Supplementary Appendix

Transcription

1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: MacLean CH, Kerr EA, Qaseem A. Time out charting a path for improving performance measurement. N Engl J Med 2018;378: DOI: /NEJMp

2 Contents Methods... 2 Committee Composition... 2 Measure Review Process... 2 Analyses... 3 Table S1. Measures Rated as Valid... 4 Table S2. Measures Rated as Uncertain Validity Table S3. Measures Rated as Not Valid References

3 Methods Committee Composition The Performance Measurement Committee is comprised of 13 volunteer ACP physician members. Members include practicing physicians from urban and rural areas from all United States regions; physicians in community- and academic-based care delivery systems; physicians in solo-, group-, and large multi-specialty practices; executives in managed care organizations; and researchers with expertise in the science of performance measurement. Measure Review Process To determine the validity of the selected performance measures as indicators of the quality of health care provided by ambulatory general internal medicine physicians, reviewers used a modification of the RAND-UCLA appropriateness method. 1,2 This method employs a formal group process in which a panel of experts discusses and rates the appropriateness of a series of indications for specific processes of health care. Preliminary ratings of the proposed indications are performed and analyzed in advance of a face-to-face meeting at which the indications and their preliminary ratings are discussed. Then, each of the indications is rerated. Results are based on these final ratings. All ratings are anonymous and the ratings of each panelist have equal weight; consensus is not required. This method has content, construct and predictive validity. 3-5 As with other studies that have used a modification of this method to define quality, 6,7 our panel rated the validity of the performance measures as indicators of quality rather than rating the appropriateness of indicators of care. We collected the measure specifications, rationale and any supporting information that were publically available for each measure and made these available online to the panelists for the first-round ratings, along with the ACP performance measure review criteria. Using an online survey tool, the panelists assessed whether the measure met criteria within each of the five domains of the ACP criteria using a 9-point scale where 1-3 indicated does not meet criteria, 4-6 meets some criteria, and 7-9 meets criteria. After considering and rating each of these domains, panelists then rated the overall measure validity. Subsequently, we conducted a face-to-face panel meeting at which the panelists discussed and re-rated each of the proposed measures. During that meeting, each panelist received an aggregate summary of pre-ratings, as well as their own pre-rating score for each measure. When each measure was discussed, the discussion focused on those measures for which there was disagreement or the ratings were indeterminate. After the discussion of each measure, the panelists re-rated each of the measures by confidential ballot using the same rating scale. The committee chair (CHM) and immediate past chair (EAK) served as moderators for the panel process and did not rate measures. One employed ACP staff-physician and one former committee member also rated the measures. For the preliminary rating round, the remaining 13 members of the PMC were split into two groups of six and seven members, each of which was assigned approximately half of the measures to pre-rate. At the face-to-face round, all 2

4 PMC members discussed and rated each measure, unless a member had a conflict of interest for a particular measure, per the ACP conflict of interest policy (available upon request). As a result, there were between 9 and 13 raters for each of the measures for the second round. Analyses We considered measures as valid if the median overall rating was 7, 8 or 9; and there was no disagreement. Measures were considered not valid if the median overall rating was 1, 2 or 3; and there was no disagreement. The validity of all other measures was considered uncertain. For measures with 8, 9 or 10 raters, disagreement was defined as having 3 or more ratings in each the lowest (1-3) and highest (7-9) rating tertiles; for measures with 11, 12, or 13 raters, disagreement was defined as having four or more ratings in each the lowest and highest tertiles. 8 Based on these criteria, each measure was assigned to one of three rating categories: valid, uncertain, or not valid. We examined the relationship between overall validity and domain scores, by calculating median domain scores for each measure as well as the average of median scores overall and within each validity category. We also examined the relationships between domains by calculating the average median domain scores for measures with median domain scores in each tertile group (<3, >3 and <7, >7). Among the measures rated, some had been endorsed by the National Quality Forum (NQF) and others had not. To assess whether overall validity or ACP domain criteria adherence differed based on NQF endorsement, measures were categorized as either NQF-endorsed or not. Overall validity ratings as well as average median criteria scores were calculated for the measures that were NQF-endorsed and for the ones that were not. 3

