Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Appendix E. Settings Involved in Episodes, by Condition and Measures Reported to Medicare Reporting Programs

02/01/2009

(as of 12/08/2008, includes measures for 2009 reporting)

Figure E1. Settings Involved in Episodes: AMI (MEGS)

AMI (MEGS)

Nearly all (97%) patients with an AMI episode utilized an acute care hospital, 86 percent utilized the hospital outpatient department (which includes the emergency department), and 23 percent visited a physician office for that episode.  Additionally, approximately 17 percent of patients utilized home health and 10 percent a skilled nursing facility.  The three most common combinations of settings accounted for 67 percent of all AMI episodes in our sample. While there are nine clinical measures reported for the hospital facility (and one for physicians in the hospital setting) and five measures for the emergency department, there is only one measure for care delivered in a physician office.  The skilled nursing and home health measures are not condition specific and apply to all patients.

Table E1. Process and Outcome Measures Reported to CMS Applicable to AMI Patients
Measure Condition Measure Hospital-Inpatient Hospital Outpatient/ED Physician
AMI Aspirin at Arrival- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -   X X X (inpatient)*
AMI Aspirin at discharge- - - - - - - - - - - - -  - - - - - - - - - - - - - - - - - - - - -  X    
AMI ACE-I or ARB for LVSD X    
AMI Adult smoking cessation advice/counseling X    
AMI Beta blocker at arrival X    
AMI Beta blocker prescribed at discharge X    
AMI Fibrinolytic medication received within 30 minutes of hospital arrival X X  
AMI PCI received within 120 minutes of hospital arrival X    
AMI 30-day AMI mortality X    
AMI Median time to fibrinolysis   X  
AMI Median time to electrocardiogram   X  
AMI Median time to transfer for primary PCI   X  
CAD Beta blocker therapy for patients with prior MI     X

*This is a PQRI physician-level measure that would apply in a hospital setting

Other Potentially Relevant Measures
There are number of measures that may apply to subsets of AMI patients.  These include CABG/Cardiac Surgery, Heart Failure, and Perioperative measures.  Additionally the PQRI measures calling for an electrocardiogram for non-traumatic chest pain or syncope may apply.

Figure E2. Settings Involved in Episodes: Diabetes (MEGS)

Diabetes (MEGS)

Over 80 percent of patients with a diabetes episode visited a physician office and 30 percent utilized the hospital outpatient department.  Only 4 percent had an acute care hospitalization related to the episode.  Additionally, 8 percent utilized home health care and 7 percent a skilled nursing facility.  The two most common combinations of settings accounted for 71 percent of the diabetes episodes in our sample. There are currently 10 measures reported to CMS for the physician office setting where the majority of the care for diabetes episodes is taking place. The skilled nursing and home health measures are not condition specific and apply to all patients.

Measure Condition Measure Physician (Ambulatory)
Table E2. Process and Outcome Measures Reported to CMS Applicable to Diabetes Patients
Diabetes Hemoglobin A1C poor control X
Diabetes LDL control X
Diabetes Blood pressure control X
Diabetes Dilated eye exam X
Diabetes Urine screening or medical attention for nephropathy X
Diabetes Foot exam X
Diabetes Foot and ankle care: neurological evaluation X
Diabetes Foot and ankle care: evaluation of footwear X
Diabetic Retinopathy Documentation of presence or absence of macular edema and level of severity of retinopathy X
Diabetic Retinopathy Communication with the physician managing ongoing diabetes care X

Other Potentially Relevant Measures
The PQRI measure for wound care for patients with venous ulcers is also potentially relevant for individuals with diabetes

Figure E3. Settings Involved in Episodes: Hip Fracture (MEGS)

Hip Fracture (MEGS)

Eighty three percent of patients with a hip fracture episode utilized an acute care hospital, 81 percent utilized the hospital outpatient department (including the emergency department) and 59 percent visited a physician office related to the episode.  Additionally, 56 percent utilized a skilled nursing facility, 40 percent home health care 18 percent inpatient rehabilitation.  The two most common combinations of settings accounted for 32 percent of the hip fracture episodes in our sample. There is currently only one measure reported to CMS for hip fracture and that is for mortality in the acute care hospital setting. The skilled nursing and home health measures are not condition specific and apply to all patients.

Table E3. Process and Outcome Measures Reported to CMS Applicable to Hip Fracture Patients
Measure Condition Measure Hospital Inpatient
Hip Fracture Hip Fracture Morality Rate X

Other Potentially Relevant Measures
As most patients who have a hip fracture will have surgery, the perioperative measures would apply as would the hospital inpatient Patient Safety Indicator for post operative wound dehiscence. Additionally, the PQRI osteoporosis measure calling for management following a fracture would likely apply

Figure E4. Settings Involved in Episodes: Bacterial Pneumonia (ETGs)

Bacterial Pneumonia (ETGs)

Eighty two percent of bacterial pneumonia episodes involved an acute care hospital, 62 percent involved the hospital outpatient department and 47 percent a physician office visit. Additionally, in nearly 28% of the episodes, patients utilized a skilled nursing facility, in 8 percent they utilized home health care, and 5 percent of episodes involved a stay in a long term care hospital.  The three most common combinations of settings accounted for 43 percent of the bacterial pneumonia episodes in our sample.  There are eight measures reported for bacterial pneumonia in the acute inpatient setting, no measures reported for the hospital outpatient setting and four measures reported for care in a physician office.  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

Figure E5. Settings Involved in Episodes: Bacterial Pneumonia (MEGS)

Bacterial Pneumonia (MEGS)

Figure E5 This chart graphic shows that Seventy percent of bacterial pneumonia episodes involved an acute care hospital, 67 percent involved the hospital outpatient department and 52 percent a physician office visit. Additionally, in 34 percent of the episodes, patients utilized a skilled nursing facility, in 11 percent they utilized home health care, and 5 percent of episodes involved a stay in a long term care hospital.-  The three most common combinations of settings accounted for 40 percent of the bacterial pneumonia episodes in our sample.-  There are eight measures reported for bacterial pneumonia in the acute inpatient setting, no measures reported for the hospital outpatient setting and four measures reported for care in a physician office.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

Table E4. Process and Outcome Measures Reported to CMS Applicable to Bacterial Pneumonia Patients

Measure Condition Measure Hospital Inpatient Physician (Ambulatory)
PN Oxygenation assessment   X
PN Assessed and given pneumococcal vaccination X  
PN Assessed and given influenza vaccination X  
PN Blood culture performed in the emergency department before the first antibiotic received in hospital X  
PN Appropriate initial antibiotic selection X X
PN Initial antibiotic received within 4 hours X  
PN Adult smoking cessation advice/counseling X  
PN 30-day PN mortality X  
PN Vital signs   X
PN Assessment of mental status   X

Other Potentially Relevant Measures
For patients who are hospitalized with bacterial pneumonia, the "Failure to Rescue" measure may apply.  For those patients with HIV/AIDS who are presenting with pneumonia, the PQRI HIV/AIDS measures would be relevant.

Figure E6. Settings Involved in Episodes: Breast Cancer (ETGs)

Breast Cancer (ETGs)

Figure E6 This chart graphic shows that Breast cancer episodes most often involved the physician office (94 percent) and/or the hospital outpatient department (79 percent).-  Twenty one percent of breast cancer episodes involved an acute hospital inpatient stay, 7 percent involved home health, and 3 percent a skilled nursing facility.-  The three most common combinations of settings accounted for 81 percent of all breast cancer episodes.-  There are only two measures reported to CMS for breast cancer, and they are both applicable to care provided by physicians in an ambulatory setting.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

 

Figure E7. Settings Involved in Episodes: Breast Cancer (MEGS)

Breast Cancer (MEGS)

Figure E7 This chart graphic shows that Breast cancer episodes most often involved the physician office (94 percent) and/or the hospital outpatient department (68 percent).-  Only 8 percent of breast cancer episodes involved an acute hospital inpatient stay, 3 percent involved home health, and 2 percent a skilled nursing facility.-  The two most common combinations of settings accounted for 80 percent of all breast cancer episodes.-  There are only two measures reported to CMS for breast cancer, and they are both applicable to care provided by physicians in an ambulatory setting.  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

Measure Condition Measure Physician

(Ambulatory)

Table E5. Measures Reported to CMS Applicable to Breast Cancer Patients
Breast cancer Hormonal therapy for stage 1C-III ER/PR positive breast cancer X
Breast cancer pT and pN category and histologic grade X

Other Potentially Relevant Measures
For those patients requiring surgery, the inpatient or outpatient perioperative measures would apply.  Additionally, the PQRI measure for nuclear medicine, "Correlation with existing imaging studies for patients undergoing bone scintigraphy" and the mammography follow-up rates measure may be relevant for some patients.

Figure E8. Settings Involved in Episodes: Cerebrovascular Disease (ETGs)

Cerebrovascular Disease (ETGs)

Figure E8 shows that Cerebrovascular episodes most often involved the physician office (75%) and/or the hospital outpatient department (68%).-  Sixty one percent of cerbrovascular episodes involved an acute hospital inpatient stay, 20 percent involved home health, and 18 percent a skilled nursing facility.-  The three most common combinations of settings accounted for 48 percent of all cerebrovascular episodes.-  There are eight stroke measures included in the PQRI, four of which are applicable to physicians in the acute care hospital setting and four of which could be applicable to the physician office setting or the acute care hospital setting.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

Figure E9. Settings Involved in Episodes: Cerebrovascular Disease (MEGS)

Cerebrovascular Disease (MEGS)

Figure E9 shows that Cerebrovascular episodes most often involved the physician office (70%) and/or the hospital outpatient department (45%).-  Thirty four percent of cerbrovascular episodes involved an acute hospital inpatient stay, 13 percent involved a skilled nursing facility, 9 percent home health care, and 4 percent an inpatient rehabilitation facility.-  The most common combination of settings was the physician ambulatory setting which accounted for 40 percent of all cerebrovascular episodes.-  There are eight stroke measures included in the PQRI, four of which are applicable to physicians in the acute care hospital setting and four of which could be applicable to the physician office setting or the acute care hospital setting.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

 

Table E6. Process and Outcome Measures Reported to CMS Applicable to Cerebrovascular Patients

Measure Condition Measure Physician
Stroke - CT or MRI reports X
Stroke Carotid imaging reports X
Stroke DVT for ischemic stroke or intracranial hemorrhage X (Inpatient)*
Stroke Discharged on antiplatelet therapy X (Inpatient)*
Stroke Anticoagulant therapy for atrial fibrillation at discharge X (Inpatient)*
Stroke Tissue Plasminogen Activator (t-PA) considered X (Inpatient)*
Stroke Screening for dysphagia X
Stroke Consideration of rehabilitation services X

*These are PQRI physician-level measures that would likely apply within the hospital inpatient setting.

Other Potentially Relevant Measures
For a subset of patients with cerebrovascular disease, the PQRI endarterectomy measure would be relevant as would the perioperative measure for recommended venous thromboembolism.

Figure E10. Settings Involved in Episodes: COPD (ETGs)

COPD (ETGs)

Figure E10 shows that COPD episodes most often involved the physician office (75%) followed by the hospital outpatient department (59%) and the acute care hospital setting (47%). Additionally, 12 percent of episodes involved a skilled nursing facility or home health care. The three most common combinations of settings accounted for 52 percent of all COPD episodes.-  There are currently two COPD measures included in the PQRI for physicians.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

Figure E11.  Settings Involved in Episodes: COPD (MEGS)

COPD (MEGS)

Figure E11 shows that COPD episodes most often involved the physician office (78%) followed by the hospital outpatient department (41%) and the acute care hospital setting (19%). Additionally, 12 percent of episodes involved a skilled nursing facility and 11 percent home health care. The two most common combinations of settings accounted for 56 percent of all COPD episodes.-  There are currently two COPD measures included in the PQRI for physicians.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

 

Table E7. Process and Outcome Measures Reported to CMS Applicable to COPD Patients

Measure Condition Measure Physician (Ambulatory)
COPD Spirometry evaluation X
COPD Bronchodilator therapy X

Other Potentially Relevant Measures
The inpatient and PQRI pneumonia measures would be relevant to those patients who develop pneumonia as a complication of COPD.

