March 31, Dear colleagues,

Transcription

1 6300 North River Road Rosemont, IL p: f: March 31, 2014 Dear colleagues, The American Joint Replacement Registry (AJRR) has submitted materials to be considered by the Centers for Medicare and Medicaid Services as a Qualified Clinical Data Registry (QCDR). As a part of the requirements to become a QCDR, we have been asked to publically post our quality measures. The attached document contains the detailed specifications of the quality measures which AJRR will collect. Please address any questions to: a) Program Representative: AJRR Executive Director, Jeffrey P. Knezovich at or knezovich@ajrr.net; b) Clinical Representative: AJRR Director of Analytics, Caryn D. Etkin at or etkin@ajrr.net ; and c) Technical Representative: AJRR Director of Information Technology, Randolph R. Meinzer at or meinzer@ajrr.net. Sincerely, Caryn D. Etkin, PhD, MPH Director of Analytics American Joint Replacement Registry

2 (NQF) 122v Diabetes: Hemoglobin A1c Poor Control N/A Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin Title Description Numerator Denominator Percentage of patient years of age with diabetes who had hemoglobin A1c >9.0% during the measurement period Percentage of surgical patients aged 18 years and older procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis Patients whose most recent HbA1c level (performed during the measurement period) is >9.0% Surgical patients who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis Patients years of age with diabetes with a visit during the measurement period patients aged 18 years and older procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic Effective Clinical Care

3 (NQF) N/A Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis N/A 350 N/A Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy Title Description Numerator Denominator Percentage of surgical patients aged 18 years and older procedures for which VTE prophylaxis is patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time regardless of age or gender a total knee replacement with documented shared decisionmaking with discussion of conservative (nonsurgical) therapy prior to the procedure. Surgical patients who had an order for LMWH, LDUH, adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time Surgical patients with documentation of shared decisionmaking with discussion of conservative (nonsurgical) therapy prior to the procedure. patients aged 18 years and older procedures for which VTE prophylaxis is patients. patients procedures for which total knee replacement is patients. Communication and Care Coordination

4 (NQF) N/A 351 N/A Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation N/A 352 N/A Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet Title Description Numerator Denominator regardless of age or gender a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke. regardless of age a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet. Surgical patients who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of DVT, PE, MI, Arrhythmia and Stroke. Surgical patients who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet. patients procedures for which total knee replacement is patients. patients procedures for which total knee replacement is patients.

5 (NQF) N/A 353 N/A Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report: 56v2 376 N/A Functional Status Assessment for Hip Replacement: Hip disability and Osteoarthritis Outcome Score (HOOS) Title Description Numerator Denominator regardless of age or gender a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of the prosthetic implant. total hip arthroplasty (THA) who completed Surgical patients whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of the prosthetic implant. results 180 the least than patients procedures for which total knee replacement is patients. Adults aged 18 and older with a

6 (NQF) 56v2 376 N/A Functional Status Assessment for Hip Replacement: Harris Hip Score 56v2 376 N/A Functional Status Assessment for Hip Replacement: Oxford Hip Score Title Description Numerator Denominator total hip arthroplasty (THA) who completed total hip arthroplasty (THA) who completed results 180 the least than results 180 the least than Adults aged 18 and older with a Adults aged 18 and older with a

7 (NQF) 56v2 376 N/A Functional Status Assessment for Hip Replacement: SF-36 66v1 TBD Functional for knee replacement Title Description Numerator Denominator total hip arthroplasty (THA) who completed total knee arthroplasty (TKA) who completed results 180 the least than results 180 the least than Adults aged 18 and older with a Adults, aged 18 and older, with a Patient and Family Engagement

8 (NQF) 66v2 375 N/A Functional Status Assessment for Knee Replacement: Knee injury and Osteoarthritis Outcome Score (KOOS) 66v2 375 N/A Functional Status Assessment for Knee Replacement: Oxford Knee Score Title Description Numerator Denominator total knee arthroplasty (TKA) who completed total knee arthroplasty (TKA) who completed results 180 the least than results 180 the least than Adults, aged 18 and older, with a Adults, aged 18 and older, with a

9 (NQF) 66v2 375 N/A Functional Status Assessment for Knee Replacement: Knee Society Knee Scoring System 66v2 375 N/A Functional Status Assessment for Knee Replacement: SF-36 Title Description Numerator Denominator total knee arthroplasty (TKA) who completed total knee arthroplasty (TKA) who completed results 180 the least than results 180 the least than Adults, aged 18 and older, with a Adults, aged 18 and older, with a

10 (NQF) 68v Documentation of Current Medications in the Medical Record Title Description Numerator Denominator Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. Eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-thecounters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route of administration. All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period.