5 Tables: Measures Rated by Category Table S1. Measures Rated as Valid Arrhythmia MIPS: 326 (NQF: 1525, Measure Steward: American College of Cardiology): Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Measure Description: Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism. Intended Level of Analysis: Clinician: Individual Overall : Valid Importance Appropriateness Evidence Specifications Feasibility Implementation may lead to meaningful improvements in clinical outcomes and a performance gap exists. While we support this measure, implementation could result in underuse of appropriately prescribed anticoagulation therapy. Denominator specifications include exclusion criteria for patients with a documented reason for not prescribing therapy. Inclusion of such broad exclusion criteria may discourage clinicians from prescribing therapy in patients where the benefits outweigh the risk of harms (e.g., documentation of "fall risk"). Developers should consider explicitly defining exclusion criteria to prevent underuse of anticoagulation therapy in clinically appropriate cases. Additionally, developers cite outdated evidence to form the basis of the measure. Developers should update the denominator specifications to include the CHADs2VASc risk stratification tool

6 Asthma MIPS: 444 (NQF: 1799-endorsement removed Aug 2016, Measure Steward: National Committee for Quality Assurance): Medication Management for People with Asthma Measure Description: The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Importance Appropriateness Evidence Specifications Feasibility Implementation may promote patient adherence to prescribed controller medication therapy and a 50% medication compliance rate is an achievable threshold. Clinicians are well aware of medication adherence issues in patients with asthma and underuse of controller medication therapy is clearly a problem. While we support this measure, we encourage developers to consider several issues that decrease the measure quality. First, we cannot estimate the clinical impact of the measure on quality outcomes because developers do not cite a performance gap. A more meaningful measure may promote appropriate use of controller medication therapy in patients who were not previously prescribed therapy during the measurement year. Second, the measure developers do not cite any evidence to support the Percentage of Days Covered (PDC) threshold. However, we support the <100% PDC threshold to appropriately account for patient adherence issues. Third, the measure is not risk-adjusted for disease severity or socioeconomic status and implementation could unfairly penalize clinicians who treat patients with barriers to medication use. Fourth, while denominator specifications include appropriate exclusion criteria for patients with controlled asthma who sparingly use controller medications to alleviate symptoms related to common pulmonary infections (e.g., viral

7 cold, bronchitis), the numerator should clearly specify an appropriate asthma controller medication list. Fifth, the measure could unfairly penalize clinicians who encounter interoperability barriers to data retrieval. Sixth, the measure uses pharmacy data to track medication adherence. However, lower socioeconomic status patients encounter cost barriers to medication access and clinicians often supply sample medications to improve patient adherence. Pharmacy data may not capture sample medication distribution. Finally, the measure intends to assess quality performance at the system level. While it is feasible for health plans to identify the denominator population within system-wide, interoperable information systems, individual clinicians may encounter interoperability barriers to data retrieval. 6

8 Bronchitis MIPS: 116 (NQF: 0058, Measure Steward: National Committee for Quality Assurance) : Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Measure Description: The percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Importance Appropriateness Evidence Specifications Feasibility Implementation could lead to measureable and meaningful improvements in clinical outcomes and prevent overuse of inappropriate antibiotic therapy in patients diagnosed with acute bronchitis. Also, measure developers cite appropriate evidence to form the basis of the measure and measure specifications include appropriate exclusion criteria for patients with Chronic Obstructive Pulmonary Disease and immunocompromised patients. While we support this measure, we note the potential for clinicians to manipulate the measure through inaccurate disease classification coding (i.e., ICD-10)

9 Cancer Screening MIPS: 112 (NQF: 2372, Measure Steward: National Committee for Quality Assurance): Breast Cancer Screening Measure Description: Percentage of women years of age who had a mammogram to screen for breast cancer. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Importance Appropriateness Evidence Specifications Feasibility Implementation promotes appropriate use of screening tools, current evidence supports the benefit of biennial screening mammography for women ages 50 to 74 years, and the measure poses low burden because most health systems have robust networks in place to specifically address this issue. While we support this measure, implementation could promote screening overuse. A stronger measure may include exclusion criteria for system and patient related issues (e.g., availability of mammography screening tools, patient preference, and limited life expectancy). Also, while the measure represents a meaningful clinical concept, implementation will likely be less impactful than implementation of other cancer screening measures (e.g., MIPS 113: Colorectal Cancer Screening)

10 Cancer Screening MIPS: 113 (NQF: 0034, Measure Steward: National Committee for Quality Assurance): Colorectal Cancer Screening Measure Description: Percentage of adults years of age who had appropriate screening for colorectal cancer. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Number of ratings per Importance Appropriateness Evidence Specifications Feasibility The measure represents an important clinical concept and reflects the importance of shared decision-making when selecting a screening test. While we support this measure, as currently specified, it is a crude translation of the guideline recommendations into a performance measure. The developer should update the measure specifications to align with current clinical recommendations on colorectal cancer screening. Specifically, numerator specifications could be more robust and should include the option for clinicians to document emerging cancer screening tests (e.g., stool FIT-DNA, CT colonography). Additionally, measure specifications do not include appropriate exclusion criteria and could promote overuse of screening in patients where the benefits do not outweigh the risk of harms. A better measure would include exclusion criteria for patients diagnosed with dementia, patients with limited life expectancy, patients with advanced comorbidities, and patient refusal. Furthermore, we suggest the developers revise the measure specifications to include some element of risk-adjustment to determine whether the screening benefits outweigh the potential harms

11 Cancer Screening MIPS: 309 (NQF: 0032, Measure Steward: National Committee for Quality Assurance): Cervical Cancer Screening Measure Description: Percentage of women years of age who were screened for cervical cancer using either of the following criteria: * Women age who had cervical cytology performed every 3 years * Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility The current evidence supports screening in women years of age and this measure is based on the most recent United States Preventive Services Task Force (USPSTF) recommendations on cervical cancer screening

12 Cancer Screening MIPS: 443 (Not NQF-endorsed, Measure Steward: National Committee for Quality Assurance): Non-recommended Cervical Cancer Screening in Adolescent Females Measure Description: The percentage of adolescent females years of age who were screened unnecessarily for cervical cancer. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Implementation will likely promote appropriate use of cervical cancer screening in adolescents, the measure is well specified, and specifications include appropriate exclusion criteria for women diagnosed with HIV. Additionally, the measure aligns with United States Preventive Services Task Force (USPSTF) recommendations on cervical cancer screening. While we support this measure, current data on cervical cancer screening in women shows that earlier screening recommendations are not as effective as previously indicated in diagnosing HPV in women aged years. The evidence base would benefit from re-evaluation as data surfaces on the benefits and risks of screening in women < 20 years old. In addition, the developers do not cite a performance gap in the measure report, and therefore, we cannot estimate the potential impact of the measure on quality outcomes

13 Chlamydia MIPS: 310 (NQF: 0033, Measure Steward: National Committee for Quality Assurance): Chlamydia Screening in Women Measure Description: Percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility The measure aligns with United States Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) recommendations on chlamydia screening, evidence supports screening in primary care as feasible and effective, and the denominator is clearly specified to capture all women who are sexually active. Specifications define three methods to identify contraceptive therapy prescription: 1) pharmacy data, 2) claims data, 3) medical records data

14 Chronic Obstructive Pulmonary Disease (COPD) MIPS: 051 (NQF: 0091, Measure Steward: American Thoracic Society): Chronic Obstructive Pulmonary Disease: Spirometry Evaluation Measure Description: Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented. Intended Level of Analysis: Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Current performance does not meet best practices and there is opportunity for improvement through improved diagnostic accuracy. Furthermore, diagnosing or labeling a patient with COPD without performing or reviewing spirometry results may adversely impact future management. In addition, measure specifications include appropriate exclusion criteria for documentation of medical reason for not documenting spirometry results. While we support this measure, we note that spirometry evaluation is only a confirmatory test. A more meaningful measure may assess for COPD misdiagnosis. Additionally, while this measure represents good clinical practice, implementation could promote overuse of pulmonary function tests (PFTs) if clinicians encounter interoperability barriers to data retrieval across incompatible information systems. Performing PFTs in asymptomatic patients is unlikely to benefit clinical outcomes

15 Coronary Artery Bypass Graft (CABG) MIPS: 243 (NQF: 0643, Measure Steward: American College of Cardiology): Cardiac Rehabilitation: Patient Referral from an Outpatient Setting Measure Description: Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility It is clinically important to refer patients who are likely to benefit from rehabilitative services to outpatient therapy centers. While we support this measure, we advise developers to address the following concerns during the update process to improve the measure quality. First, the measure is nearly capped out. Developers cite a 97% performance rate based on data collected from the PINNACLE registry during the 2011 reporting year. However, this data may inaccurately represent national performance rates because it only represents clinicians who choose to participate in the cardiology registry. Second, implementation of this measure could unfairly penalize clinicians who practice in rural areas and who care for medically complex patient populations. The developers should consider revising the specifications to include a riskadjustment model for patients with multiple comorbidities, lower socioeconomic status, and limited access to rehabilitative services. Third, while this measure appropriately assesses performance of clinicians participating in the cardiology registry, it is an inappropriate accountability measure for general internists who do not report data in the PINNACLE registry. Lastly, while this measure is appropriately

