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PCHQR Program: 2018 Updates to Measures Lisa Vinson, BS, BSN, RN Program Lead PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Contractor (SC) February 22, 2018
Acronyms and Abbreviations ASTRO ADT AHRQ AJCC CAUTI CDC CDI CE CLABSI CMS CPT CST CY EBRT ECE ED EOL FY HAI HCAHPS HCP American Society for Radiation Oncology Androgen Deprivation Therapy Agency for Healthcare Research and Quality American Joint Committee on Cancer Catheter-Associated Urinary Tract Infections Centers for Disease Control and Prevention Clostridium difficile Infection Continuing Education Central Line-Associated Bloodstream Infection Centers for Medicare & Medicaid Services Current Procedural Terminology Cancer-Specific Treatment Calendar Year External Beam Radiotherapy Extraordinary Circumstances Exception Emergency Department End-of-Life Fiscal Year Healthcare-Associated Infection Hospital Consumer Assessment of Healthcare Providers and Systems Healthcare Personnel ICD-10-CM ICU MRSA NHSN NQF OCM OQR PCH PCHQR PLND POS PPS PQRS PSA Q QPP SBRT SC SRS SSI VIQR International Classification of Diseases, Tenth Revision, Clinical Modification Intensive Care Unit Methicillin-Resistant Staphylococcus aureus National Healthcare Safety Network National Quality Forum Oncology Care Measure Outpatient Quality Reporting PPS-Exempt Cancer Hospital PPS-Exempt Cancer Hospital Quality Reporting Pelvic Lymph Node Dissection Place of Service Prospective Payment System Physician Quality Reporting System Prostate Specific Antigen Quarter Quality Payment Program stereotactic body radiation therapy Support Contractor Stereotactic Radiosurgery Surgical Site Infection Value, Incentives, and Quality Reporting 02/22/2018 6
Purpose This presentation will provide participants in the PCHQR Program an overview of the changes in the measure specifications effective for CY 2018. 02/22/2018 7
Objectives Upon completion of this event, participants will be able to: Locate the source documentation for the significant specification changes. Apply the updated specifications to accurately abstract the measures for CY 2018. 02/22/2018 8
Safety and HAI Measures for the FY 2020 Program Year and Subsequent Years Safety and HAI Short Name NQF # Measure Name CLABSI 0139 NHSN Central line-associated Bloodstream Infection Outcome Measure CAUTI 0138 NHSN Catheter-associated Urinary Tract Infection Outcome Measure SSI 0753 ACS-CDC Harmonized Procedure Specific SSI Outcome Measure (currently includes SSIs following colon surgery and abdominal hysterectomy surgery) CDI 1717 NHSN Facility-wide Inpatient Hospital-onset CDI Outcome Measure MRSA 1716 NHSN Facility-wide Inpatient Hospital-onset MRSA Bacteremia Outcome Measure HCP 0431 Influenza Vaccination Coverage Among HCP 02/22/2018 9
Clinical Process/OCMs and Intermediate Clinical Outcome Measures for FY 2020 Program Year and Subsequent Years Clinical Process/OCMs Short Name NQF # Measure Name N/A 0382 Oncology: Radiation Dose Limits to Normal Tissues N/A 0383 Oncology: Plan of Care for Pain Medical Oncology and Radiation Oncology N/A 0384 Oncology: Medical and Radiation Pain Intensity Quantified N/A 0390 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients N/A 0389 EOL-Chemo 0210 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Proportion of Patients Who Died From Cancer Receiving Chemotherapy in the Last 14 Days of Life* EOL-Hospice 0215 Proportion of Patients Who Died from Cancer Not Admitted to Hospice* Intermediate Clinical Outcome Measures Short Name NQF # Measure Name EOL-ICU 0213 Proportion of Patients Who Died From Cancer Admitted to the ICU in the Last 30 Days of Life* EOL-3DH 0216 Proportion of Patients Who Died From Cancer Admitted to Hospice for Less than Three Days* *This measure is finalized for adoption for the FY 2020 program year in section IX.B.4.b of the preamble of this final rule. 02/22/2018 10
Patient Engagement/Experience of Care, Clinical Effectiveness, and Claims-Based Outcome Measures for FY 2020 Program Year and Subsequent Years Patient Engagement/Experience of Care Short Name NQF # Measure Name HCAHPS 0166 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Clinical Effectiveness Measure Short Name NQF # Measure Name EBRT 1822 External Beam Radiotherapy for Bone Metastases Claims-Based Outcome Measure Short Name NQF # Measure Name N/A N/A Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy 02/22/2018 11
