National Committee for Quality Assurance / The Physician Consortium for Performance Improvement

Transcription

1 National Committee for Quality Assurance / The Physician Consortium for Performance Palliative and End of Life Care Physician Performance Measurement Set Status: Approved 2008

2 Work Group Members Work Group Members Palliative and End of Life Care David Casarett, MD, MA Denys Lau, PhD Dale Lupu, PhD Anna Schenk, PhD, MSPH Neil Wenger, MD (Co-chair) Sydney Dy, MD (Co-chair) Donald Casey, Jr, MD, MPH, MBA, FACP Karl A. Lorenz, MD, MSHS Joanne Lynn, MD, MA, MS Work Group Staff National Committee for Quality Assurance Aisha Pittman, MPH Kiran Johal, MPH Sepheen Byron, MHS Philip Renner, MBA American Medical Association Shannon Sims, MD PhD Mathematica Policy Research Leslie Conwell, PhD 2

3 Table of Contents Purpose of Measures:... 5 Intended Audience, Care Setting, and Patient Population:... 5 Importance of Topic:... 5 Measure Harmonization:... 7 Measure Testing & Implementation:... 8 Measure #1: Advance Care Planning... 8 Measure #2: Dyspnea Screening and Management

4 Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium) and the National Committee for Quality Assurance (NCQA). These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of the Consortium) or NCQA. Neither the AMA, NCQA, Consortium nor its members shall be responsible for any use of the Measures. THE MEASURES AND SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND American Medical Association and National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, NCQA, the Consortium and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. 4

5 CPT contained in the Measures specifications is copyright 2007 American Medical Association. Purpose of Measures: These clinical performance measures, developed by the National Committee for Quality Assurance and the Physician Consortium for Performance (Consortium), are designed for individual quality improvement. The measures may also be used in data registries, continuing medical education programs, and in board certification programs. The measure titles listed below may be used for accountability: Measure #1: Advance Care Planning Measure #2: Dyspnea Screening and Dyspnea Management Intended Audience, Care Setting, and Patient Population: These measures are designed for use by physicians and other health professionals managing ongoing care for patients aged 18 years and older with palliative and end of life care in the ambulatory care setting. These measures are meant to be used to calculate for performance and/or reporting at the individual level. Importance of Topic: Incidence, Prevalence, & Cost The development of palliative care measures is aligned with the NQF priority area of end-of-life care (as delineated by NQF consensus statement for the delivery of quality palliative care). Additionally, these measures address issues as prepared by NIH State of the Science panel on improving end-of-life care. The NQF and NIH priority areas address gaps in quality care measurement as defined by the Institutes of Medicine in their report Approaching Death: Improving Care at the End-of-Life, published in Additionally, these areas are aligned with the priorities set by NQF s National Priorities Partners. From , the number of hospital based palliative care programs has grown by over 60% such that now one in four U.S. hospitals have a palliative care program and all U.S. medical schools must provide training in palliative medicine. 1 Research shows that rates of palliative services have increased among the elderly (by 28.2% in 2002) and will continue to rise as the population grows. 2 Although hospices have primarily been used by those dying of cancer, a 2007 estimate indicates only 44.1% of hospice patients are those with cancer. 3 From a cost perspective, patients enrolled in palliative hospice care cost Medicare less than the standard plan for covering terminally ill patients. Palliative hospice cost savings for Medicare range from $1,115 for colon cancer patients to $8,879 for congestive heart failure patients. The study also revealed that palliative hospice patients live longer on the average than similar patients who did not choose palliative hospice care. This ranged from 20 days for those with a diagnosis of gall bladder cancer to 69 days for the group of breast cancer patients. 4 Opportunity for Improvement/Gap or Variation in Care A major area of concern for palliative researchers and policymakers lies in the definition of palliative care. Although palliative care may be offered to patients with various advanced illnesses and disability, there is no common indexing term. 5 Lack of a standardized approach for identification of the eligible population is a challenge for measurement. Limitations exist due to the heterogeneity of individuals involved with palliative/hospice services, and there are few methodological studies which examine effectiveness indicators. Available Evidence Evidence-based clinical practice guidelines are available for the management of palliative and end of life care. This measurement set is based on clinical guidelines from the following: ACOVE Project American College of Physicians Institute for Clinical Systems Improvement 5

