Merge pull request #749 from CMSgov/feat/QPPA-8503

QPPA-8503: update measures PY24
CMSgov · Jan 8, 2024 · b1cd43c · b1cd43c
2 parents f194a55 + 58a7fde
commit b1cd43c
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diff --git a/measures/2024/measures-data.json b/measures/2024/measures-data.json
@@ -9449,7 +9449,7 @@
     "isClinicalGuidelineChanged": false,
     "isIcdImpacted": false,
     "clinicalGuidelineChanged": [],
-    "metricType": "singlePerformanceRate",
+    "metricType": "multiPerformanceRate",
     "allowedPrograms": [
       "mips",
       "pcf"
@@ -9461,7 +9461,18 @@
       "neurosurgical",
       "orthopedicSurgery"
     ],
-    "measureSpecification": {}
+    "measureSpecification": {},
+    "overallAlgorithm": "weightedAverage",
+    "strata": [
+      {
+        "name": "discectomyLaminectmy",
+        "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively"
+      },
+      {
+        "name": "lumbarFusion",
+        "description": "Percentage of lumbar fusion procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric pain scale at one year (9 to 15 months) postoperatively"
+      }
+    ]
   },
   {
     "title": "Leg Pain After Lumbar Surgery",
@@ -9483,7 +9494,7 @@
     "isClinicalGuidelineChanged": false,
     "isIcdImpacted": false,
     "clinicalGuidelineChanged": [],
-    "metricType": "singlePerformanceRate",
+    "metricType": "multiPerformanceRate",
     "allowedPrograms": [
       "mips",
       "pcf"
@@ -9495,7 +9506,18 @@
       "neurosurgical",
       "orthopedicSurgery"
     ],
-    "measureSpecification": {}
+    "measureSpecification": {},
+    "overallAlgorithm": "weightedAverage",
+    "strata": [
+      {
+        "name": "discectomyLaminectmy",
+        "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports leg pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively"
+      },
+      {
+        "name": "lumbarFusion",
+        "description": "Percentage of lumbar fusion procedures for which the patient reports leg painless than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at one year (9 to 15 months) postoperatively after lumbar fusion."
+      }
+    ]
   },
   {
     "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy",
@@ -9727,7 +9749,7 @@
     "isClinicalGuidelineChanged": false,
     "isIcdImpacted": false,
     "clinicalGuidelineChanged": [],
-    "metricType": "singlePerformanceRate",
+    "metricType": "multiPerformanceRate",
     "allowedPrograms": [
       "mips",
       "pcf"
@@ -9739,7 +9761,18 @@
       "neurosurgical",
       "orthopedicSurgery"
     ],
-    "measureSpecification": {}
+    "measureSpecification": {},
+    "overallAlgorithm": "weightedAverage",
+    "strata": [
+      {
+        "name": "discectomyLaminectmy",
+        "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at three months (6 to 20 weeks) postoperatively"
+      },
+      {
+        "name": "lumbarFusion",
+        "description": "Percentage of lumbar fusion procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool at one year (9 to 15 months) postoperatively"
+      }
+    ]
   },
   {
     "title": "Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture",
@@ -18476,36 +18509,6 @@
       "registry"
     ]
   },
-  {
-    "measureId": "PP11",
-    "title": "Improvement Or Maintenance In Recovery For All Individuals Seen For Mental Health And/Or Substance Use Care",
-    "description": "The percentage of individuals aged 18 and older with a mental and/or substance use disorder who demonstrated improvement or maintenance in recovery (as defined, prioritized, and/or reported by the individual) based on results from the 24-item Recovery Assessment Scale (RAS-R) 150 to 210 days after an index assessment.",
