QCDR Measure Specifications

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2019 QCDR Measure IDs

Measure Title (REQUIRED)

Measure Description (REQUIRED)

Denominator (REQUIRED)

Numerator (REQUIRED)

Denominator Exclusions (REQUIRED)

 Denominator Exceptions (REQUIRED)

Numerator Exclusions (REQUIRED)

Data Source Used for the Measure (REQUIRED)

(Administrative clinical data, Facility discharge data, Chronic condition data warehouse (CCW), Claims, CROWNWeb, EHR (enter relevant parts), Hybrid, IRF-PAI, LTCH CARE data set, National Healthcare Safety Netwo

If applicable, please enter additional information regarding the data source used

Provide a concise summary of evidence of a performance gap, in addition to any study citation (citations should be the most current available or within 5 years) (REQUIRED)

Is there a variance in the measure rate? If yes, indicate if the variance is within your registry and/or from another source. If another source, please cite the source.

QCDR Measure Type (REQUIRED)

If this is an existing measure with changes, do the changes impact the intent of the measure?

Please indicate what has changed to the existing measure and how the change impacts the intent of the 2018 version

Can the measure be benchmarked against the previous performance year's data?

If applicable, please Indicate why the 2018 benchmark cannot be used

Does this measure belong to another entity/organization?  (REQUIRED)

If applicable, please indicate you have the appropriate documentation to use the measure

NQF ID Number (if applicable)

Is the QCDR measure a high priority measure? (REQUIRED)

High Priority Type (REQUIRED)

Measure Type (REQUIRED)


What one meaningful measure area applies to this measure? (REQUIRED)

Meaningful Measure Area Rationale (REQUIRED)

Inverse Measure (REQUIRED)

Proportional Measure (REQUIRED)

Continuous Variable Measure (REQUIRED)

Ratio Measure (REQUIRED)

If Continuous Variable and/or Ratio is chosen, what would be the range of the score(s)?

(if not continuous variable and/or ratio measure enter N/A)

Number of performance rates to be calculated and submitted in the XML

(Enter the # of performance rates or N/A. If only one rate is calculated, enter “1”. Also, provide the name for each performance rate, if there is more than one performance rate calcula

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 da

Risk-Adjusted (REQUIRED)

If risk-adjusted, indicate which score is risk-adjusted (REQUIRED)

Please provide any test data on reliability/validity.

Provide current clinical guideline the measure is derived from (REQUIRED)

Please indicate which specialty/specialties this measure applies to (REQUIRED) (i.e., Anesthesiology, Neurology, Urology, etc.)

Preferred measure published clinical category (REQUIRED) (i.e., Diabetes, Substance Use/Management)




Pain, Function and General Health Postoperative Improvement

Performance Measure #1 - Change in the calculated score of a validated general health, function, and/or pain score using a standard patient reported outcome survey from before to after surgery.

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

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


Rationale: Understanding a patient’s mental and general physical improvement, functional improvement, and improvement in pain levels as a result of surgery is an important aspect of clinical care. The general health scores, functional scores, and pain 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. Doctors have the option of collecting a postoperative outcomes 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. Valid pain and function 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 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.


Hybrid, Survey

Evidence indicates that clinicians can not accurately assess patient improvement without asking the patients about their health state directly (1). The use of patient reported outcomes surveys to measure the patient's postoperative improvement in general health, function, and pain addresses this performance gap.


1 - Justice AC, Rabeneck L, Hays RD, Wu AW, Bozzette SA, for the Outcomes

Committee of the ACTG. Sensitivity, specificity, reliability, and clinical

validity of provider-reported symptoms: a comparison with self-reported

symptoms. J Acquir Immune Defic Syndr. 1999;21(2):126-33.


Existing Approved QCDR Measure With Changes


Three previous measures from 2018- MICS1, MICS2,  and MICS3 - were combined into a single new measure


This is a new measure, so no previous benchmarks apply






Patient Reported Outcome (PRO)

Effective Clinical Care

Patient Reported Functional Outcomes

This measure is using standard PROs to assess patient improvement for general health, function, and pain scores. Thus, the meaningful measure is "Patient Reported Functional Outcomes"







2nd Performance Rate




The guideline that this measure is derived from comes from the AHRQ set of clinicial guidelines titled "Registires for Evaluating Patient Outomces: A User's Guide". Source: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/registries-guide_research.pdf

General Surgery

Surgical/Procedural Care