6 Assessing Care of Vulnerable Elders- Quality Indicators for Palliative and End-of-Life Care in Vulnerable Elders (ACOVE project - RAND Health) If a Vulnerable Elder (VE) dies an expected death with metastatic cancer, oxygen dependent pulmonary disease, NYHA Class III to IV congestive heart failure, end stage liver disease, end stage renal disease or dementia, the following should be considered and reflected in the patient s medical record: 1. Comprehensive Palliative Assessments. Pain and other symptoms. Spiritual and existential concerns. Caregiver burdens. Needs for practical assistance. Needs for advanced care planning. 2. Care Surrogate Discussion. Goals of treatment are discussed with Care Surrogate (if applicable). 3. Advan ce Care Planning Discussion documented in chart. 4. Advance Directive and Surrogate Continuity. If VE is transported to alternate treatment site, medical record should document advanced directives and/or surrogate decision maker. 5. Care Preference Documentations, including: Decisions about Life-Sustaining Treatments. Gastronomy Tube Placement. Mechanical Ventilator withdrawal. 6. Symptom Treatment and Management 7. Effects of Caregiver Stress, including bereavement Level of Evidence: C Pharmaceutical Therapies for Palliative Care (American College of Physicians) Managing pain: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage pain. For patients with cancer, this includes nonsteroidal antiinflammatory drugs, opioids, and biphosphonates. (Grade I) Managing dyspnea: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. (Grade I) Managing depression: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage depression. For patients with cancer, this includes tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention. (Grade II) Grade I: Strong recommendation, moderate quality of evidence. Grade II: Evidence from observational studies (e.g., correlational descriptive studies) or controlled trials with inconsistent results. Psychological and Social Aspects of Care for Palliative patients (Institute for Clinical Systems Improvement) 1. Regular ongoing assessment of a patient s psychological status is important. (Grade I) 2. In patients with serious illness at the end of life, clinicians should regularly assess patients for pain, dyspnea, and depression 3. The interdisciplinary team includes professionals with specific skills in assessment and development of a social care plan. (Grade II) 4. Conduct regular care conferences. (Grade II) Gra de I : Consensus statement, Consensus report, Narrative review Grade II: Consensus statement, Consensus report, Narrative review, Medical Opinion Structure and Processes of Palliative Care (Institute for Clinical Systems Improvement) Early identification of patients with conditions that would benefit from palliative care planning can be accomplished by considering conditions and symptoms that are appropriate for palliative care services Consensus statement, Consensus report, Narrative review 6

