PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

Transcription

1 Support Contractor PCHQR Program: Overview of the 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) Measure Presentation Transcript Speakers Denise Morse, MBA Senior Manager, Quality Analytics City of Hope National Medical Center Barbara Jagels, RN, MHA, CPHQ Vice President of Quality, Safety and Value Seattle Cancer Center Alliance Moderator Lisa Vinson, BS, BSN, RN PCHQR Program Lead Hospital Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor November 29, p.m. ET DISCLAIMER: This transcript was current at the time of publication and/or upload onto the Quality Reporting Center and QualityNet websites. Medicare policy changes frequently. Any links to Medicare online source documents are for reference use only. In the case that Medicare policy, requirements, or guidance related to this transcript change following the date of posting, this transcript will not necessarily reflect those changes; given that it will remain as an archived copy, it will not be updated. This transcript was prepared as a service to the public and is not intended to grant rights or impose obligations. Any references or links to statutes, regulations, and/or other policy materials included in the presentation are provided as summary information. No material contained therein is intended to take the place of either written laws or regulations. In the event of any conflict between the information provided by the transcript and any information included in any Medicare rules and/or regulations, the rules and regulations shall govern. The specific statutes, regulations, and other interpretive materials should be reviewed independently for a full and accurate statement of their contents. Page 1 of 12

2 Lisa Vinson: Good afternoon and thank you for joining today s educational event, entitled Overview of the 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) Measure. My name is Lisa Vinson, and I am the program lead for the PPS-Exempt Cancer Hospital Quality Reporting, or PCHQR, Program within the Hospital Inpatient Value, Incentives, and Quality Reporting, or VIQR, Outreach and Education Support Contractor. I will be the moderator for today s event, and our guest speaker is Denise Morse, who is a Senior Manager of Quality Analytics at City of Hope National Medical Center in Duarte, California. As the title suggests, our discussion today will focus on the newly-adopted Claims-Based outcome measure, 30-Day Unplanned Readmissions for Cancer Patients, also identified by NQF #3188. This measure was added to the PCHQR Program in the Fiscal Year 2019 IPPS/LTCH PPS Final Rule, which was published in August of this year. I would like to emphasize that specific content for today s webinar is only applicable to the participants in the PCHQR Program as it relates to participation and reporting in CMS Quality Reporting Programs. Please be sure to refer to information provided by the Support Contractor for your program. As a reminder, the slides for today s event were posted on QualityReportingCenter.com prior to the event. The questions and answers, transcript, and recording of today s event will be posted on the same website and QualityNet.org in the near future. Lastly, as discussed on the previous slide, if you have a question as we go along through today s presentation, please type your question in the chat window. At the end of this event, we will have a question and answer session. For the speakers to best answer your question, we ask that, at the beginning of your question, please reference the slide number, along with your question, in the chat window. Questions that are not addressed during the question and answer session will be posted to the QualityReportingCenter.com website at a later date. Here is our customary list of acronyms and abbreviations. This list includes acronyms and abbreviations you may hear throughout today s event, such as ADCC, for Alliance of Dedicated Cancer Centers; C4QI, for Comprehensive Cancer Centers Consortium for Quality Improvement; and NQF, for National Quality Forum. Page 2 of 12

3 The purpose of today s event is to explain the development, endorsement, and application of the 30-Day Unplanned Readmissions for Cancer Patients measure in the PCHQR Program, assist program participants in understanding the measure specifications, and share lessons learned for the purpose of quality improvement. Upon completion of today s event, we hope that participants will be able to discuss the history of Unplanned Readmissions for Cancer Patients metric development and implementation, clearly state the requirements and methodology for Unplanned Readmissions for Cancer Patients and discuss how centers can use the Unplanned Readmissions for Cancer Patients for performance improvement. This concludes my introductory remarks. Now, I would like to turn the presentation over to Denise. Denise Morse: Thank you. My name is Denise Morse, and I am the Senior Manager of Quality Analytics at City of Hope Cancer Center in Duarte, California. At City of Hope, I am responsible for quality measure reporting, including metric development, internal and external reporting, and data acquisition. Today, I will be providing an overview of the 30-Day Unplanned Readmissions for Cancer Patients measure. Next slide. It is important to focus specifically on cancer patients for quality improvement metrics and projects because the incidence is growing every year. The Agency for Healthcare Research and Quality estimates that there will be 1.7 million new cancer cases this year and direct medical costs are over $80 billion per year, with close to 40% of that cost relating directly to the cost of inpatient hospital stays. Unplanned and potentially avoidable readmissions can contribute to higher cost and lower quality of care, and a reduction in these readmissions can improve quality of care and lower cost. Prior to the cancer readmissions metric, the readmissions metric landscape included measures relating to overall all-cause readmissions and several measures directly related to specific procedures and diagnoses, primarily related to heart disease. None of these measures specifically related Page 3 of 12

4 directly to cancer patients, and internal analysis showed that the all-cause readmissions rate tended to over include cases that were planned admissions for cancer care. The Comprehensive Cancer Center Consortium for Quality Improvement, also known as C4QI, is a collaborative group of cancer centers that meet regularly to share best practices with the goal of improving quality for all cancer patients. The C4QI centers recognize the need for a readmissions measure that would help focus on potentially preventable readmissions and provide opportunities for improvement. Using a shared database, Vizient, formerly University HealthSystem Consortium, the C4QI centers went through several iterations of the metric inclusions and exclusions. The cancer centers worked with their physicians, clinical staff, ancillary staff, and coding/billing teams to identify code sets and applicability to the populations. The Alliance of Dedicated Cancer Centers recognized the applicability of this measure to the PCHQR Program and worked with the National Quality Forum to refine and submit the measure specifications for endorsement and use in future program years. The 30-Day Unplanned Readmissions for Cancer Patients [measure] was submitted to the National Quality Forum, or NQF, and received endorsement in The measure steward is the Seattle Cancer Care Alliance. The process of NQF endorsement is a journey, and the measure went through several rounds of alpha testing, beta testing, and risk adjustment. The metric was added to the FY 2019 IPPS/LTCH [PPS] Final Rule. The metric will be reported for the FY 202[1] program year and subsequent years. The metric, as written, can be applied to all cancer patients at any short-term acute care hospital. NQF #3188, 30-Day Unplanned Readmissions for Cancer Patients, is a Claims-Based measure. Therefore, no date of submission will be required from the cancer hospitals. The numerator includes all eligible unplanned readmissions to any shortterm acute care hospital within 30-days of the discharge date, from an index admission that is included in the measure denominator. Page 4 of 12

5 Readmissions with an admission type of urgent or emergent are considered unplanned readmissions within this measure. Readmissions for patients with progression of disease, using a principle diagnosis of metastatic disease as a proxy, and for patients with planned admissions for treatment, defined as a principle diagnosis of chemotherapy or radiation therapy, are excluded from the measure numerator. The following readmissions are excluded from the measure numerator: 1) Primary claim diagnosis codes of metastatic disease, as defined by the ICD-10 codes on the slide The rationale for the exclusion is that a primary or principle diagnosis of metastatic disease serves as a proxy for disease progression. Readmissions for conditions or symptoms associated with disease progression are not reflective of poor clinical care, but rather advanced disease. 2) Patients with a primary claim diagnosis of chemotherapy or radiation encounter, as defined by the ICD-10 codes on the slide The rationale for the exclusion is that readmissions are expected and planned for some patients who require additional cancer treatment in the inpatient setting. These readmissions reflect high quality care that is focused on patient safety and are reliably distinguishable in claims data. The denominator includes inpatient admissions for all adult fee-for-service Medicare beneficiaries where the patient is discharged from a short-term acute care hospital with a principle or secondary diagnosis of malignant cancer, within the defined measurement period. The following index admissions are excluded from the measure denominator: Patients that are less than 18 years of age Patients who died during the index admission Patients discharged against medical advice Page 5 of 12

