High Priority Measure? Type NQS Domain None None N/A Yes Outcome Outcome Communication. None None N/A Yes Patient Safety

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1 Name IDs Title Description Denominator Numerator Denominator Exclusions NPA11 Unplanned Readmission Percentage of patients aged 1 QOD Patients Number of patients aged 1 Denominator Exclusions Following Spine Procedure years and older who had any Denominator: The patient years and older who had any Excluded are patients with within the 30 Day Postoperative unplanned readmission for spine populatiorelated includes patients unplanned readmission for spine circumstances that interfere Period procedure within the 30 aged 1 years and older eligible related procedure within the 30 with or prevent data collection day postoperative period for, enrolled, and engaged in the day postoperative period. or patients with conditions that (). For the QOD, the cervical NPA12 Selection of Prophylactic Antibiotic Prior to Spine Procedure Percentage of patients aged 1 an index spine related procedure with the indications for QOD Patients Denominator: The patient population includes patients aged 1 years and older eligible prophylactic antibiotics who had for, enrolled, and engaged in the an order for antimicrobial prophylaxis (). For the QOD, the cervical Number of patients aged 1 Denominator Exclusions an Excluded are patients with index spine related procedure circumstances that interfere with the indications for with or prevent data collection prophylactic antibiotics who had or patients with conditions that an order for antimicrobial prophylaxis? NQS Domain None None N/A Yes Outcome Outcome Communication and Coordination None None N/A Yes Patient Safety Process Patient Safety Preventable Healthcare Harm Meaningful Inverse Proportional Area Admissions and Readmissions to Hospitals Ratio Risk Adjusted Vendor Organization Staff Yes Yes No No No Irene Zyung: icz@neuropoint.org, page 1 of2/4/ updated 1/17/

2 Name IDs Title Description Denominator Numerator Denominator Exclusions NPA1 Smoking Assessment and Percentage of patients aged 1 QOD Patients Number of patients aged 1 Cessation Coincident With Spine years and older who were Denominator: The patient years and older who were Related Therapies population includes patients assessed for tobacco use prior aged 1 years and older eligible to spine related therapy( ies) NPA19 assessed for tobacco use prior to spine related therapy( ies) and who received cessation counseling intervention if identified as a tobacco user. Body Mass Assessment and Percentage of patients aged 1 Follow up Coincident With Spine a weight Related Therapies and height recorded in the medical record at the time of initial evaluation and/or treatment of spine related disorder and, if the most recent body mass index (BMI) is outside of normal parameters (BMI 23 and < 30 for patients 65 years and older; BMI 1.5 and < 25 for patients 1 64 for, enrolled, and engaged in the (). For the QOD, the cervical QOD i Patients d li d Denominator: The patient population includes patients aged 1 years and older eligible for, enrolled, and engaged in the (). For the QOD, the years of age), a follow up plan is documented (example: Patient referred to nutrition counseling for BMI above normal parameters ). cervical and who received cessation counseling intervention if identified as a tobacco user. Number of patients aged 1 a weight and height recorded at time of initial evaluation and/or treatment of spine related disorder documented in the medical record and if the most recent BMI is outside of normal parameters Denominator Exclusions Excluded are patients with circumstances that interfere with or prevent data collection or patients with conditions that Denominator Exclusions Excluded are patients with circumstances that interfere with or prevent data collection or patients with conditions that? NQS Domain None None N/A No N/A Process Community/Popula tion Health None None N/A No N/A Process Community/Popula is tion Health Personalized and Aligned with Patient s Goals Meaningful Inverse Proportional Area Prevention and Treatment of Opioid and Substance Use Disorders Ratio Risk Adjusted Vendor Organization Staff page 2 of2/4/ updated 1/17/

3 Name IDs Title Description Denominator Numerator Denominator Exclusions NPA24 Narcotic Pain Medicine Management Following Elective Spine Procedure NPA25 Depression and Anxiety Assessment Prior to Spine Related Therapies Percentage of patients aged 1 documentation of narcotic use/requirements at baseline (initial encounter) and at 3 months following initial assessment and interventions pain symptoms and Percentage of patients aged 1 documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to index therapy( ies) for treatment of spine related pain symptoms. 1) Patients who are 1 years and older meeting inclusion criteria, with documentation of narcotic use/requirements at baseline (initial encounter) and at 3 months following initial assessment and interventions pain symptoms and 2) Patients who are 1 years and older, meeting inclusion i i d d i i 1) Patients who are 1 years and older meeting inclusion criteria with documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to index therapy( ies) for treatment of spine related pain symptoms. 2) Patients who are 1 years and older, meeting inclusion with documentation of d i d/ i Number of patients aged 1 documentation of narcotic use/requirements at baseline (initial encounter) and at 3 months following initial assessment and interventions pain symptoms and? None None None N/A Yes Opioidrelated * NQS Domain Process Communication and Coordination Number of patients aged 1 documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to index therapy( ies) for treatment of spine related pain symptoms. None None None N/A No N/A Process Effective Clinical Meaningful Inverse Proportional Area Prevention and Treatment of Opioid and Substance Use Disorders Ratio Risk Adjusted Vendor Organization Staff ; Beth Prevention, Treatment, and Management of Mental Health ; Beth page 3 of2/4/ updated 1/17/

