Medicare Post-Acute Care: Quality Measurement Final Report. APPENDIX C. Sample Rating Form (Back & Neck Condition)

Table of Contents

Physical Function Outcomes

Mental Health Outcomes

Quality of Life Outcomes

Utilization Outcomes

Physiology Outcomes

Satisfaction Outcomes

Process

Notes

Outcome indicators refer to change (e.g., decline, improvement, recovery) in the item listed.

Indicator Rating Scale:
     0 = negligible value
     1 = definite value
     2 = extremely important for measuring quality of care

Measure Rating:
     R = recommend
     NR = not recommend
     Blank = not familiar

Physical Function Outcomes
Rating Indicator Rating Measure
  General/Global Function
      Patient Questionnaire for Lumbar Spinal Stenosis
      Oswestry Low Back Pain Disability Questionnaire
      Functional Rating Scale (FRS)
      Low Back Pain Rating Scale (RS)
      Roland and Morris Disability Questionnaire
      Quebec Back Pain Disability Scale
      SF-36
      Sickness Impact Profile
      Functional Independence Measure (FIM)
      Restricted Activity Days
      Bed Days
      Nottingham Health Profile
      Duke Health Profile
      Million Instrument
  Self Care
      Oswestry Low Back Pain Disability Questionnaire
      Neck Disability Index (revised form of Oswestry)
      Dallas Pain Questionnaire (DPQ)
      Functional Rating Scale (FRS)
      Revised Oswestry Disability Index
      Revised Oswestry Pain Questionnaire
      Northwick Park Neck Pain Questionnaire
      Million Instrument
      Functional Status Questionnaire (Jette)
      6 Item Activities of Daily Living (ADL) (Katz)
      Weighted 7 Item ADL (Kane)
      5 Item ADL Recovery (Kramer)
      Bristol ADL (for persons with dementia) Barthel Index
      Lawton Instrumental Activities of Daily Living (IADLs)
      OARS (Older American Resources and Services) Multidemensional
      Physical Performance Test (Reuben)
  Ambulation/Mobility
      Limp
      Walking
      Discharge with assistive devices for ambulation
      Oswestry Low Back Pain Disability Questionnaire
      Gait speed
      Walking distance
      Tinetti Gait and Balance
       
       
       
       
       
       

 

Mental Health Outcomes
Rating Indicator Rating Measure
  Anxiety-Depression   Dallas Pain Questionnaire (DPQ)
  Depression
      Geriatric Depression Scale (GDS)
      DSM IV
      CES-D
      HAM-D
      Life Satisfaction Index K
      Zung Self-Rating Depression Scale
  Cognition
      MMSE
      Short Portable (Pfiefer)
      Blessed Dementia Scale
      Abbreviated Mental Test
      Clock Drawing Test
      Neuropsychological Testing
  Delirium    
  Anxiety
      DSM IV
  Patient Motivation    
       
       
       
       
       

 

Quality of Life Outcomes
Rating Indicator Rating Measure
  Social Life   Oswestry Low Back Pain Disability Questionnaire
  Social Interest   Dallas Pain Questionnaire (DPQ)
  Travel   Oswestry Low Back Pain Disability Questionnaire
  Work Activities   Dallas Pain Questionnaire (DPQ), Functional Rating Scale (FRS)
  Leisure Activities   Dallas Pain Questionnaire (DPQ)
  Time Spent in Bed   Functional Rating Scale (FRS)
  Health-Related Quality of Life
      SF-36 (mental health score)
      Sickness Impact Profile (SIP)
      Quality of Well-Being Scale (QWB)
      Reintegration to Normal Living Scale
  Self-Perceived Ability to Participate in Social/Recreational Activities
      Activity Pattern Indicator
  Subjective Well-Being    
  Days of Work Absenteeism
      Health Interview Survey Items
  Days in Bed
      Health Interview Survey Items
  Days of Limited Activity
      Health Interview Survey Items
  Work Status
      NASS Questionnaire
  Compensation Status
      NASS Questionnaire
  Job Description
      NASS Questionnaire
  Vocational Outcomes    
  Social Function
      Sickness Impact Profile (SIP)
      Oswestry Disability Questionnaire
      Nottingham Health Profile
  Household Activities
      Sickness Impact Profile (SIP)
  Recreation
      Sickness Impact Profile (SIP)
  Living Situation    
       
       
       
       
       

 