7 Cultural Aspects of Care (Institute for Clinical Systems Improvement) Patient and family reactions to serious illness and decisions about end-of-life care are influenced by cultural factors. (Grade I) 1. Specific cultural assessment promotes patient/family-centered decision-making and offers the opportunity to identify care preferences. (Grade I) 2. Every attempt should be made to utilize professional medical interpreters. (Grade I) 3. Stereotyping should be avoided, as generalizations about specific cultures are not always applicable to specific patients. (Grade II) Grade I: Cross-sectional study, Case series, Case report, Consensus statement, Consensus report, Narrative review Grade II: Consensus statement, Consensus report, Narrative review Ethical and Legal Aspects of Palliative Care (Institute for Clinical Systems Improvement) 1. Informed consent for any treatment or plan of care requires a patient with decision-making capacity or an appropriate surrogate decision-maker. (Grade II) 2. The patient's goals, preferences and choices are respected within the limits of applicable state and federal laws, and form the basis for the plan of care (Grade I) Grade I: Consensus statement, Consensus report, Narrative review Grade II: Cross-sectional study, Case series, Case report, Consensus statement, Consensus report, Narrative review ACOVE project- The guideline developers used a total of 299 articles; 74 were identified through a web search; 120 through references mining; 50 through the Accessing Care of Vulnerable Elders (ACOVE)-3 literature searches; and 55 from reference mining the ACOVE-1 monograph. Each recommendation cites a literature source or expert opinion. American College of Physicians- The guideline rating process was adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup. The quality of evidence was rated on a low, moderate, and high scale. The strength of recommendation was rated on a strong (benefits clearly outweigh risks and burden risk and burden clearly outweigh benefits) or weak (benefits finely balanced with risks and burden) scale. Institute for Clinical Systems Improvement- Classes of research reports are broken into categories: Primary Reports of New Data Collection and Reports that Synthesize or Reflect upon Collection of Primary Reports. Primary Reports of New Data are further subcategorized into, Class A: Randomized Controlled trial; Class B: Cohort Study; Class C: Non-randomized trial with concurrent or historical controls, Case control study, Study of sensitivity and specificity of a diagnostic test, or a Population-based descriptive study; Class D: Cross sectional study, Case series, or Case report. Reports that synthesize or reflect upon collections of primary reports are further subcategorized into, Class M: Meta-analysis, Systematic Review, Decision Analysis, Cost Effective Analysis; Class R: Consensus statement, Consensus report, Narrative Review; Class X: Medical Opinion. The performance measures found in this document have been developed with these guidelines, enabling the physician to track his or her performance in individual patient care across patient populations. Please note that treatment must be based on individual patient needs and professional judgment. Measure Harmonization: There is not an existing set of palliative/end of life care measures, but when there were similar measures in other disease areas, NCQA and the Consortium attempted to harmonize the measures to the extent feasible. The Advance Care Planning measure was adopted from the 2008 Physician Quality Reporting 7

8 Initiative Measure #47, this measure extends the denominator population to capture people under the age of 65 who are at the end of life. Measure Testing & Implementation: Measure Testing & Implementation Measures in the palliative and end of life care measurement set have not yet been tested or implemented. Measure Description Palliative and End of Life Care Measure #1: Advance Care Planning Percentage of patients with advanced chronic or serious life threatening illness who have an advance care plan or surrogate decision maker documented in the medical record Documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan in the medical record. Measure Detail Numerator Denominator Denominator Exclusions Supporting Guideline Patients who have an advance care plan or surrogate decision maker documented in the medical record Documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Patients with a substantial risk of death within one year, based on the physician s clinical judgment integrating the patients co-morbidities, health status, social and other factors (identified with CPT-II code) Patients with advanced disease whose goals of care prioritize comfort (identified with CPT-II code) Patients with incurable cancer, organ system failure, or severe progressive neurological conditions (identified with ICD-9 code) None The following evidence statements are quoted verbatim from the referenced clinical guidelines. Vulnerable Elders ACOVE project- RAND Health If a Vulnerable Elder (VE) dies an expected death with metastatic cancer, oxygen dependent pulmonary disease, NYHA Class III to IV congestive heart failure, end stage liver disease, end stage renal disease or dementia, the following should be considered and reflected in the patients medical record: 1. Comprehensive Palliative Assessments. Pain and other symptoms. Spiritual and existential concerns. Caregiver burdens. Needs for practical assistance. Needs for advanced care planning. 2. Care Surrogate Discussion. 8

9 Goals of treatment are discussed with Care Surrogate (if applicable). 3. Advance Care Planning Discussion documented in chart. 4. Advance Directive and Surrogate Continuity. If VE is transported to alternate treatment site, medical record should document advanced directives and/or surrogate decision maker. 5. Care Preference Documentations, including: Decisions about Life-Sustaining Treatments. Gastronomy Tube Placement. Mechanical Ventilator withdrawal. 6. Symptom Treatment and Management 7. Effects of Caregiver Stress, including bereavement Level of Evidence: C Cultural Aspects of Care Institute for Clinical Systems Improvement Patient and family reactions to serious illness and decisions about end-of-life care are influenced by cultural factors. (Grade I) 1. Specific cultural assessment promotes patient/family-centered decision-making and offers the opportunity to identify care preferences. (Grade I) 2. Every attempt should be made to utilize professional medical interpreters. (Grade I) 3. Stereotyping should be avoided, as generalizations about specific cultures are not always applicable to specific patients. (Grade II) Grade I: Cross-sectional study, Case series, Case report, Consensus statement, Consensus report, Narrative review Grade II: Consensus statement, Consensus report, Narrative review Ethical and Legal Aspects of Palliative Care Institute for Clinical Systems Improvement 1. Informed consent for any treatment or plan of care requires a patient with decision-making capacity or an appropriate surrogate decision-maker. (Grade II) 2. The patient's goals, preferences and choices are respected within the limits of applicable state and federal laws, and form the basis for the plan of care (Grade I) Grade I: Consensus statement, Consensus report, Narrative review Grade II: Cross-sectional study, Case series, Case report, Consensus statement, Consensus report, Narrative review ACOVE project- The guideline developers used a total of 299 articles; 74 were identified through a web search; 120 through references mining; 50 through the Accessing Care of Vulnerable Elders (ACOVE)-3 literature searches; and 55 from reference mining the ACOVE-1 monograph. Each recommendation cites a literature source or expert opinion. Institute for Clinical Systems Improvement- Classes of research reports are broken into categories: Primary Reports of New Data Collection and Reports that Synthesize or Reflect upon Collection of Primary Reports. Primary Reports of New Data are further subcategorized into, Class A: Randomized Controlled trial; Class B: Cohort Study; Class C: Non-randomized trial with concurrent or historical controls, Case control study, Study of sensitivity and specificity of a diagnostic test, or a Population-based descriptive study; Class D: Cross sectional study, Case series, or Case report. Reports that synthesize or reflect upon collections of primary reports are further subcategorized into, Class M: Meta-analysis, Systematic Review, Decision Analysis, Cost 9

10 Effective Analysis; Class R: Consensus statement, Consensus report, Narrative Review; Class X: Medical Opinion. Measure Importance Relationship to desired outcome Opportunity for Improvement Harmonization with Existing Measures Guidelines strongly suggest that patients approaching the end of life have an advance care plan before incapacity. The purpose of the advance care plan is to address a patient s wishes including but not limited to the areas of: resuscitation procedures, mechanical respiration, chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood products, transfusions, and intentional deep sedation. Patients may opt against an advance care plan depending on personal preferences. The purpose of this measure is to determine whether advance care planning was discussed with a practitioner. Proper advance care planning ensures that patient s treatment wishes are met through the end of life. Most inpatients want to discuss end of life issues with physicians. However, many physicians believe it is not appropriate to begin advance directive planning until a patient nears end of life. Studies have shown that patients would like to discuss advance care planning with them before becoming seriously ill. 6 This measure is harmonized with measure #47- Advance Care Plan from the 2008 Physician Quality Reporting Initiative program Measure Designation Measure purpose Type of measure Care setting Data source Accountability Process Ambulatory Paper Medical Record, Administrative Claims, Electronic Medical Record, Administrative Claims supplemented by Medical Records Actionable Feedback Percentage of patients 18 years and older with a substantial risk of death within one year, based on the physician s clinical judgment integrating the patients co-morbidities, health status, social and other factors (identified with CPT-II code) patients with advanced disease whose goals of care prioritize comfort (identified with CPT-II code) patients with incurable cancer, organ system failure, or severe progressive neurological conditions (identified with ICD-9 code) Patients who have an advance care plan or surrogate decision maker documented in the medical record at least once within 12 months Documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Patients who did NOT have an advance care plan or surrogate decision maker documentation in the medical record that an advance care plan was discussed 0