PCHQR Program: 2018 Updates to Measures Quality Payment Program 02/22/2018 12
Where to Find the Clinical Process/OCM and Intermediate Clinical Outcome Measures Specifications The PQRS measures are listed on the CMS Quality Payment Program website at https://qpp.cms.gov/. 02/22/2018 13
Where are the Specifications? Scroll to the bottom of the QPP home page. 02/22/2018 14
QPP Resource Library Direct link: https://qpp.cms.gov/about/resource-library 02/22/2018 15
2018 QPP Resources 02/22/2018 16
QPP PCH Measure Crosswalk Name NQF Measure # PCH Measure # QPP Quality ID # Radiation Dose Limits to Normal Tissues 0382 PCH-14 156 Plan of Care for Pain 0383 PCH-15 144 Pain Intensity Quantified 0384 PCH-16 143 Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer 0389 PCH-18 102 Combination Androgen Deprivation Therapy for High or Very High Risk Prostate Cancer 0390 PCH-17 104 02/22/2018 17
QPP PCH Measure Crosswalk (continued) Name NQF Measure # PCH Measure # QPP Quality ID # Proportion of Patients Who Died From Cancer Receiving Chemotherapy in the Last 14 Days of Life Proportion of Patients Who Died From Cancer Admitted to the ICU in the Last 30 Days of Life Proportion of Patients Who Died From Cancer Not Admitted to Hospice Proportion of Patients Who Died From Cancer Admitted to Hospice for Less Than Three Days 0210 PCH-32 453 0213 PCH-33 455 0215 PCH-34 456 0216 PCH-35 457 02/22/2018 18
Quality Measure Specifications Select here for EOL measures specifications 02/22/2018 19
Locating and Opening the Claim-Registry File 02/22/2018 20
PCHQR Program: 2018 Updates to Measures 2018 Quality Payment Program Measure Specifications 02/22/2018 21
2018 QPP Measure Specifications NQF #0382 What remains the same? o Expanded diagnosis cohort which includes patients with a diagnosis of pancreatic, lung breast or rectal cancer AND o Receiving 3D conformal radiation therapy o Excludes patients with metastatic cancer What is new? o No significant changes 02/22/2018 22
2018 QPP Measure Specifications NQF #0383 What remains the same? o Includes patients with a diagnosis of cancer AND o Currently receiving chemotherapy OR o Radiation therapy o Report having pain with a documented plan of care to address it What is new? o Denominator changes Updated denominator criteria telehealth modifiers to include 95 and POS 02 Updated denominator coding Deleted ICD-10-CM: C93.2, D47.0 Added ICD-10-CM: C49.4, C96.20, C96.21, C96.22, C96.29, D49.5 Deleted CPT: 77470 02/22/2018 23
2018 QPP Measure Specifications NQF #0384 What remains the same? o Includes patients with a diagnosis of cancer AND o Receiving chemotherapy OR o Radiation therapy o Pain intensity is quantified What is new? o Denominator changes Updated denominator criteria telehealth modifiers to include 95 and POS 02 Updated denominator coding Added ICD-10-CM: C49.4, C96.20, C96.21, C96.22, C96.29, D49.5 Deleted CPT code: 77470 o Updated rationale and clinical recommendation statements 02/22/2018 24
2018 QPP Measure Specifications NQF #0389 What remains the same? o Includes patients with prostate cancer at low risk (or very low) of recurrence o Includes patients receiving interstitial prostate brachytherapy, OR EBRT to prostate, OR radical prostatectomy, OR cryotherapy to prostate o Denominator includes patients with a diagnosis of prostate cancer at low (or very low) risk of recurrence 02/22/2018 25
2018 QPP Measure Specifications NQF #0389 (continued) What is new? o Updated denominator definitions Very low risk: PSA density changed from < 0.15 ng/ml/cm3 to < 0.15 ng/ml/cm3 Low risk: Gleason score changed from 6 or less to 6 o Added Numerator Note: Denominator exception(s) are determined any time after diagnosis of prostate cancer o Updated rationale and clinical recommendation statements 02/22/2018 26
2018 QPP Measure Specifications NQF #0390 What remains the same? o Includes patients with prostate cancer at high or very high risk of recurrence receiving EBRT to the prostate (prescribed androgen deprivation therapy in combination with EBRT to the prostate) o Measure codes o Patients with multiple adverse factors may be shifted to an elevated risk category Intermediate risk to high risk High risk to very high risk 02/22/2018 27
