OrthoQCDR

MIPs Reporting for Orthopaedics and Physical Therapy

Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.
Measure ID: IROMS19

High Priority Measure
Measure Type: Patient Reported Outcome
NQS Domain: Effective Clinical Care
Meaningful Measure: Functional Outcomes
Risk Adjusted: Yes
Care Setting: Ambulatory Care: Clinician Office/Clinic Includes Telehealth
Inverse Measure: yes
Proportional Measure: yes
Continuous Variable: No
Ratio Measure: No
Overall Performance Rate: 2nd Performance Rate

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included:

1) Overall proportion of patients achieving an MCID in DASH change score will be reported.
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported.

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in DASH change score will be reported.
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported.

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in DASH change score will be reported.
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported.


Measure Description
The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder or hand injury treated during the observation period will be reported.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH or QDASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.
Denominator Description
The total number of all patients with arm, shoulder, or hand injury evaluated and treated by a PT or OT, or PT or OT Group, during the observation window.
Numerator Description
The total number of patients with arm, shoulder, or hand injuries to not achieve an MCID in their DASH change score (MCID ≥ 10 for DASH, MCID ≥ 8 for QDASH) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.
Denominator Exclusions
Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.
Denominator Exceptions
Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.