11 There is no medical reason exclusion allowed in this measure There is no patient reason exclusion allowed in this measure There is no system reason exclusion allowed in this measure Technical Specifications: Administrative Data Denominator (Eligible Population) Patients should be included in denominator (eligible population) calculations if any of the following three criteria are met: Criteria #1: Patients with a substantial risk of death within one year, based on the physician s clinical judgment integrating the patients co-morbidities, health status, social and other factors (identified with CPT-II code) Criteria #2: patients with advanced disease whose goals of care prioritize comfort (identified with CPT-II code) Criteria #3: patients with incurable cancer, organ system failure, or severe progressive neurological conditions (identified with ICD-9 code) Criteria #1 CPT E/M Service Code: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99342, 99343, 99344, 99345, 99347, 99348, 99349, AND CPT Category II code 1150F: Documentation that a patient has a substantial risk of death within one year NOTE: For REPTING programs, CPT Category II code 1151F: Documentation that a patient does not have a substantial risk of death within one year may be used to indicate patients not eligible for inclusion in reporting calculations. Criteria #2 CPT E/M Service Code: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99342, 99343, 99344, 99345, 99347, 99348, 99349, AND CPT Category II code 1152F: Documentation of advanced disease diagnosis, goals of care prioritize comfort NOTE: For REPTING programs, CPT Category II code 1153F: Documentation of advanced disease diagnosis, goals of care do not prioritize comfort may be 1

12 used indicate patients not eligible for inclusion in reporting calculations. Criteria #3 CPT E/M Service Code: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99342, 99343, 99344, 99345, 99347, 99348, 99349, AND One of the following conditions in the Description column as specified by the codes in the ICD-9-CM Diagnosis column Description ICD-9-CM Diagnosis Pancreatic Cancer 157.0, 157.1, 157.2, 157.3, 157.8, Esophageal Cancer 150.3, 150.5, , 150.1, 150.2, 150.4, Stomach Cancer Brain Cancer Lung Cancer Peritoneal Cancer Secondary malignant neoplasm of respiratory and digestive systems , 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, , 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, , 162.3, 162.2, 162.4, 162.5, 162.9, , 158.9, , 197.1, 197.2, 197.3, 197.4, 197.5,197.6, 197.7, Secondary malignant neoplasm of other specified sites 198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, 198.8, , , , COPD and ventilator support or oxygen dependence AND V46.1,V46.2 Heart Failure , , , , , , , , , , 428.0, 428.1, 428.2,428.3, 428.4, ESRD 585.5, 585.6, V42.0, V45.1, V56 2

13 Dementia 290.0, 290.1, 290.2, 290.3, 290.4, 290.8, 290.9, 331.0, 331.1, , , Stroke Parkinson s ALS Cystic Fibrosis and ventilator support or oxygen dependence AND V46.1,V46.2 General Palliative Care V66.7 Numerator Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. CPT Category II code 1123F: Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record CPT Category II code 1124F: Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Denominator Exclusions None Technical Specifications: Electronic Health Record System Technical specifications for electronic health record systems are developed for all measures after they are approved. Technical Specifications: Prospective Data Collection Flow sheet Prospective data collection flow sheets are developed for measure sets after they are approved. 3

14 Palliative and End of Life Care Measure #2: Dyspnea Screening and Management Measure Description Percentage of patients with advanced chronic or serious life threatening illnesses that are screened for dyspnea. For those that are diagnosed with moderate or severe dyspnea, a documented plan of care to manage dyspnea exists. Measure Detail Numerator 1. Patients who are screened for dyspnea. 2. Patients who are screened for dyspnea and diagnosed with moderate or severe dyspnea, who have a documented plan of care* to manage dyspnea Denominator Denominator Exclusions Supporting Guideline *A documented plan of care includes: a plan for treatment of dyspnea, including but not limited to: nonpharmacologic treatments (e.g. repositioning, improving air circulation, relaxation techniques) and pharmacologic methods (e.g. oxygen, opioids, anxiolytics) a statement about why no intervention is undertaken AND a plan for assessment including indication of reassessment time or interval Patients with incurable cancer, organ system failure, or severe progressive neurological conditions (identified with ICD-9 code) AND Patients with a substantial risk of death within one year, based on the physician s clinical judgment integrating the patients co-morbidities, health status, social and other factors (identified with CPT-II code) Patients with advanced disease whose goals of care prioritize comfort (identified with CPT-II code) None The following evidence statements are quoted verbatim from the referenced clinical guidelines. Assessing Care of Vulnerable Elders- Quality Indicators for Palliative and End-of-Life Care in Vulnerable Elders ACOVE project- RAND Health If a Vulnerable Elder (VE) dies an expected death with metastatic cancer, oxygen dependent pulmonary disease, NYHA Class III to IV congestive heart failure, end stage liver disease, end stage renal disease or dementia, the following should be considered and reflected in the patients medical record: 1. Comprehensive Palliative Assessments. Pain and other symptoms. Spiritual and existential concerns. Caregiver burdens. Needs for practical assistance. Needs for advanced care planning. 2. Care Surrogate Discussion. Goals of treatment are discussed with Care Surrogate (if applicable). 3. Advance Care Planning Discussion documented in chart. 4. Advance Directive and Surrogate Continuity. If VE is transported to alternate treatment site, medical record should document advanced directives and/or surrogate decision maker. 5. Care Preference Documentations, including: Decisions about Life-Sustaining Treatments. Gastronomy Tube Placement. 4