2018 QPP Measure Specifications NQF #0390 (continued) What is new? o Updated Title and Description Replaced adjuvant hormonal therapy with combination androgen deprivation therapy or androgen deprivation therapy in combination with EBRT to the prostate o Updated Denominator Definitions Gleason grade groups now included for all risk strata Very low risk: PSA density changed from < 0.15 ng/ml/cm3 to < 0.15 ng/ml/cm3 Low risk: Gleason score changed from 6 or less to 6 02/22/2018 28
2018 QPP Measure Specifications NQF #0390 (continued) Updated the numerator o Added Numerator Note: Denominator Exception(s) are determined on the date of the denominator eligible encounter. o Added numerator options Performance Met (G9894) Denominator Exception of Medical Reasons (G9895) Denominator Exception of Patient Reasons (G9896) Performance Not Met (G9897) Updated rationale and clinical recommendation statements 02/22/2018 29
Rationale and Clinical Recommendation Statements NQF #0390 Rationale o Research studies have shown with androgen deprivation therapy in combination with EBRT: Patients can live longer and have lower risk of recurrence. Cost-effectiveness and quality-adjusted life years increase. Utilization rates have increased, but they still remain suboptimal. Clinical rationale statements updates o Recommended options for patients at very high risk: Option for EBRT plus ADT and docetaxel has been removed. Radical prostatectomy plus PLND is for younger, healthier patients with no tumor fixation to the pelvic side wall. ADT or observation is for patients not candidates for definitive therapy. 02/22/2018 30
2018 QPP Measure Specifications NQF #0210 Who is included? o Patients who died from cancer receiving chemotherapy in the last 14 days of life What is new? o Updated denominator coding Deleted ICD-10-CM: C96.2 Added ICD-10-CM: C96.20, C96.21, C96.22, C96.29 02/22/2018 31
2018 QPP Measure Specifications NQF #0215 Who is included? o Patients who died from cancer not admitted to hospice What is new? o Updated denominator coding Deleted ICD-10-CM: C96.2 Added ICD-10-CM: C96.20, C96.21, C96.22, C96.29 02/22/2018 32
2018 QPP Measure Specifications NQF #0213 Who is included? o Patients who died from cancer admitted to the ICU in the last 30 days of life What is new? o Updated denominator coding Deleted ICD-10-CM: C96.2 Added ICD-10-CM: C96.20, C96.21, C96.22, C96.29 02/22/2018 33
2018 QPP Measure Specifications NQF #0216 Who is included? o Patients who died from cancer, were admitted to hospice, and spent less than three days there What is new? o Updated denominator coding Deleted ICD-10-CM: C96.2 Added ICD-10-CM: C96.20, C96.21, C96.22, C96.29 02/22/2018 34
PCHQR Program: 2018 Updates to Measures Other PCHQR Program Measure Information 02/22/2018 35
EBRT NQF #1822 New measure specifications currently under consideration by NQF On-going collaboration with: o CMS o Hospital Outpatient Quality Reporting (OQR) Program SC o American Society for Radiation Oncology (ASTRO) 02/22/2018 36
PCHQR Program Measures CST measures (NQF #0223, #0559, #0220) o Finalized for removal in the FY 2018 final rule publication. o No data collection required for diagnoses effective for January 1, 2018. HAI measures (NQF #0139, #0138, #0753, #1717, #1716, #0431) o Currently no changes. HCAHPS Survey Data (NQF #0166) o New pain questions effective for discharges January 1, 2018, and forward. o For more information, visit HCAHPS home page and technical specifications page. Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy measure o Chemotherapy Dry Run Summary Report available on QualityNet Chemotherapy Measure Dry Run Resources page. 02/22/2018 37
PCHQR Program: 2018 Update to Measures Key Dates and Reminders 02/22/2018 38
Updated NHSN Agreement to Participate and Consent The updated NHSN agreement is for all current NHSN users who enrolled in NHSN prior to December 2, 2017. o Includes primary contacts and facility administrators As of January 30, 2018, the updated consent is available for review and electronic signature. o Must be completed by April 14, 2018 If you have questions, email NHSN@cdc.gov with subject line NHSN Re-consent. Refer to the Winter 2018 Quality Reporting Center Newsletter. 02/22/2018 39
