The CMS has issued a proposed rule that would add four new surgical process measures and one outcomes measure to bring to 32 the number of quality measures hospitals must publicly report beginning next fall to avoid being docked under the Medicare reimbursement program.
The proposed additional reporting measures for pre- and post-surgery patients are for payments in fiscal 2009, which starts Oct. 1, 2008. The measures and their clinical rationales are:
- Control of serum glucose levels in post-operative cardiac surgery patients. Published reports have shown patients with blood sugar levels higher than 200 mg/dl had substantially higher risk of infection.
- Appropriate hair removal. This measure seeks to encourage either having no hair removal or the use of clippers as studies have shown an increase in the risk of surgical site infections when razors were used to shave the sites.
- Surgical patients on beta blockers prior to admission who remain on beta blocker during the perioperative period. Cessation of beta blockers is associated with increased risk as patient stress increases around the time of surgery.
- Immediate post-operative normothermia (bringing the patient to normal body temperature) after colorectal surgery. Some studies have indicated patients with lowered body temperatures for extended periods after surgery have higher rates of infection.
- Pneumonia, 30-day mortality rate.
The CMS, in a fact sheet released Friday, is also soliciting comments on whether and how to add other measures to the set for payments beginning in fiscal 2009 and beyond.
The proposed new measures are in line to be incorporated into the Medicare Reporting Hospital Quality Data for Annual Payment Update program, which began in 2001 with 10 measures. Under the Deficit Reduction Act of 2005, beginning with the current fiscal year (and the current load of 27 measures), most acute-care hospitals that do not submit the data will have their annual percentage increase in Medicare reimbursements cut by 2 percentage points.
According to the CMS, the five new measures have been offered for inclusion in the Hospital Quality Alliance public reporting data setcontingent upon their endorsement by the National Quality Forum. The HQA is a collaboration of federal and private-sector organizations, including the American Hospital Association, Federation of American Hospitals and the Joint Commission.
In addition, the five newcomers are also candidates for inclusion in the CMS/Joint Commission "Specifications Manual for National Hospital Quality Measures," again subject to their passing muster with the NQF, according to Jerod Loeb, executive vice president for research at the Joint Commission.
"I think that's really an important point," Loeb said. "We have formally committed to an alignment process that the measures we use are not just the same as CMS, but identical." In addition, Loeb said, "There has been a commitment on the point of CMS and the Joint Commission we will not implement measures unless they've cleared the NQF consensus process."
Sometimes in the measure-setting debate, "people feel strongly, but not always with a strong evidence base," Loeb said. "That's the beauty of the NQF process, that everybody gets to weigh in and (the outcome) will be decided in a very democratic method."
All five new measures are under NQF review.
Helen Burstin, senior vice president for performance measures at NQF, said the five newest measures are "in various stages of review and approval. The pneumonia mortality one (had) been approved a couple of weeks ago. The second two (glucose and hair removal) should be going out for public comment in the next couple of weeks. The steering committee believes they should go forward for voting by members of NQF.
"The one on beta blockers is under review as we speak," Burstin said. "There are no recommendations from the committee yet." That could come by fall followed by submission for balloting to NQF members. If it passes, the measure could be available by November or December, Burstin said.
"The one on normothermia has not been recommended by the steering committee," she said.
Subject to NQF passage, the CMS has indicated it intends to begin collecting data on the new measures in calendar year 2008.
The proposed measures come on top of the recent additions to the CMS list: three process measures, two outcomes measures and a patient-satisfaction assessment using the HCAHPS patient survey, that are scheduled to go online at the start of fiscal 2008, which starts on Oct. 1 this year.
All three of those process measures fall under the rubric of surgical-care improvementordering venous thromboembolism, or VTE, prophylaxis for surgery patients, providing VTE prophylaxis within 24 hours pre- and post-surgery and prophylactic antibiotic selection for surgical patients. The two outcomes measures require reporting 30-day mortality following treatment for acute myocardial infarction and 30-day mortality for patients with heart failure.
Loeb said he has heard of no estimates of how much hospitals will spend to collect the data to support the CMS and other reporting programs, but the lack of IT systems and the low capabilities of those that are in place surely make reporting more expensive than it needs to be.
The 11 new measures added to the CMS list in just two years represent more bricks on the scale weighing in favor of healthcare IT systems capable of reporting quality measures as part of a regular program of clinical data collection and dissemination. For now, though, that capability is only a dream, Loeb said.
"We don't collect data as a byproduct of care delivery because we don't have an IT infrastructure yet," Loeb said. "Anytime you add to the data-collection effort and you don't provide a streamlined infrastructure to collect those data you are adding to the cost. We have to dream of collections, but we have to focus on what we can do today. We're living with legacy systems, many of which can't accommodate the collection of these measures. We don't build IT systems to measure quality. But these are tied to areas where quality can clearly be improved, so the juice will be worth the squeeze."
Loeb said that VTE is a hidden public health issue, which is why the CMS is seeking to measure not only the ordering, but also the delivery of prophylaxis.
"The notion that something is ordered but not received is a very sensitive issue to the panel that has been working on VTE for a number of years," Loeb said. "I think it is the nature of healthcare today. This is a means to ensure that an opportunity to do the right thing is realized."What do you think? Write us with your comments at [email protected]. Please include your name, title and hometown.