15 Mechanical Ventilator withdrawal. 6. Symptom Treatment and Management 7. Effects of Caregiver Stress, including bereavement Level of Evidence: C Pharmaceutical Therapies for Palliative Care American College of Physicians Managing pain: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage pain. For patients with cancer, this includes nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates. (Grade I) Managing dyspnea: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. (Grade I) Managing depression: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage depression. For patients with cancer, this includes tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention. (Grade II) Grade I: Strong recommendation, moderate quality of evidence. Grade II: Evidence from observational studies (e.g., correlational descriptive studies) or controlled trials with inconsistent results. Psychological and Social Aspects of Care for Palliative patients Institute for Clinical Systems Improvement 1. Regular ongoing assessment of a patient's psychological status is important. (Grade I) 2. In patients with serious illness at the end of life, clinicians should regularly assess patients for pain, dyspnea, and depression 3. The interdisciplinary team includes professionals with specific skills in assessment and development of a social care plan. (Grade II) 4. Conduct regular care conferences. (Grade II) Grade I: Consensus statement, Consensus report, Narrative review Grade II: Consensus statement, Consensus report, Narrative review, Medical Opinion Structure and Processes of Palliative Care Institute for Clinical Systems Improvement Early identification of patients with conditions that would benefit from palliative care planning can be accomplished by considering conditions and symptoms that are appropriate for palliative care services Consensus statement, Consensus report, Narrative review Measure Importance Relationship to desired outcome Opportunity for Improvement Exclusion Justification Assessment and treatment of symptoms such as dyspnea are deemed critical for palliative care. Dyspnea is a symptom frequently seen in the end of life population. Identification and treatment (if necessary) of dyspnea improves quality of life at the end of life. While no published data regarding a quality gap or variation in performance are available for this measure topic, the work group was in consensus that this is an aspect of care that is not regularly performed for all patients. Through implementation and testing of this measure, it is expected that we will be able to collect data that will help us demonstrate whether or not a gap in care or variation in performance exists This measure has no exclusions 5

16 Harmonization with Existing Measures This measure is not harmonized with any existing measures. Measure Designation Measure purpose Type of measure Care setting Data source Accountability Process Ambulatory Paper Medical Record, Administrative Claims, Electronic Medical Record, Administrative Claims supplemented by Medical Records Actionable Feedback Percentage of patients 18 years and older with a substantial risk of death within one year, based on the physician s clinical judgment integrating the patients co-morbidities, health status, social and other factors (identified with CPT-II code) patients with advanced disease whose goals of care prioritize comfort (identified with CPT-II code) AND patients with incurable cancer, organ system failure, or severe progressive neurological conditions (identified with ICD-9 code) Patients who are screened for dyspnea at least once within 12 months On screening, absent or mild dyspnea Dyspnea screened, moderate to sever dyspnea Patients who are screened for dyspnea at least once within 12 months There is no medical reason exclusion allowed in this measure There is no patient reason exclusion allowed in this measure There is no system reason exclusion allowed in this measure Patients who are screened for dyspnea and diagnosed with moderate or severe dyspnea who have a documented plan of care* to manage dyspnea Patients who are screened for dyspnea and diagnosed with moderate or severe dyspnea who did NOT have a documented plan of care to manage dyspnea There is no medical reason exclusion allowed in this measure There is no patient reason exclusion allowed in this measure There is no system reason exclusion allowed in this measure 6

17 Technical Specifications: Administrative Data Denominator (Eligible Population) Patients with incurable cancer, organ system failure, or severe progressive neurological conditions (identified with ICD-9 code) AND Patients with a substantial risk of death within one year, based on the physician s clinical judgment integrating the patients co-morbidities, health status, social and other factors (identified with CPT-II code) Patients with advanced disease whose goals of care prioritize comfort (identified with CPT-II code) The denominator requires codes from each of the following three elements: 1) an ICD-9-CM code, 2) a CPT E/M Service code, and 3) a CPT category II code. Element #1: ICD-9 CM code One of the following conditions in the Description column as specified by the codes in the ICD-9-CM Diagnosis column Description COPD and ventilator support or oxygen dependence Heart Failure ICD-9-CM Diagnosis 492.0, AND V46.1,V , , , , , , , , , , 428.0, 428.1, 428.2,428.3, 428.4, Lung Cancer 162.8, 162.3, 162.2,162.4, 162.5, 162.9, Cystic Fibrosis and ventilator support or oxygen dependence AND V46.1,V46.2 Pulmonary Embolism

18 AND COPD AND Incurable Cancers 492, 496, 491.2, 493.2, V46.1, V46.2 Element #2: CPT E/M Service Code: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99342, 99343, 99344, 99345, 99347, 99348, 99349, AND Element #3: CPT Category II Code: CPT Category II code 1150F: Documentation that a patient has a substantial risk of death within one year AND , 157.1, 157.2, 157.3, 157.8, , 150.5, , 150.1, 150.2, 150.4, , 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, , 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, , 162.3, 162.2, 162.4, 162.5, 162.9, , 158.9, , 197.1, 197.2, 197.3, 197.4, 197.5,197.6, 197.7, , 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, 198.8, , , NOTE: For REPTING programs, CPT Category II code 1151F: Documentation that a patient does not have a substantial risk of death within one year may be used to indicate patients not eligible for inclusion in reporting calculations. CPT Category II code 1152F: Documentation of advanced disease diagnosis, goals of care prioritize comfort NOTE: For REPTING programs, CPT Category II code 1153F: Documentation of advanced disease diagnosis, goals of care do not prioritize comfort may be used indicate patients not eligible for inclusion in reporting calculations. Numerator 1. Patients who are screened for dyspnea 2. Patients who are screened for dyspnea and diagnosed with moderate or severe dyspnea, who have a documented plan of care* to manage dyspnea * A documented plan of care includes: a plan for treatment of dyspnea, including but not limited to: nonpharmacologic treatments (e.g. repositioning, improving air 8

19 circulation, relaxation techniques) and pharmacologic methods (e.g. oxygen, opioids, anxiolytics) a statement about why no intervention is undertaken CPT Category II Codes 3450F: Dyspnea screened, no dyspnea or mild dyspnea 3451F: Dyspnea screened, moderate to severe dyspnea AND 0535F: Dyspnea management plan of care documented Denominator Exclusions None Technical Specifications: Electronic Health Record System Technical specifications for electronic health record systems are developed for all measures after they are approved. Technical Specifications: Prospective Data Collection Flow sheet Prospective data collection flow sheets are developed for measure sets after they are approved. 9

20 Reference 1 Morrison RS, Maroney-Galin C, Kralovec PD, Meier DE. The growth of palliative care programs in United States hospitals. Journal of Palliative Medicine Dec;8(6): Connor SR, Elwert F, Spence C, Christakis NA. Geographic variation in hospice use in the United States in J Pain Symptom Manage Sep;34(3): NHPCO Facts and Figures on Hospice Care in America: November ( (Last accessed March 27, 2008) 4 Aseracare, Inc: Study Reveals Good News About the Cost of Hospice Care. ( Accessed March 20, Lorenz et al. Evidence for Improving Palliative Care at the End of Life: A Systematic Review. Annals of Internal Medicine. 2008;148: Warm E. Fast fact and concept #012:myths about advance directives. Available at: 0