16 specified to assess the performance quality of clinicians practicing in metropolitan areas, it may not apply well to clinicians practicing in rural settings where patients have limited access to rehabilitative services. Specifications include exclusion criteria for no rehabilitation program available within 60 minutes from patient home, but 60 minutes is an unfair expectation. Patients who are faced with significant travel burdens are less likely to adhere to prescribed services. 15

17 Coronary Artery Disease (CAD) MIPS: 006 (NQF: 0067, Measure Steward: American Heart Association): Coronary Artery Disease: Antiplatelet Therapy Measure Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility It is clinically important for clinicians to prescribe anti-platelet therapy to patients with CAD and a performance gap exists. Additionally, the measure is reasonably specified. As written, specifications limit the potential for unintended consequences by excluding patients who currently receive warfarin therapy. While strong evidence exists to form the basis of the measure, the evidence base would benefit from re-evaluation as data surfaces on the benefits and risks of aspirin therapy in patients who are already prescribed warfarin therapy. The European Cardiology Society and the American College of Cardiology have divergent recommendations on this area. Lastly, while feasibility of data collection and implementation burden is appropriate, it may be difficult for clinicians to capture over the counter aspirin use unless explicitly stated by the patient

18 Coronary Artery Disease (CAD) MIPS: 007 (NQF: 0070, Measure Steward: Physician Consortium for Performance Improvement): Coronary Artery Disease: Beta-Blocker Therapy Prior Myocardial Infarction or Left Ventricular Systolic Dysfunction (LVEF <40%) Measure Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility A performance gap exists and the measure represents an important and highly beneficial clinical concept. Additionally, measure specifications include appropriate exclusion criteria for documentation of medical, patient, or system reason for not prescribing beta-blocker therapy. However, skepticism exits surrounding consistency across operating systems to include all billing codes for appropriate exclusion criteria. Furthermore, while the measure is based on clinical recommendations of the ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, there is some question surrounding the need for continued beta-blocker therapy for three years in low-risk patients in the contemporary era of revascularization. Lastly, while the myocardial infarction (MI) look-back period is limited to those occurring within the past 3 years, the measure specifications do not limit the documentation of prior LVEF <40% look-back period. It is unnecessarily burdensome for clinicians to look at all LVEF assessments in a complete patient history. Developers should consider revising the specifications to limit the look-back window and exclude patients with a normal LVEF without history of LVSD

19 Depression MIPS: 107 (NQF: 0104, Measure Steward: Physician Consortium for Performance Improvement): Adult Major Depressive Disorder: Suicide Risk Assessment Measure Description: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility It is clinically important to assess for suicide risk in patients with MDD. While we support this measure, we note several recommendations that could improve the measure quality. First, the measure is close to being topped out. The measure developers cite a 96% compliance rate. However, this data only represents clinicians who chose to report on the measure for the 2010 PQRS reporting year and therefore, may inaccurately represent nation-wide performance levels. Developers should include current, national performance data in the updated measure report. Second, the numerator is not clearly specified. In particular, it is not well defined what constitutes a recurrent episode. The developers should consider revising the specifications to stipulate that this is an episode associated with the initiation of new treatment for depression. As currently stated, the measure could apply to all follow-up visits with the mention of even well-controlled depression. Third, this is a check the box measure with little potential to shift the quality needle as evidenced by the small performance gap. Lastly, the measure poses significant burden

20 Headache MIPS: 419 (Not NQF-endorsed, Measure Steward: American Academy of Neurology): Overuse of Neuroimaging for patients with Primary Headache and a Normal Neurological Evaluation Measure Description: Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Implementation will likely promote appropriate use of neuroimaging in patients with primary headache and the data source attributes the measure outcome to the ordering clinician. While we support this measure, the measure developers cite outdated evidence to form the basis of the measure. Additionally, quality reporting programs should be aware of the potential for clinicians to manipulate the measure to work in their favor by documenting an exception to the rule (e.g., "change in the type of headache ). To avoid potential measure gaming, developers should consider revising the specifications to clearly define appropriate exceptions to eligibility

