QCDR Measure Specifications

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QCDR Name Measure ID Measure Title Measure Description Denominator Numerator Denominator Exclusions Denominator Exceptions Numerator Exclusions Data Source Used for the Measure
Does this measure belong to another QCDR? If so, which one? NQF Number (if applicable) NQS Domain NQS Domain Rationale Outcome High Priority High Priority Type Measure Type Inverse Measure Proportional Measure
Continuous Variable Measure Ratio Measure If Continuous Variable and/or Ratio is chosen, what would be the range of the score(s)?
Number of performance rates to be submitted Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted. Specify which of the submitted rates will represent an overall performance rate for the measure or how an overall performance rate could be calculated based on the data submitted [for example, simple average of the performance rates submitted or weighted average (sum of the numerators divided by the sum of the denominators), etc.] (REQUIRED) Is the Measure Risk-Adjusted If risk-adjusted, indicate which score is risk-adjusted Please indicate which specialty/specialties this measure applies to
CareSense MICS1 General Health Postoperative Improvement Performance Measure #1 - Change in the calculated score of a validated general health patient reported outcome survey from before to after surgery.

Performance Measure #2 - The overall percentage of patients that improve their general health scores beyond a minimum threshold for each postoperative interval.

Instructions: Patients who undergo a surgical procedure are asked to complete a general health outcomes survey both preoperatively and following surgery.

Rationale: Understanding a patient’s mental and general physical improvement as a result of surgery is an important aspect of clinical care. The general health scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. In addition, general health scores can be used to risk adjust other, surgery specific outcomes scores that are collected. Doctors have the option of collecting a postoperative general health survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.
The number of patients that have a postoperative score and a preoperative score. Patients must take a preoperative survey (within 2 months of surgery) and a postoperative survey at 1 month (+/-1 one week), 6-weeks (+/- one week), 3 months (+/- two weeks), or 6 months (+/- three weeks).
Valid general health questionnaires include, but are not limited to, the VR-12, PROMIS, PROMIS-10, VR-6D, SF-12, SF-36, and EQ-5D.
Each individual patient improvement score is calculated by subtracting the preoperative survey score from the postoperative survey score. The numerator is calculated by summing all the improvement scores for each patient. Patients who did not receive surgery. Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent. Survey scores that can not be calculated due to incomplete surveys. Claims, Hybrid, Survey No N/A Community/Population Health Assessing a patient's general health improvement from before to after surgery is an important aspect of assessing and understanding how surgical care is improving community/population health. Outcome High Priority Outcome Patient Reported Outcome No Yes No No N/A 2 2. The overall percentage of patients that improve beyond a minimum threshold of 5% from preoperatively to 4 weeks postoperatively; 7% from preoperatively to 6 weeks postoperatively; 10% from preoperatively to 3 months postoperatively; and 15% from preoperatively to 6 months postoperatively. No N/A Orthopedics
CareSense MICS2 Surgery Specific Postoperative Improvement in Pain Levels Performance Measure #1 - Change in the calculated pain scores of a validated surgery specific patient reported outcome survey from before to after surgery.

Performance Measure #2 - The overall percentage of patients that improve their pain scores beyond a minimum threshold for each postoperative interval.

Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes survey both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient pain levels.

Rationale: Understanding the change in a patient’s pain levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall pain treatment methodologies. Surgeons have the option of collecting the surveys at different intervals following surgery to account for different surgery types and physician follow-up patterns.
The number of patients that have a postoperative surgery-specific pain score and a preoperative surgery-specific pain score. Patients must take a preoperative survey (within 2 months of surgery) and a postoperative survey at 1 month (+/-1 one week), 6-weeks (+/- one week), 3 months (+/- two weeks), or 6 months (+/- three weeks). Valid questionnaires include, but are not limited to, the Neck Disability Index, the Quick DASH, the HOOS-JR, the KOOS-JR, and the Foot Function Index. Each individual patient improvement score is calculated by subtracting the preoperative surgery-specific pain score from the postoperative surgery-specific pain score. The numerator is calculated by summing all the improvement scores for each patient. Patients who did not receive surgery. Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent. Survey scores that can not be calculated due to incomplete surveys. Claims, Hybrid, Survey No N/A Effective Clinical Care Assessing the reduction in patient pain levels from before to after surgery is an important marker in how effective the surgery was as a method of clinical care. Outcome High Priority Outcome Patient Reported Outcome No Yes No No N/A 2 2. The overall percentage of patients that improve beyond a minimum threshold of 10% from preoperatively to 4 weeks postoperatively; 15% from preoperatively to 6 weeks postoperatively; 20% from preoperatively to 3 months postoperatively; and 25% from preoperatively to 6 months postoperatively. No N/A Orthopedics
CareSense MICS3 Surgery Specific Postoperative Improvement in Function Levels Performance Measure #1 - Change in the calculated function scores of a validated surgery specific patient reported outcome survey from before to after surgery.

Performance Measure #2 - The overall percentage of patients that improve their function scores beyond a minimum threshold for each postoperative interval.

Instructions: Patients who undergo a surgical procedure are asked to complete one or more surgery specific outcomes surveys both preoperatively and following surgery. These outcomes surveys must contain one or more scores relevant to patient function levels such as mobility or the ability to complete common tasks.

Rationale: Understanding the change in a patient’s function levels from before to after surgery is an important aspect of clinical care. The scores that are calculated can be used to improve a specific patient’s care plan or can be analyzed retrospectively to modify overall treatment methodologies. Surgeons have an option of collecting a postoperative survey at different intervals following surgery to account for different surgery types and physician follow-up patterns.
The number of patients that have a postoperative surgery-specific function score and a preoperative surgery-specific function score. Patients must take a preoperative survey (within 2 months of surgery) and a postoperative survey at 1 month (+/-1 one week), 6-weeks (+/- one week), 3 months (+/- two weeks), or 6 months (+/- three weeks). Valid questionnaires include, but are not limited to, the Neck Disability Index, the Quick DASH, the HOOS-JR, the KOOS-JR, and the Foot Function Index. Each individual patient improvement score is calculated by subtracting the preoperative surgery-specific function score from the postoperative surgery-specific function score. The numerator is calculated by summing all the improvement scores for each patient. Patients who did not receive surgery. Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent. Survey scores that can not be calculated due to incomplete surveys. Claims, Hybrid, Survey No N/A Effective Clinical Care Assessing the increase in patient function from before to after surgery is an important marker in how effective the surgery was as a method of clinical care. Outcome High Priority Outcome Patient Reported Outcome No Yes No No N/A 2 2. The overall percentage of patients that improve beyond a minimum threshold of 10% from preoperatively to 4 weeks postoperatively; 15% from preoperatively to 6 weeks postoperatively; 20% from preoperatively to 3 months postoperatively; and 25% from preoperatively to 6 months postoperatively. No N/A Orthopedics