4 Name IDs Title Description Denominator Numerator Denominator Exclusions NPA26 Functional Outcome Assessment Percentage of patients aged 1 for Spine Intervention NPA27 Spine/Extremity Pain Assessment spine intervention(s) who functional outcome assessment, with at least 10% improvement in the functional status scaled score from the baseline. This measure will be calculated with 2 performance rates: with improvement in functional status after Follow up/patient population with Follow up. Percentage of patients aged 1 documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s) AND/ leg or arm pain tool(s) at baseline and 3 months following initial assessment and intervention(s) pain symptoms with at least 10% improvement in the pain status from the baseline and This measure will be calculated with 2 performance rates: with improvement in pain status after Follow up/patient population with Follow up. 1) Patients who are 1 years and older meeting inclusion criteria, undergoing spine intervention who completed baseline and 3 month follow up (patient reported) functional outcome assessment. 2) Patients who are 1 years and older, meeting inclusion cervical spine surgery, who h f ll ( i 1) Patients who are 1 years and older meeting inclusion criteria, with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s) AND/ leg or arm pain tool(s) at baseline and 3 months following initial assessment and intervention(s) for treatment of spine related pain symptoms. 2) Patients who are 1 years and ld i Q i l i Percentage of patients aged 1 spine intervention(s) who functional outcome assessment (with an improvement in the quality of life status from the baseline). Number of patients with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s) AND/ leg or arm pain tool(s) at baseline and 3 months following initial assessment and intervention(s) pain symptoms with at least 10% improvement in the pain status from the baseline and? None None None N/A Yes Outcome Patient Reported Outcome (PRO) NQS Domain Person and giver Centered None None None N/A Yes Outcome Outcome Person and giver Centered Meaningful Area Patient Reported Functional Patient s Experience of Inverse Proportional Ratio Risk Adjusted Vendor Organization Staff ; Beth, Beth Radtke: bradkte@aapmr.org; page 4 of2/4/ updated 1/17/

5 Name IDs Title Description Denominator Numerator Denominator Exclusions? NQS Domain NPA2 Patient Satisfaction With Spine None None None N/A Yes Outcome Outcome Person and giver Centered NPA29 of Life Assessment for Spine Intervention Percentage of patients aged 1 spine intervention(s) who completed 3 month follow up (patient reported) satisfaction with care assessment. Satisfaction will be reported as % of patients reporting satisfaction with procedure. This measure will be calculated with 2 performance rates: with improvement in satisfaction with care status after Follow up/patient population with Follow up. Percentage of patients aged 1 index spine intervention(s) who quality of life assessment, with an improvement in the quality of life status from baseline. This measure will be calculated with 2 performance rates: with improvement in quality of life status after Followup/Patient population with Follow up. 1) Patients who are 1 years and older meeting inclusion criteria, undergoing spine intervention(s) who completed 3 satisfaction with care assessment. 2) Patients who are 1 years and older, meeting inclusion cervical spine surgery, who completed 3 month follow up ( i d) if i 1) Patients who are 1 years and older meeting inclusion criteria, undergoing index spine intervention(s) who completed baseline and 3 month follow up (patient reported) quality of life assessment. 2) Patients who are 1 years and older, meeting inclusion cervical spine surgery, who h f ll ( i Number of patients aged 1 index intervention(s) who completed 3 month follow up (patient reported) satisfaction with care assessment. Percentage of patients aged 1 index spine intervention(s) who quality of life assessment (with an improvement in the quality of life status from the baseline). None None None N/A Yes Outcome Outcome Person and giver Centered Meaningful Area Patient s Experience of Patient Reported Functional Inverse Proportional Ratio Risk Adjusted Vendor Organization Staff ; Beth ; Beth page 5 of2/4/ updated 1/17/

6 Name IDs Title Description Denominator Numerator Denominator Exclusions NPA6 Spine Related Procedure Site Percentage of patients aged 1 QOD Patients Number of patients aged 1 Denominator Exclusions Infection years and older who had a Denominator: The patient years and older who had an SSI Excluded are patients with surgical site infection (SSI) population in 30 days of the index spine circumstances that interfere within 30 days of the index spine aged 1 years and older eligible procedure. procedure. for, enrolled, and engaged in the (). For the QOD, the cervical with or prevent data collection or patients with conditions that? NQS Domain None None N/A Yes Outcome Outcome Effective Clinical Inverse Proportional Ratio Risk Adjusted Vendor Organization Staff Yes Yes No No No Irene Zyung: icz@neuropoint.org, Meaningful Area Healthcareassociated Infections page 6 of2/4/ updated 1/17/