Upcoming PCHQR Program Event and Deadlines March 22, 2018 o PCHQR Program: Updates to Measure Information Forms (MIFs), Algorithms, and Paper Tools April 4, 2018 o 4Q 2017 HCAHPS Survey Data May 15, 2018 o 3Q 2017 CST colon and breast data o 1Q 2017 CST hormone data o 4Q 2017 HAI data o 4Q 2017 1Q 2018 Influenza Vaccination Coverage Among HCP data* *Note: HCP measure data falls under the CMS-granted hurricane-related ECE. 02/22/2018 40
Hospital Compare Key Dates April 2018 contains: o o o 1Q 2016 through 4Q 2016 chemo data 3Q 2015 through 2Q 2016 hormone data 3Q 2016 through 2Q 2017 HCAHPS Survey data Preview period is February 1 through March 2, 2018. Hospital Compare tentative release is April 25, 2018. July 2018 contains: o o o 2Q 2016 through 1Q 2017 chemo data 4Q 2015 through 3Q 2016 hormone data 4Q 2016 through 3Q 2017 HCAHPS Survey data Preview period is tentatively scheduled for May 4 through June 2, 2018. Hospital Compare tentative release is July 25, 2018. 02/22/2018 41
Accessing the QualityNet Questions and Answers Tool QualityNet Questions and Answers Tool 02/22/2018 42
Continuing Education Approval This program has been pre-approved for 1.0 continuing education (CE) unit for the following professional boards: National o Board of Registered Nursing (Provider #16578) Florida o Board of Clinical Social Work, Marriage & Family Therapy and Mental Health Counseling o Board of Nursing Home Administrators o Board of Dietetics and Nutrition Practice Council o Board of Pharmacy Please Note: To verify CE approval for any other state, license, or certification, please check with your licensing or certification board. 02/22/2018 43
CE Credit Process Complete the ReadyTalk survey that will pop up after the webinar, or wait for the survey that will be sent to all registrants within the next 48 hours. After completion of the survey, click Done at the bottom of the screen. Another page will open that asks you to register in the HSAG Learning Management Center. o This is a separate registration from ReadyTalk. o Please use your personal email so you can receive your certificate. o Healthcare facilities have firewalls up that block our certificates. 02/22/2018 44
CE Certificate Problems If you do not immediately receive a response to the email that you signed up with in the Learning Management Center, you have a firewall up that is blocking the link that was sent. Please go back to the New User link and register your personal email account. o Personal emails do not have firewalls. *Please download your continuing education certificate for your records. HSAG retains attendance records for four years, not certificates. 02/22/2018 45
CE Credit Process: Survey 02/22/2018 46
CE Credit Process: Certificate 02/22/2018 47
CE Credit Process: New User 02/22/2018 48
CE Credit Process: Existing User 02/22/2018 49
PCHQR Program: 2017 Update to Measures Closing Remarks 02/22/2018 50
Disclaimer This presentation was current at the time of publication and/or upload onto Quality Reporting Center and QualityNet websites. Medicare policy changes frequently. Any links to Medicare online source documents are for reference use only. In the case that Medicare policy, requirements, or guidance related to this presentation change following the date of posting, this presentation will not necessarily reflect those changes; given that it will remain as an archived copy, it will not be updated. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. Any references or links to statutes, regulations, and/or other policy materials included in the presentation are provided as summary information. No material contained therein is intended to take the place of either written laws or regulations. In the event of any conflict between the information provided by the presentation and any information included in any Medicare rules and/or regulations, the rules and regulations shall govern. The specific statutes, regulations, and other interpretive materials should be reviewed independently for a full and accurate statement of their contents. 02/22/2018 51