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  1. eCQM Issue Tracker
  2. CQM-4902

Revise timing of follow-up assessments

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    • EP/EC eCQMs
    • Status: Open
    • Moderate
    • Resolution: Unresolved
    • None

    Description

      Brief Description of Measure:

      ​CMS56: Functional Status Assessment for Total Hip Replacement:
      Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery
      CMS66: Functional Status Assessment for Total Knee Replacement:
      Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

      Description of Issue:

      Currently, the total hip replacement (THA)/total knee replacement (TKA) process eCQMs (i.e., CMS 56, CMS 66) look for follow-up functional assessments 9-12 months after surgery. However, we have received feedback that patients may not always have a follow-up appointment exactly by 12 months post-surgery. ** 

      Proposed Solution:

      ​CMS 56:

      Update the timing for the follow-up assessment from 270-365 days after surgery to 300-425 days after surgery.

      Current Description header:
      Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

      Updated Description header:
      Percentage of patients 19 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 300 - 425 days after the surgery

      Current Numerator header:
      Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [PROMIS]-10-Global Health, Hip Disability and Osteoarthritis Outcome Score [HOOS], HOOS Jr.) in the 90 days prior to or on the day of the primary THA procedure, and in the 270 - 365 days after the THA procedure

      Updated Numerator header:
      Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [PROMIS]-10-Global Health, Hip Disability and Osteoarthritis Outcome Score [HOOS], HOOS Jr.) in the 90 days prior to or on the day of the primary THA procedure, and in the 300 - 425 days after the THA procedure

      Current logic:
      oHas THA with Initial and Follow Up HOOS Assessments

      exists ( "Total Hip Arthroplasty Procedure" TotalHip
          with "Time HOOS Total Assessment Completed" InitialHipAssessmentHOOS
            such that TotalHip.relevantPeriod starts 90 days or less on or after InitialHipAssessmentHOOS
          with "Time HOOS Total Assessment Completed" FollowupHipAssessmentHOOS
            such that FollowupHipAssessmentHOOS in Interval[
            end of TotalHip.relevantPeriod + 270 days, 
            end of TotalHip.relevantPeriod + 365 days]
      )

      Updated logic:
      oHas THA with Initial and Follow Up HOOS Assessments

      exists ( ("Total Hip Arthroplasty Procedure" THAProcedure
       return Global.”NormalizeInterval”(THAProcedure.relevantDatetime, THAProcedure.relevantPeriod )) TotalHip
          with "Time HOOS Total Assessment Completed" InitialHipAssessmentHOOS
            such that TotalHip starts 90 days or less on or after InitialHipAssessmentHOOS
          with "Time HOOS Total Assessment Completed" FollowupHipAssessmentHOOS
            such that FollowupHipAssessmentHOOS during day of Interval[
            end of TotalHip + 300 days, 
            end of TotalHip + 425 days]
      )

       

      Current:
      oHas THA with Initial and Follow Up HOOSJr Assessments

      exists ( "Total Hip Arthroplasty Procedure" TotalHip
          with "HOOSJr Total Assessment Completed" InitialHipAssessment
            such that TotalHip.relevantPeriod starts 90 days or less on or after InitialHipAssessment.relevantDatetime
          with "HOOSJr Total Assessment Completed" FollowupHipAssessment
            such that FollowupHipAssessment.relevantDatetime in Interval[
            end of TotalHip.relevantPeriod + 270 days, 
            end of TotalHip.relevantPeriod + 365 days]
      )

      Updated:
      oHas THA with Initial and Follow Up HOOSJr Assessments

      exists ( ("Total Hip Arthroplasty Procedure" THAProcedure
      return Global.”NormalizeInterval”(THAProcedure.relevantDatetime, THAProcedure.relevantPeriod)) TotalHip
          with "Time HOOSJr Total Assessment Completed" InitialHipAssessment
            such that TotalHip starts 90 days or less on or after InitialHipAssessment
          with "Time HOOSJr Total Assessment Completed" FollowupHipAssessment
            such that FollowupHipAssessment during day of Interval[
            end of TotalHip + 300 days, 
            end of TotalHip + 425 days]
      )

