QCDR Measure Specifications


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QCDR Vendor ID QCDR Organization Name Measure ID Measure Title Measure Description NQS Domain Numerator Denominator Denominator Exclusions Denominator Exceptions Number of performance rates to be included in the XML Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted
Specify which rate will represent an overall performance rate for the measure or how an overall performance rate could be calculated based on the data submitted in the XML [for example, simple average of the performance rates submitted or weighted average (sum the numerators divided by the sum of the denominators), etc].
Measure Types High Priority Outcome Inverse Measure (Y/N) Proportional Measure (Y/N) Continuous Variable Measure (Y/N) Ratio Measure (Y/N) Risk-Adjusted (Y/N)
8458231 MedTrak, Inc. CareSense QCDR 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.
Community/Population Health 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. 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.
Patients who did not receive surgery. Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent. 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. Outcome Outcome N N Y Y N
8458231 MedTrak, Inc. CareSense QCDR 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.
Effective Clinical Care 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. 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. Patients who did not receive surgery. Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent. 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. Outcome Outcome N N Y Y N
8458231 MedTrak, Inc. CareSense QCDR 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.
Effective Clinical Care 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. 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. Patients who did not receive surgery. Patients who are unable to answer questions due to illiteracy, language difficulties, mental illness, or non-consent. 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. Outcome Outcome N N Y Y N

Measure ID Measure Title Measure Description
Q109 Osteoarthritis (OA): Function and Pain Assessment Percentage of patient visits for patients age 21 and older with a diagnosis of osteoarthritis (using a pain and motion assessment)
Q111 Pneumonia Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
Q128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Percentage of patients aged 18 years and older with a BMI outside of normal parameters (BMI ≥ 18.5 and < 25 kg/m2) captured within the last 6 months
Q130 Documentation of Current Medications in the Medical Record Percentage of visits for patients aged 18 years and older for which the clinician documents a list of current medications on the date of the encounter
Q131 Pain Assessment and Follow-Up Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit and documentation of a follow-up plan when pain is present
Q154 Falls: Risk Assessment Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
Q155 Falls: Plan of Care Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months
Q178 Rheumatoid Arthritis (RA): Functional Status Assessment Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) that had a functional status assessment performed at least once within 12 months
Q182 Functional Outcome Assessment Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment and documentation of a care plan based on the outcome of that assessment
Q217 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments Percentage of visits with documentation of a standardized functional outcome assessment on the date of the visit and documentation of a care plan based on the outcome of the assessment
Q218 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments Change in functional status for patients with a knee impairment using a Patient Reported Outcome Measure (PROM)
Q220 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments Change in functional status for patients with lumbar impairments using a Patient Reported Outcome Measure (PROM)
Q226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older who received smoking cessation counseling intervention if identified as a tobacco user during the past 24 months
Q317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older who received a follow-up plan based on results in a high blood pressure screening
Q350 Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy Percentage of patients undergoing a total knee replacement who received information on non-surgical treatments prior to the procedure
Q351 Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation Percentage of patients undergoing a total knee replacement who were screened for venous thromboembolic and cardiovascular risk factors within 30 days prior to the surgery
Q352 Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet Percentage of patients undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet
Q353 Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report Percentage of patients undergoing a total knee replacement whose operative report identifies the following implant information: prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant
Q358 Patient-centered Surgical Risk Assessment and Communication Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon