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, there has been feedback suggesting that patients may not always have a follow-up appointment exactly by 12 months post-surgery. Through a comment from the public, we identified an issue that the update to the FSA time period can allow for follow up assessments that were performed after the reporting period to now be counted towards the measure.  

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 developer is proposing expanding the window to complete the follow up assessments from 10-14 months after surgery. We are also proposing to update the timing of the THA/TKA procedure to be between March 7 and November 1 of the year prior to the measurement period which would allow patients to have the full 14 months to complete the post-procedure FSA while also ensuring that patients complete the post-procedure FSA during the measurement period.

Proposed Solution:

​CMS 56 Changes:

We propose to update the timing for the follow-up assessment from 270-365 days after surgery to 300-425 days after surgery. We are also proposing to update the timing for the THA procedure.
 
 
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 Initial Population header:
Patients 19 years of age and older who had a primary total hip arthroplasty (THA) in the year prior to the measurement period and who had an outpatient encounter during the measurement period

Updated Initial Population header: 
Patients 19 years of age and older who had a primary total hip arthroplasty (THA) March 7 and November 1 of the year prior to the measurement period and who had an outpatient encounter during the measurement period.

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:
"Has 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:
"Has 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 logic:
"Has 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 logic:
"Has 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 logic:
"Has 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 logic:
"Has 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 logic:
"Has 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 logic:
"Has 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 logic:
"Has 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 logic:
"Has 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] )
 
Current logic:
"Total Hip Arthroplasty Procedure"
  ["Procedure, Performed": "Primary THA Procedure"] THAProcedure
    where Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) starts 12 months or less on or before start of "Measurement Period"

Updated logic:
"Total Hip Arthroplasty Procedure"
  ["Procedure, Performed": "Primary THA Procedure"] THAProcedure
    where Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) during day of Interval[start of "Measurement Period" - 300 days, start of "Measurement Period" - 61 days]

CMS 66 Changes:
We propose to 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 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 Initial Population header:
Patients 19 years of age and older who had a primary total knee arthroplasty (TKA) in the year prior to the measurement period and who had an outpatient encounter during the measurement period

Updated Initial Population header: 
Patients 19 years of age and older who had a primary total knee arthroplasty (TKA) March 7 and November 1 of the year prior to the measurement period and who had an outpatient encounter during the measurement period.

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:
"Has 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:
"Has 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:
"Has 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:
"Has 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:
"Has 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:
"Has 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:
"Has 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:
"Has 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:
"Has 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:
"Has 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] )

Current logic:
"Total Knee Arthroplasty Procedure"
   ["Procedure, Performed": "Primary TKA Procedure"] TKAProcedure
     where Global."NormalizeInterval" ( TKAProcedure.relevantDatetime, TKAProcedure.relevantPeriod ) starts 12 months or less before start of "Measurement Period"

Updated logic:
"Total Knee Arthroplasty Procedure"
   ["Procedure, Performed": "Primary TKA Procedure"] TKAProcedure
     where Global."NormalizeInterval" ( TKAProcedure.relevantDatetime, TKAProcedure.relevantPeriod ) during day of Interval[start of "Measurement Period" - 300 days, start of "Measurement Period" - 61 days]

Rationale for Change:

Expanding the allowable timeframe for the collection of the post-replacement assessments allows a grace period for patients who may not return within 12 months; updating the timing of the THA/TKA procedure will ensure all patients have the full 14 months to complete the assessment.