      Current:
      oHas THA with Initial and Follow Up PROMIS10 Assessments

      exists ( "Total Hip Arthroplasty Procedure" TotalHip
          with "Time PROMIS10 Total Assessment Completed" InitialHipAssessmentPROMIS10
            such that TotalHip.relevantPeriod starts 90 days or less on or after InitialHipAssessmentPROMIS10
          with "Time PROMIS10 Total Assessment Completed" FollowupHipAssessmentPROMIS10
            such that FollowupHipAssessmentPROMIS10 in Interval[
            end of TotalHip.relevantPeriod + 270 days, 
            end of TotalHip.relevantPeriod + 365 days]
      )

       

      Updated:
      oHas THA with Initial and Follow Up PROMIS10 Assessments

      exists ( ("Total Hip Arthroplasty Procedure" THAProcedure
      return Global.”NormalizeInterval”(THAProcedure.relevantDatetime, THAProcedure.relevantPeriod)) TotalHip
          with "Time PROMIS10 Total Assessment Completed" InitialHipAssessmentPROMIS10
            such that TotalHip starts 90 days or less on or after InitialHipAssessmentPROMIS10
          with "Time PROMIS10 Total Assessment Completed" FollowupHipAssessmentPROMIS10
            such that FollowupHipAssessmentPROMIS10 during day of Interval[
            end of TotalHip + 300 days, 
            end of TotalHip + 425 days]
      )

      Current:
      oHas THA with Initial and Follow Up VR12 Oblique Assessments

      exists ( "Total Hip Arthroplasty Procedure" TotalHip
          with "Time VR12 Oblique Total Assessment Completed" InitialHipAssessmentOblique
            such that TotalHip.relevantPeriod starts 90 days or less on or after InitialHipAssessmentOblique
          with "Time VR12 Oblique Total Assessment Completed" FollowupHipAssessmentOblique
            such that FollowupHipAssessmentOblique in Interval[
            end of TotalHip.relevantPeriod + 270 days, 
            end of TotalHip.relevantPeriod + 365 days]
      )

      Updated:
      oHas THA with Initial and Follow Up VR12 Oblique Assessments

      exists ( ("Total Hip Arthroplasty Procedure" THAProcedure
      return Global.”NormalizeInterval”(THAProcedure.relevantDatetime, THAProcedure.relevantPeriod)) TotalHip
          with "Time VR12 Oblique Total Assessment Completed" InitialHipAssessmentOblique
            such that TotalHip starts 90 days or less on or after InitialHipAssessmentOblique
          with "Time VR12 Oblique Total Assessment Completed" FollowupHipAssessmentOblique
            such that FollowupHipAssessmentOblique during day of Interval[
            end of TotalHip + 300 days, 
            end of TotalHip + 425 days]
      )

      Current:
      oHas THA with Initial and Follow Up VR12 Orthogonal Assessments

      exists ( "Total Hip Arthroplasty Procedure" TotalHip
          with "Time VR12 Orthogonal Total Assessment Completed" InitialHipAssessmentOrthogonal
            such that TotalHip.relevantPeriod starts 90 days or less on or after InitialHipAssessmentOrthogonal
          with "Time VR12 Orthogonal Total Assessment Completed" FollowupHipAssessmentOrthogonal
            such that FollowupHipAssessmentOrthogonal in Interval[
            end of TotalHip.relevantPeriod + 270 days, 
            end of TotalHip.relevantPeriod + 365 days]
      )

      Updated:
      oHas THA with Initial and Follow Up VR12 Orthogonal Assessments

      exists (( "Total Hip Arthroplasty Procedure" THAProcedure
      return Global.”NormalizeInterval”(THAProcedure.relevantDatetime, THAProcedure.relevantPeriod)) TotalHip
          with "Time VR12 Orthogonal Total Assessment Completed" InitialHipAssessmentOrthogonal
            such that TotalHip starts 90 days or less on or after InitialHipAssessmentOrthogonal
          with "Time VR12 Orthogonal Total Assessment Completed" FollowupHipAssessmentOrthogonal
            such that FollowupHipAssessmentOrthogonal during day of Interval[
            end of TotalHip + 300 days, 
            end of TotalHip + 425 days]
      )

       

      CMS 66:

      CMS 66 Changes:
      Current Description header:
      Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

      Updated Description header:
      Percentage of patients 19 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 300-425 days after the surgery

      Current Numerator header:
      Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, Knee Injury and Osteoarthritis Outcome Score [KOOS], KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 270 - 365 days after the TKA procedure

      Updated Numerator header:
      Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, Knee Injury and Osteoarthritis Outcome Score [KOOS], KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 300 - 425 days after the TKA procedure

      Current logic:
      oHas TKA with Initial and Follow Up KOOS Assessments

      exists ( "Total Knee Arthroplasty Procedure" TotalKnee
          with "Time KOOS Total Assessment Completed" InitialKOOSAssessmentTime
            such that TotalKnee.relevantPeriod starts 90 days or less on or after InitialKOOSAssessmentTime
          with "Time KOOS Total Assessment Completed" FollowupKOOSAssessmentTime
            such that FollowupKOOSAssessmentTime in Interval[
            end of TotalKnee.relevantPeriod + 270 days, 
            end of TotalKnee.relevantPeriod + 365 days]
      )

      Updated logic:
      oHas TKA with Initial and Follow Up KOOS Assessments

      exists ( ("Total Knee Arthroplasty Procedure" TKAProcedure
      return Global."NormalizeInterval"(TKAProcedure.relevantDatetime, TKAProcedure.relevantPeriod)) TotalKnee
          with "Time KOOS Total Assessment Completed" InitialKOOSAssessmentTime
            such that TotalKnee starts 90 days or less on or after InitialKOOSAssessmentTime
          with "Time KOOS Total Assessment Completed" FollowupKOOSAssessmentTime
            such that FollowupKOOSAssessmentTime during day of Interval[
            end of TotalKnee + 300 days, 
            end of TotalKnee + 425 days]
      )

      Current logic:
      oHas TKA with Initial and Follow Up KOOSJr Assessments

      exists ( "Total Knee Arthroplasty Procedure" TotalKnee
          with "KOOSJr Total Assessment Completed" InitialKOOSJrAssessment
            such that TotalKnee.relevantPeriod starts 90 days or less on or after InitialKOOSJrAssessment.relevantDatetime
          with "KOOSJr Total Assessment Completed" FollowupKOOSJrAssessment
            such that FollowupKOOSJrAssessment.relevantDatetime in Interval[
            end of TotalKnee.relevantPeriod + 270 days, 
            end of TotalKnee.relevantPeriod + 365 days]
      )

      Updated logic:
      oHas TKA with Initial and Follow Up KOOSJr Assessments

      exists (( "Total Knee Arthroplasty Procedure" TKAProcedure
      return Global.”NormalizeInterval”(TKAProcedure.relevantDatetime, TKAProcedure.relevantPeriod)) TotalKnee
          with "Time KOOSJr Total Assessment Completed" InitialKOOSJrAssessment
            such that TotalKnee starts 90 days or less on or after InitialKOOSJrAssessment
          with "Time KOOSJr Total Assessment Completed" FollowupKOOSJrAssessment
            such that FollowupKOOSJrAssessment during day of Interval[
            end of TotalKnee + 300 days, 
            end of TotalKnee + 425 days]
      )

      Current logic:
      oHas TKA with Initial and Follow Up PROMIS10 Assessments

      exists ( "Total Knee Arthroplasty Procedure" TotalKnee
          with "Time PROMIS10 Total Assessment Completed" InitialPROMIS10AssessmentTime
            such that TotalKnee.relevantPeriod starts 90 days or less on or after InitialPROMIS10AssessmentTime
          with "Time PROMIS10 Total Assessment Completed" FollowupPROMIS10AssessmentTime
            such that FollowupPROMIS10AssessmentTime in Interval[
            end of TotalKnee.relevantPeriod + 270 days, 
            end of TotalKnee.relevantPeriod + 365 days]
      )