21 Heart Failure MIPS: 005 (NQF: 0081, Measure Steward: Physician Consortium for Performance Improvement): Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction Measure Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge. Intended Level of Analysis: Clinician: Group/Practice, Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility There is good evidence that ACE inhibitors and ARBs improve the health of people with heart failure and LVEF <40%, and the measure aligns with current guidelines and represents high-value care for patients with chronic heart failure

22 Heart Failure MIPS: 008 (NQF: 0083, Measure Steward: Physician Consortium for Performance Improvement): Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction Measure Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility There is good evidence that ARBs improve the health of people with heart failure and LVEF <40%, and the measure aligns with current guidelines and represents high-value care for patients with chronic heart failure

23 Hepatitis C (HCV) MIPS: 387 (Not NQF-endorsed, Measure Steward: Physician Consortium for Performance Improvement): Annual Hepatitis C Virus Screening for Patients who are Active Injection Drug Users Measure Description: Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Implementation will likely lead to measurable and meaningful improvements in clinical outcomes, it is clinically appropriate to screen active injection drug users for HCV, and the measure aligns with United States Preventive Task Force (USPSTF) recommendations on HCV screening in patients who are at risk for infection. The measure also aligns with American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommendations for testing, managing, and treating Hepatitis C, and the measure specifications include appropriate exclusion criteria for patients where the treatment benefits do not outweigh the risk of harms (e.g., advanced liver disease, limited life expectancy). While we support this measure, we advise developers to address the following concerns during the update process. First, while the developers describe the measure s potential to positively impact clinical outcomes, the benefit of diagnosing active injection drug users on injection habits is unclear. Additionally, implementation is unlikely to largely benefit population health outcomes because most clinicians treat a low patient denominator for the measure. Second, the denominator specifications may not capture patients who deny injection drug use status. Therefore, it is may be difficult to estimate the true impact of the measure on quality outcomes. Developers should consider revising the

24 denominator specifications to be more inclusive of all patients at risk for HCV (e.g., baby-boomer populations). Third, clinicians may encounter barriers to data access. Information systems may not automatically identify the denominator population unless end users create a specific code to capture injection drug use. 23

25 Hepatitis C (HCV) MIPS: 400 (Not NQF-endorsed, Measure Steward: Physician Consortium for Performance Improvement): One-Time Screening for Hepatitis C Virus for Patients at Risk Measure Description: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years who received one-time screening for hepatitis C virus (HCV) infection. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility A performance gap exists, it is important to screen for HCV in patients at risk because it is a treatable disease, the measure aligns with Centers for Disease Control and Prevention (CDC) and United States Preventive Services Task Force (USPSTF) recommendations on screening for HCV in patients at risk, and the measure specifications include appropriate exclusion criteria. Additionally, the USPSTF found little evidence on the harms of screening for HCV. While the measure is clearly specified, clinicians may encounter interoperability barriers to patient information retrieval. Also, while we support this measure, we suggest the measure developers re-assess the benefit of screening all patients included in the denominator population during the measure update, particularly patients born in the years

26 Hypercholesterolemia MIPS: 438 (Not NQF-endorsed, Measure Steward: Centers for Medicare & Medicaid Services): Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Measure Description: Percentage of the following patients-all considered at high risk of cardiovascular events-who were prescribed or were on statin therapy during the measurement period: Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults aged >=21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dl or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR Adults aged years with a diagnosis of diabetes with a fasting or direct LDL-C level of mg/dl. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility The performance gap has increased significantly due to new United States Preventive Task Force (USPSTF) and American College of Cardiology/American Heart Association (ACC/AHA) clinical recommendations on treatment of cardiovascular disease to expand the at-risk patient population. Additionally, the balance of evidence provides a strong foundation for the treatment of blood cholesterol for the primary and secondary prevention of atherosclerotic cardiovascular disease in adult men and women. Furthermore, measure specifications include appropriate exclusion criteria for patient intolerance. While we support this measure, we note that implementation of statin therapy alone does not guarantee meaningful improvements in clinical outcomes. A more meaningful measure may examine patient adherence to prescribed statin therapy. Additionally, a high percentage of patients prescribed statin therapy for the management of cardiovascular disease exacerbations (e.g., acute MI) discontinue therapy without consulting their clinician. Therefore, the measure may unfairly penalize clinicians for lack of control over nonadherent patients

27 Ischemic Vascular Disease (IVD) MIPS: 204 (NQF: 0068, Measure Steward: National Committee for Quality Assurance): Ischemic Vascular Disease: Use of Aspirin or Another Antiplatelet Measure Description: Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Implementation will likely lead to meaningful and measurable improvements in clinical outcomes and promote appropriate use of antiplatelet therapy in patients with IVD. Furthermore, measure specifications include appropriate exclusion criteria for patients with documented use of anticoagulant medications during the measurement year. While the measure does not exclude patients who are at risk for gastrointestinal (GI) bleeding, the American Gastrointestinal Association recommends continuation of antiplatelet therapy despite diagnosis of GI bleed because treatment benefits (e.g., preventing myocardial infarction and mortality risk) outweigh the associated risks of harms. We note that it may be difficult for clinicians to capture patients prescribed over the counter aspirin therapy

28 Low Back Pain MIPS: 312 (NQF: 0052-endorsement removed May 2017, Measure Steward: National Committee for Quality Assurance): Use of Imaging Studies for Low Back Pain Measure Description: Percentage of patients years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. Intended Level of Analysis: Health plan, Integrated delivery system Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Inappropriate imaging is not associated with improved clinical outcomes. Implementation will likely prevent prescription of unnecessary imaging in patients with low back pain and unnecessary radiation exposure and treatment. Furthermore, measure specifications include appropriate exclusion criteria and high-quality evidence exists to form the basis of the measure

29 Myocardial Infarction (MI) MIPS: 442 (NQF: 0071, Measure Steward: National Committee for Quality Assurance): Persistence of Beta-Blocker Treatment After a Heart Attack Measure Description: The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge. Intended Level of Analysis: Health plan, Integrated delivery system Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility The exclusion criterion is broad and it is appropriate to attribute the measure outcomes to the individual clinician. Additionally, the measure is based on high-quality evidence from the most recent recommendations of various organizations (*ACP, ACC, ACCF/AHA, ESC). While we support this measure, we note the measure is close to being topped out. Data from the 2014 HEDIS reporting period demonstrates an 84% compliance rate. *American College of Physicians, American College of Cardiology, American College of Cardiology Foundation/American Heart Association, European Society of Cardiology

30 Osteoporosis MIPS: 039 (NQF: 0046, Measure Steward: National Committee for Quality Assurance): Screening for Osteoporosis for Women Year of Age Measure Description: Percentage of female patients aged years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Implementation will likely result in meaningful and measurable improvements in clinical outcomes, measure developers cite a performance gap based on the 2012 PQRS claims data (mean = 57%), and the measure aligns with United States Preventive Services Task Force (USPSTF) recommendations on screening for osteoporosis. While we support this measure, we note that implementation could promote overuse of screening if patients receive care from multiple clinicians and/or have poor record continuity, and in women who are at lower risk for osteoporosis based on reasonably identifiable factors (e.g., BMI, ethnicity). Additionally, developers should consider updating the denominator specifications to include exclusion criteria for patients who have already been assessed with the FRAX tool and for patients receiving hospice and palliative care where the intervention has the potential to cause more harms than benefits

31 Osteoporosis MIPS: 418 (NQF: 0053, Measure Steward: National Committee for Quality Assurance): Osteoporosis Management in Women who had a Fracture Measure Description: The percentage of women age who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice, Health Plan, Integrated Delivery System Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility A performance gap exists, the specifications align with current recommendations to screen for osteoporosis in women aged 65 years and older, and specifications include appropriate exclusion criteria for women with fracture related to traumatic injury. While we support this measure, implementation may promote overuse of bone mineral density testing. Developers should consider tapering the fracture definition to only include women with vertebral and hip fractures

32 Pain Assessment and Management MIPS: 412 (Not NQF-endorsed, Measure Steward: American Academy of Neurology): Documentation of Signed Opioid Treatment Agreement Measure Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility This measure protects clinicians from the repercussions of patients who violate the opioid agreement. Also, considering the magnitude and urgency of the opioid epidemic, quality programs should adopt this measure unless data is otherwise available to describe the negative consequences of this measure. While we support this measure, we suggest the developers update the measure specifications to include appropriate exclusion criteria for patients receiving active cancer treatment, and patients receiving palliative and end-of-life care

33 Pain Assessment and Management MIPS: 414 (Not NQF-endorsed, Measure Steward: American Academy of Neurology): Evaluation or Interview for Risk of Opioid Misuse Measure Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Implementation will likely lead to measureable and meaningful improvements in patient outcomes and prevent the misuse and abuse of opioid prescription therapy. Additionally, the measure aligns with clinical recommendations and state requirements on opioid prescription therapy. While we support this measure, evidence exists to suggest that opioid addiction develops in less than 6 weeks duration of prescribed therapy. As such, this measure could unfairly penalize clinicians who do not initiate opioid therapy (e.g., therapy initiated as part of a post-operative care program). Measure developers should consider updating the denominator specifications to include an evidence-based therapy duration. Also, the opioid measures would benefit from additional testing to determine which interventions are most impactful in preventing opioid misuse and abuse. Finally, a better measure may include exclusion criteria for patients receiving active cancer treatment, palliative care, and end-of-life care

34 Preventive Care MIPS: 226 (NQF: 0028, Measure Steward: Physician Consortium for Performance Improvement): Tobacco Use: Screening & Cessation Intervention Measure Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Reduction of tobacco use slows the progression of respiratory disease and is a key element in the management of pulmonary disease, tobacco use is a modifiable risk factor and clinical evidence suggests that patient counseling and recounseling by physicians increase attempts to quit, and the measure aligns with clinical recommendations of the ACP/ACCP/ ATS/ERS*and the United States Preventive Services Task Force on tobacco use and offer cessation interventions. *American College of Physicians (ACP)/American College of Chest Physicians (ACCP), American Thoracic Society (ATS)/European Respiratory Society (ERS)

35 Preventive Care MIPS: 402 (Not NQF-endorsed, Measure Steward: National Committee for Quality Assurance): Tobacco Use and Help with Quitting Among Adolescents Measure Description: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user. Intended Level of Analysis: Health Plan, Integrated Delivery System Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility Reduction of tobacco use slows the progression of respiratory disease and is a key element in the management of pulmonary disease, tobacco use is a modifiable risk factor and clinical evidence suggests that patient counseling and recounseling by physicians increase attempts to quit, and the measure aligns with clinical recommendations of the ACP/ACCP/ ATS/ERS*and the United States Preventive Services Task Force on tobacco use and offer cessation interventions. While we support the measure, as currently specified, the denominator population is unclear. The developer should consider separating the measure into two distinct measures: 1) tobacco use screening measure and 2) tobacco cessation measure for patients who screened positive on measure 1. *American College of Physicians (ACP)/American College of Chest Physicians (ACCP), American Thoracic Society (ATS)/European Respiratory Society (ERS)

36 Preventive Care MIPS: 431 (NQF: 2152, Measure Steward: Physician Consortium for Performance Improvement): Unhealthy Alcohol Use: Screening & Brief Counseling Measure Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. Intended Level of Analysis: Clinician: Individual, Clinician: Group/Practice Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility It is clinically important to screen for unhealthy alcohol use, the measure aligns with the United States Preventive Services Task Force (USPSTF) recommendations on screening and behavioral health counseling interventions in primary care, and the measure does not pose undue burden on clinicians. While we support this measure, we suggest the developers revise the numerator specifications to clearly define "brief counseling"

37 Sinusitis MIPS: 333 (Not NQF-endorsed, Measure Steward: American Academy of Otolaryngology-Head and Neck Surgery): Adult Sinusitis: CT for Acute Sinusitis (Overuse) Measure Description: Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis. Intended Level of Analysis: Clinician: Individual Overall : Valid Median Overall Importance Appropriateness Evidence Specifications Feasibility It is clinically important to promote appropriate use of CT scans in patients diagnosed with acute sinusitis. While we support this measure, developers do not clearly define denominator exclusion criteria and as such, implementation could promote underuse of CT scans in clinically appropriate cases. The developers should revise the exclusion criteria to explicitly align with Infectious Diseases Society of America (IDSA) recommendations on treatment of acute sinusitis (i.e., patients with symptoms> 10 days, severe or worsening symptoms (102 degrees F fever with nasal discharge) > 3 days, onset with worsening symptoms/double sickening patients (new onset of fever, headache, or increased nasal discharge following viral URI) > 5-6 days)