Utilization Outcomes
Rating Indicator Rating Measure
  Repeat Spinal Surgery    
  Hospitalization
      Hospitalized in Fixed Time Period
      Number of Hospitalizations in Fixed Time Period
      Total Hospital Days in Fixed Time Period
      Average Length of Stay of Hospitalizations Occurring within Fixed Time Period
      Length of Stay >10 days
      Total Hospital Cost/Charges in Fixed Time Period
      Days Until Hospitalized
      Hospitalized for Same Condition
      Hospitalized for New Condition
  Admission to ICU    
  Emergency Room Admission
      ER Admission in Fixed Time Period
      Total ER Admissions in Fixed Time Period
      Total ER Cost/Charges in Fixed Time Period
      Days Until ER Admission
  Rehabilitation Facility Admission
      Admission to RF in Fixed Time Period
      Number of RF Admissions in Fixed Time Period
      Total RF Days in Fixed Time Period
      Average Length of Stay of RF Admissions Occurring within Fixed Time Period
      Total RF Cost/Charges in Fixed Time Period
      Days Until RF Admission
  Skilled Nursing Facility Admission
      Admission to SNF in Fixed Time Period
      Number of SNF Admissions in Fixed Time Period
      Total SNF Days in Fixed Time Period
      Average Length of Stay of SNF Admissions Occurring within Fixed Time Period
      Total SNF Cost/Charges in Fixed Time Period
      Days Until SNF Admission
  Home Health Care Use
      Use of Home Health Aide
      Use of Home Health Nurse
      Number of Home Health Aide Visits in Fixed Time Period
      Number of Home Health Nurse Visits in Fixed Time Period
      Total Home Health Aide+Nurse Cost/ Charges in Fixed Time Period
  Total Combined PAC
      Total Days in PAC in Fixed Time Period
      Number of PAC Settings in Fixed Time Period
      Number of PAC Admissions in Fixed Time Period
      Average Length of Stay of PAC Admissions in Fixed Time Period
      Total PAC Cost/Charges in Fixed Time Period
  Level of Care Provided
      Admission to Long Term Care (NH)
      Days Until NH Placement
      Transferred from RF to SNF
      Transferred from RF to HH
      Transferred from SNF to HH
      Transferred from HH to SNF
  Use of Home-Delivered Meals (Meals-on-Wheels)    
  Amount and Intensity of Care Provided   TISS (Therapeutic Intervention Scoring System)
       
       
       
       
       

 

Physiology Outcomes
Rating Indicator Rating Measure
      Blood Transfusion Rate
      Straight Leg Raising
      Tendon Reflex
      Lumbar Movement
  Symptom Severity   Patient Questionnaire for Lumbar Spinal Stenosis
  Pain Intensity
      Oswestry Low Back Pain Disability Questionnaire
      Low Back Pain Rating Scale (RS)
      Revised Oswestry Pain Questionnaire
      Revised Oswestry Disability Index
      NASS Questionnaire
  Pain
      Patient Pain Scale 1-10
      Dallas Pain Score
      Chronic Pain Grade (VonKorff)
      Visual Analog Scale
      Hospice QI
      Pain and Impairment Relationship Scale (PAIRS)
      Pain Disability Index
      Functional Interference Estimate
      McGill Pain Questionnaire
      The Modified Somatic Perception Questionnaire (MSPQ)
  Fatigue    
  Nausea    
  Vomiting    
  Dyspnea    
  Cough    
  Sensory Changes    
  Urinary Incontinence    
  Fecal Incontinence    
  Anorexia, Diminished Appetite    
  Sleep Disorder    
  Chest Pain    
  Sputum Production    
  Heart Rate    
  Respiratory Rate    
  Blood Pressure    
  Oxygenation    
  Deep Venous Thrombosis    
  Pulmonary Embolism    
  Aspiration Pneumonia    
  Pressure Sores    
  Flexion Contractures    
  Dehydration    
  Falls    
  Falls with Injury    
  Constipation    
  Fecal Impaction    
  Electrolyte Complications    
  Adverse Drug Reactions    
  Wound Infections    
  Nosocomial Infections    
  Rash    
  Renal Failure    
  Hepatic Function Abnormalities    
  Pleural Effusion    
  Urinary Retention    
  Clostridium Difficile Infection    
  Malnutrition    
  Mortality    
       
       
       
       
       

 

Satisfaction Outcomes
Rating Indicator Rating Measure
  Patient Satisfaction   Patient Questionnaire for Lumbar Spinal Stenosis
      Satisfaction with Results of Surgery
      Satisfaction with Treatment Outcome
      Would Go Through Operation Again for the Same Result
      Would Still Choose Back Operation
      Surgery was Worthwhile
      Would be Satisfied to Spend Rest of Life Like Now
  Patient Satisfaction
      MOS Items
      Nursing Home Resident Satisfaction Scale
  Caregiver Satisfaction
      Family Assessment Device
       
       
       
       
       

 

Process
Rating Indicator Rating Measure
  Use of Prescription Analgesic Medications   Functional Rating Scale (FRS)
  Transcutaneous Electrical Nerve Stimulator (TNS) Usage   Functional Rating Scale (FRS)
  Neurological Checks    
  Depression Treatment
      Anti-Depressants
      Psychotherapy
  Patient Education    
  Family Education    
  Caregiver Education    
  Integrated, Multidisciplinary Care Program    
  Time to Nurse or Physician Follow-up After Hospital Discharge    
  Discussion of Advance Care Directives    
  Persistence of Urinary Catheter    
  Immunization Status    
  Monitoring Drug Therapy    
  Dietician Evaluation    
  Sedative Hypnotic Use    
  Antipsychotic Drug Use