6 Patients transferred to another acute care hospital during the index admission Patients discharged with a planned readmission Patients having missing incomplete data Patients not admitted to an inpatient bed The rates will be risk adjusted using a logistic regression model. Some of the risk factors being looked at are gender, ICU stays, comorbidities, cancer type, length of stay, age, and discharge location. Per the FY 2019 IPPS [LTCH PPS] Final Rule, the following equation as seen on this slide will be used to generate the risk-adjusted 30-Day Unplanned Readmissions for Cancer Patients rate. Now, I will discuss some of the projects that City of Hope has undertaken using the 30-Day Unplanned Readmissions for Cancer Patients measure. City of Hope is currently using the 30-Day Unplanned Readmissions for Cancer Patients measure as part of the internal quality reporting and performance improvement. The measure is part of a readmissions task force, embedded into the physician department quarterly quality reports, and included on The Joint Commission-mandated Ongoing Professional Practice Evaluations, also known as OPPE. In the following slides, three specific projects will be highlighted: cystectomy, post- discharge phone calls, and symptom management/triage support. The initial project and opportunity identified following the creation of the measure was surgical readmissions for specific procedures. The first procedure looked at was cystectomy. The City of Hope Quality Physician Lead was a urologist who recognized, through compared data using the Vizient University HealthSystem Consortium database, that there was an opportunity to improve the readmissions rate in this patient population. Compared data had shown that City of Hope had a 30% higher readmissions rate than the aggregate of the other cancer centers. Using the readmissions measure, we isolated the patient population with preventable readmissions. The metric specifications allowed the team to Page 6 of 12

7 remove the planned admissions and focus directly on patients admitted for more acute conditions. Using the specific measure focused on unplanned readmissions, we were able to isolate potentially preventable readmissions. The most common readmission reason, using the principle diagnosis in the population, was fever, dehydration, and complications. These symptom-related reasons for admission were concerning and led to opportunities for improvement in outpatient management of patients, including enhanced discharge instructions and more timely follow-up visits. This discovery led to the creation of a Cystectomy Care Pathway, which focused on not just preventing future readmissions, but completely changing the way these patients were treated, from initial consult through the postoperative period, providing more supportive resources throughout the patient s journey. The results were impressive with sustainable readmissions reductions of close to 40%, and this model has been able to be used and applied to other disease programs and procedures. Use of the metric also identified opportunities to reduce post-stem cell transplant readmissions in both the autologous and allogeneic populations. A review of the data for the transplant patient population showed that those patients who were readmitted could benefit from additional support post-discharge to answer questions and identify potential health outcomes earlier for intervention. A pilot program was started to provide postdischarge follow-up phone calls to all inpatient transplant discharges, both in the adult and pediatric population. The calls were done using case management, with scripting and pathways, to escalate any situation to the appropriate care provider. The results showed a sustained decrease of readmissions in the population of close to 30%. The current project at City of Hope to reduce readmissions, particularly in the medical oncology population, is improving ambulatory symptom management and an overhaul of triage support tools and pathways. The data from the readmissions metric is helping to inform the work teams on patients most at risk for readmission, symptoms most often seen in readmitted patients, and services or disease programs that could serve as Page 7 of 12

8 pilot populations. The project also includes building a predictive model for readmissions to predict which patients are more likely to return and provide more real time, proactive interventions. The project is scheduled to roll out in the next few months. Thank you for the opportunity to present, and, if you have any questions, please feel free to reach out to me. Thank you. Lisa Vinson: Thank you, Denise. For your convenience, here are a few references with hyperlinks. In the Fiscal Year 2019 final rule, which was published on August 17, 2018, you will find information on the 30-Day Unplanned Readmissions for Cancer Patients measure on pages through The second link will take you to the NQF documents for this measure. So, this will conclude the didactic portion of today s presentation. Next slide, please. At this time, I would like to provide some key program dates and reminders, beginning with our upcoming outreach and education event dates. Our next two educational events are tentatively scheduled for Wednesday, December 19, and Thursday, January 24, Please stay tuned for communications regarding these events that will be sent to those who are subscribed to the PCHQR Program Notifications Distribution List. If you are not subscribed, please visit the QualityNet home page and locate the Join ListServe link for instructions. Upcoming data submission dates are as follows: Quarter HCAHPS Survey data is due by Thursday, January 3, Quarter CST hormone data and Quarter HAI data, which includes CLABSI, CAUTI, CDI, SSI for colon and abdominal hysterectomy, and MRSA, are due Friday, February 15, Please note that this is the last reporting period for the CST hormone data. So, February 15, 2019, will be the last time you are required to submit data for this measure for the PCHQR Program. Page 8 of 12

9 The next anticipated Hospital Compare refresh will now take place in February 2019, rather than January, as originally scheduled. We hope that you were able to attend the webinar held earlier this week, hosted by our public reporting team, which was dedicated to using the new Next Generation User Interface for accessing and previewing your facility s data prior to the February 2019 refresh. If you were not able to attend this event, please visit the QualityReportingCenter.com website to view and listen to this informative presentation. As noted during the event, there will be a designated queue for submitting inquiries pertaining to public reporting and preview reports, which is housed within the QualityNet Questions and Answers Tool. Then, the next refresh is tentatively scheduled to occur in April 2019, containing the data displayed on this slide, with tentative preview dates of February 1 through March 2, Please remember that all dates for public reporting are subject to change. As we get closer to the preview periods and refresh dates, we will always notify you of the exact dates via ListServe communication. As the Support Contractor, we are available to answer questions you may have, and the QualityNet Questions and Answers Tool can assist you with this. As illustrated on this slide by the red box on the right-hand side, this is the QualityNet Questions and Answers Tool for the PPS-Exempt Cancer Hospitals, which is found on the QualityNet home page. Also remember that if you are a first-time user, you will need to complete the registration process to establish your login credentials. It is now time for our question and answer session. Denise, along with Barb Jagels, who is representing the measure steward, which is Seattle Cancer Center Alliance, will be addressing questions as time allows. We will not be asking questions in any particular order as to how they were received in the chat box. So, let s begin. Our first question: How did NQF #3188 evolve to apply to all cancer programs? Barb Jagels: Denise Morse: Denise, do you want me to take that one? Yes, please, Barb. Page 9 of 12

10 Barb Jagels: Lisa Vinson: Barb Jagels: Lisa Vinson: Barb Jagels: Denise Morse: Barb Jagels: Yes, very good. It was a fortuitous day in Washington, D.C., when, for the first round of measure testing and reporting, I arrived at the National Quality Forum to defend and explain the measure, and the MAP had a really valid question: You all can measure your cancer-specific readmissions among yourselves, but how do you compare to other noncancer specific centers? So, that was our opportunity and inspiration to go back, expand the measures and the related specifications, and actually take a newer, broader data set with CMS data and test those specifications to compare performance of this measure within just our PCHQR against all centers. Lisa, do you think that gets at the spirit of the question, or I could keep going. Yes. I think that was sufficient. Thank you. We actually learned a great deal in that analytic endeavor, and I think we substantively improved both the denominator and numerator definitions, and the specification advancement that occurred in that particular round of testing created a much better measure that I think is more easily deployable in a realm of cancer centers. So, in this case, I d say NQF input turned out to be very valuable and improved the measure. Thank you, Barb. Our next question: What about hematology patients, since the exclusions seem to be solid tumor focused? Denise, how about I ll start, and I ll turn it over to you? Okay. So, hemalignancy, BMT, liquid and solid tumors, like lymphoma, really are not well-served by this measure. So, honestly during the measure development and measure testing rounds, we repeatedly asked ourselves - and Denise can give specific examples - whether or not we needed to create a separate and distinct measure that honors the comorbidities and care challenges of hemalignancy patients. So, the clinical context for this is that leukemia and lymphoma patients, number one, are sicker by virtue of their disease related to their cancer diagnosis and that they re readmitted more frequently for appropriate purposes. Think neutropenic Page 10 of 12

11 fevers, hemodynamic support. Think blood and platelet transfusions, things that are hard to do in the outpatient setting, 24/7. So, we did elect to keep the measure denominator definition whole and not distinguish hemalignancy and simply hope to achieve that distinction through the exclusion criteria; but, I will acknowledge, I think that s a substantive and meaningful weakness of this measure. Denise, what would you add? Denise Morse: Lisa Vinson: Barb Jagels: Yes. So, this is something we have discussed at length at City of Hope. We have a very high proportion of our inpatients that have a hemalignancy. There are really two ways that I m looking at this when I look at this measure. One, I think for the national measure, the risk adjustment is going to take this into account. So, when CMS calculates the measure, the [hematologic] patients should come out with an appropriate risk level and that will be factored into the calculation. Secondly, if you re going to use the measure internally, there are several things that I think that you can do to make it work better for the [hematologic] population. My first recommendation would be to stratify your data by disease site, whether it s just the solid tumor hemalignancies in those two buckets or by the individual disease; and then, to look and spend time on the principle diagnosis of those hematology readmissions, and I found that the majority of our readmit cases in this population end up having a non-cancer principle diagnosis code, such as a transplant complication, an infection, or GVHD. By looking closely at this population and their top reasons for readmission, centers should be able to get a fairly clean population for potentially preventable readmissions, to start fact-finding missions and potential quality improvement projects. Thank you both for that. Next question: Briefly, can you provide details as to what the NQF process was like to get this measure endorsed? Yes. Once again, I think I ll start. Denise, you can chime in. So, the NQF process, in and of itself, is very episodic. So, the real heart and soul of the measure development work is really in developing the specifications and running the testing. The writing of the report and making our way through the labyrinthine process that the NQF offers was actually second order effort. Now, I will acknowledge that this was really the Alliance of Page 11 of 12

12 Dedicated Cancer Centers first excursion into attempting to achieve NQF endorsement for cancer measure development. So, part of the investment and the significance of the investment probably relates to our inexperience rather than the validity or ease of the process; but, I will say, I personally travelled to Washington, D.C. on three occasions to defend the measure in person before the MAP. I think it s important to do that because the dialogue is very sensitized to which panel members are in the room that day and which questions they come prepared to ask. We definitely - I ll mention it again - had a significant do-over when the MAP rejected our first attempt at this measure, having it just be relevant to PCHQR and then expanding it. So, the measure report, in and of itself, is not for the fainthearted. I think ours ended up being 48 pages long in its final iteration, complete with literature review and bibliography. Defending the measure in person also requires significant preparation and some courage to face very direct questions, especially from those who might be methodologically skeptical of our approach. Number three, we were in a bit of unchartered territory in that, once again, we had some risk of cancer centers developing measure buyouts for us in service desk, and there was some political risk that we were seen as doing this in our own favor, which is where, I think, offsetting it by having it be a broadly-based measure relevant to all hospitals, including [PCHs] was helpful. So, overall, I d report that the NQF process was collaborative, complex, and lengthy, and, ultimately, worthwhile. Denise, what would you add? Denise Morse: Lisa Vinson: I would agree with all of that and I d say educational, as well. Great. Thank you all so much for that information. This does conclude our question and answer session. Please remember, if we did not address your question today, all questions and answers will be posted to QualityReportingCenter.com in the near future. As always, we would like to thank you for your time and attention during today s event, and we hope that the information provided was insightful. Thank you and enjoy the remainder of your day. Page 12 of 12