      Updated logic:
      oHas TKA with Initial and Follow Up PROMIS10 Assessments

      exists ( ("Total Knee Arthroplasty Procedure" TKAProcedure
      return Global.”NormalizeInterval”(TKAProcedure.relevantDatetime, TKAProcedure.relevantPeriod)) TotalKnee
          with "Time PROMIS10 Total Assessment Completed" InitialPROMIS10AssessmentTime
            such that TotalKnee starts 90 days or less on or after InitialPROMIS10AssessmentTime
          with "Time PROMIS10 Total Assessment Completed" FollowupPROMIS10AssessmentTime
            such that FollowupPROMIS10AssessmentTime during day of Interval[
            end of TotalKnee + 300 days, 
            end of TotalKnee + 425 days]
      )

      Current logic:
      oHas TKA with Initial and Follow Up VR12 Oblique Assessments

      exists ( "Total Knee Arthroplasty Procedure" TotalKnee
          with "Time VR12 Oblique Total Assessment Completed" InitialKneeAssessmentObliqueTime
            such that TotalKnee.relevantPeriod starts 90 days or less on or after InitialKneeAssessmentObliqueTime
          with "Time VR12 Oblique Total Assessment Completed" FollowupObliqueAssessmentTime
            such that FollowupObliqueAssessmentTime in Interval[
            end of TotalKnee.relevantPeriod + 270 days, 
            end of TotalKnee.relevantPeriod + 365 days]
      )

      Updated logic:
      oHas TKA with Initial and Follow Up VR12 Oblique Assessments

      exists ( ("Total Knee Arthroplasty Procedure" TKAProcedure
      return Global.”NormalizeInterval”(TKAProcedure.relevantDatetime, TKAProcedure.relevantPeriod)) TotalKnee
          with "Time VR12 Oblique Total Assessment Completed" InitialKneeAssessmentObliqueTime
            such that TotalKnee starts 90 days or less on or after InitialKneeAssessmentObliqueTime
          with "Time VR12 Oblique Total Assessment Completed" FollowupObliqueAssessmentTime
            such that FollowupObliqueAssessmentTime during day of Interval[
            end of TotalKnee + 300 days, 
            end of TotalKnee + 425 days]
      )

      Current logic:
      oHas TKA with Initial and Follow Up VR12 Orthogonal Assessments

      exists ( "Total Knee Arthroplasty Procedure" TotalKnee
          with "Time VR12 Orthogonal Total Assessment Completed" InitialOrthogonalAssessmentTime
            such that TotalKnee.relevantPeriod starts 90 days or less on or after InitialOrthogonalAssessmentTime
          with "Time VR12 Orthogonal Total Assessment Completed" FollowupOrthogonalAssessmentTime
            such that FollowupOrthogonalAssessmentTime in Interval[
            end of TotalKnee.relevantPeriod + 270 days, 
            end of TotalKnee.relevantPeriod + 365 days]
      )

      Updated logic:
      oHas TKA with Initial and Follow Up VR12 Orthogonal Assessments

      exists ( ("Total Knee Arthroplasty Procedure" TKAProcedure
      return Global.”NormalizeInterval”(TKAProcedure.relevantDatetime, TKAProcedure.relevantPeriod)) TotalKnee
          with "Time VR12 Orthogonal Total Assessment Completed" InitialOrthogonalAssessmentTime
            such that TotalKnee starts 90 days or less on or after InitialOrthogonalAssessmentTime
          with "Time VR12 Orthogonal Total Assessment Completed" FollowupOrthogonalAssessmentTime
            such that FollowupOrthogonalAssessmentTime during day of Interval[
            end of TotalKnee + 300 days, 
            end of TotalKnee + 425 days]
      )

      Rationale for Change:

      The measures are intended to include post-replacement assessments completed 9-12 months after surgery. However, since patients may not have a follow-up exactly at 12 months, the measure has a window from 10-14 months after surgery. ** 

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            khancock Mathematica EC eCQM Team
            sgearhart Mathematica EH eCQM Team
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              Created:
              Updated: