on appropriate initial antibiotic selection. The other measures in the programs do not overlap. The other three PQRI pneumonia measures focus on the patient's oxygen saturation, vital signs and assessment of mental status. The remaining RHQDAPU pneumonia measures address the performance of blood cultures prior to receipt of antibiotics, the timing of antibiotic administration, assessment for and administration of pneumococcal and influenza vaccinations, smoking cessation advice and 30-day mortality.
  • Depression measures are included in the PQRI (3 measures) and NHQI (1 measure) reporting programs. While both PQRI and NHQI measures focus on the assessment of depression, the specifications differ so the measures are not completely aligned. Two PQRI measures focus on the use of antidepressants and assessing depressed patients for their suicide risk and do not appear as measures in any other setting.
  • End stage renal disease is addressed by two programs: PQRI (6 measures) and the dialysis facility program (3 measures). The PQRI measures focus on vascular access for patients receiving hemodialysis, influenza vaccination status and care plans (2 measures) for ESRD patients as well as two pediatric measures, while the measures in the dialysis facility program focus on anemia control, hemodialysis adequacy and ESRD patient survival.
  • Heart failure measures are included in the RHQDAPU (6 measures) and PQRI (2 measures) reporting programs. Both programs include a measure assessing the receipt of ACE-inhibitors or ARB for LVSD. - Other RHQDAPU measures focus on left ventricular function assessment, care around the time of discharge from the hospital, 30-day mortality, and 30 day readmission. PQRI includes a measure on the use of beta blocker therapy for LVSD, which is not included in RHQDAPU.
  • Pain measures are found in two reporting programs. The NHRI includes two measures, one for long stay patients and one for short stay patients that assess the presence of moderate to severe pain. The HHQI program includes a measure on improvement in the extent to which pain affects functioning.
  • Prevention/Screening measures are contained in the PQRI program (15 measures), and the NHQI includes 4 measures (two for long-term stay residents and two for short stay residents). The nursing home measures (receipt of influenza vaccination during the flu season, and pneumococcal vaccination) are analogous to two of the measures in PQRI.  PQRI also has an influenza vaccination measure that focuses on patients with ESRD (therefore, this measure is counted under ESRD). In addition, PQRI includes a variety of screening, counseling, care planning and immunization measures. RHQDAPU also includes the two vaccination measures for influenza and pneumococcal, but limits the eligible population to individuals hospitalized with community acquired pneumonia (therefore, these measures are counted under pneumonia).

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