Figure E12. Settings Involved in Episodes: Congestive Heart Failure (CHF) (ETGs)

Congestive Heart Failure (CHF) (ETGs)

Figure E12 shows that CHF episodes most often involved the physician office (65%) followed by the hospital outpatient department (57%) and the acute care hospital setting (51%). Additionally, 16 percent of episodes involved a skilled nursing facility, 13 percent home health care, and 4 percent hospice. The three most common combinations of settings accounted for 42 percent of all CHF episodes.-  There are currently five measures addressing CHF in the acute care hospital setting and two for physicians.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

 

Figure E13. Settings Involved in Episodes: Congestive Heart Failure (CHF) (MEGSs)

Congestive Heart Failure (CHF) (MEGSs)

Figure E13 shows that CHF episodes most often involved the physician office (74%) followed by the hospital outpatient department (49%) and the acute care hospital setting (26%). Additionally, 16 percent of episodes involved a skilled nursing facility, 9 percent home health care, and 3 percent hospice. The two most common combinations of settings accounted for 49 percent of all CHF episodes.-  There are currently five measures addressing CHF in the acute care hospital setting, a 30 day readmission measure (new for 2009) and two for physicians.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

 

Table E8. Process and Outcome Measures Reported to CMS Applicable to CHF Patients
Measure Condition Measure Hospital Inpatient Physician (Ambulatory)
HF Discharge instructions X  
HF Left ventricular function assessment X  
HF ACE-I or ARB for LVSD X X
HF Adult smoking cessation advice/counseling X  
HF 30-day HF mortality X  
HF 30-day HF readmission X  
HF Beta blocker therapy for LVSD   X

Other Potentially Relevant Measures

For some patients with congestive heart failure, some of the AMI, cardiac surgery and coronary artery disease measures would be relevant.

Figure E14. Settings Involved in Episodes: Low Back Pain (ETGs)

Low Back Pain (ETGs)

Figure E14 shows that Low back pain episodes most often involved the physician office (91%) followed by the hospital outpatient department (47%) and the acute care hospital setting (12%). Additionally, 8 percent of episodes involved home health care, and 4 percent skilled nursing facilities. The two most common combinations of settings accounted for 70 percent of all low back pain episodes.-  There are currently four measures reported to CMS addressing low back pain in the physician office setting and one measure related to imaging appropriateness for the hospital outpatient department.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

Figure E15. Settings Involved in Episodes: Low Back Pain (MEGS)

Low Back Pain (MEGS)

Figure E15 shows that Low back pain episodes most often involved the physician office (87%) followed by the hospital outpatient department (30%) and the acute care hospital setting (4%). Additionally, 4 percent of episodes involved home health care, and 3 percent skilled nursing facilities. The two most common combinations of settings accounted for 78 percent of all low back pain episodes.-  There are currently four measures reported to CMS addressing low back pain in the physician office setting and one measure related to imaging appropriateness in the hospital outpatient department.-  The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.

Table E9. Process and Outcome Measures Reported to CMS Applicable to Low Back Pain Patients

Measure Condition Measure Hospital Outpatient Physician (Ambulatory)
Imaging MRI lumbar spine for low back pain X  
Back pain Initial visit   X
Back Pain Physical Exam   X
Back Pain Advice for normal activities   X
Back Pain Advice against bed rest   X

Other Potentially Relevant Measures
The two PQRI measures for osteoarthritis may be relevant for patients with low back pain.  Additionally, the PQRI measure calling for functional outcome assessments for chiropractic care would be relevant to those patients who utilize chiropractic care for low back pain.

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