-    "nqfId": null,
-    "measureType": "patientReportedOutcome",
-    "isHighPriority": true,
-    "isInverse": false,
-    "isRiskAdjusted": false,
-    "primarySteward": "PsychPRO in Collaboration with Health Catalyst",
-    "firstPerformanceYear": 2022,
-    "allowedVendors": [
-      "4078845"
-    ],
-    "allowedPrograms": [
-      "mips",
-      "pcf"
-    ],
-    "category": "quality",
-    "lastPerformanceYear": null,
-    "eMeasureId": null,
-    "nqfEMeasureId": null,
-    "measureSets": [],
-    "isRegistryMeasure": true,
-    "isIcdImpacted": false,
-    "metricType": "registrySinglePerformanceRate",
-    "submissionMethods": [
-      "registry"
-    ]
-  },
   {
     "measureId": "PQRANES1",
     "title": "Use of Peripheral Nerve Block within the Emergency Department in Patients Admitted with Low Energy Hip Fracture",

diff --git a/package-lock.json b/package-lock.json
diff --git a/updates/measures/2024/Quality_QCDR_PY2024_CR_01032024.csv b/updates/measures/2024/Quality_QCDR_PY2024_CR_01032024.csv
@@ -0,0 +1,4 @@
+Category ,Measure Title,CMS eCQM ID,eCQM NQF,NQF,*** Quality Number (#) / QCDR #,Primary Measure Steward,Allowed QCDR Vendor ID,Measure Description,*** Measure Type  ,High Priority,First Performance Year,Year Removed,*** Collection Type(s) for Submission,Specialty Measure Sets,*** Inverse,*** Metric Type,*** Calculation Type,Collection Type(s) where Historic Benchmark Removed,Collection Type(s) where Suppressed,Collection Type(s) where Truncated,Is Risk Adjusted 
+Quality,,,,,459,,,,,,,,,,,multiPerformanceRate,weightedAverage,,,,
+Quality,,,,,461,,,,,,,,,,,multiPerformanceRate,weightedAverage,,,,
+Quality,,,,,471,,,,,,,,,,,multiPerformanceRate,weightedAverage,,,,
diff --git a/updates/measures/2024/Quality_QCDR_PY24_CR_20240104.csv b/updates/measures/2024/Quality_QCDR_PY24_CR_20240104.csv
@@ -0,0 +1,2 @@
+Category ,Measure Title,CMS eCQM ID,eCQM NQF,NQF,*** Quality Number (#) / QCDR #,Primary Measure Steward,Allowed QCDR Vendor ID,Measure Description,*** Measure Type  ,High Priority,First Performance Year,Year Removed,*** Collection Type(s) for Submission,Specialty Measure Sets,*** Inverse,*** Metric Type,*** Calculation Type,Collection Type(s) where Historic Benchmark Removed,Collection Type(s) where Suppressed,Collection Type(s) where Truncated,Is Risk Adjusted 
+QCDR,,,,,PP11,,,,,,,2024,,,,,,,,,
diff --git a/updates/measures/2024/changes.meta.json b/updates/measures/2024/changes.meta.json
@@ -9,5 +9,7 @@
   "Quality_PY24_CR_Split_20231201.csv",
   "Cost_PY24_20231127.csv",
   "Quality_QCDR_PY24_CR_20231211.csv",
-  "Quality_QCDR_PY24_CR_20231219.csv"
+  "Quality_QCDR_PY24_CR_20231219.csv",
+  "Quality_QCDR_PY2024_CR_01032024.csv",
+  "Quality_QCDR_PY24_CR_20240104.csv"
 ]
diff --git a/util/measures/2024/quality-strata.csv b/util/measures/2024/quality-strata.csv
@@ -41,6 +41,12 @@
 431,reporting,Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months
 431,performance,Percentage of patients aged 18 years and older who were identified as unhealthy alcohol users who received brief counseling
 431,combinedPopulations,Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as unhealthy alcohol users
+459,discectomyLaminectmy,Percentage of lumbar discectomy/laminectomy procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively
+459,lumbarFusion,Percentage of lumbar fusion procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric pain scale at one year (9 to 15 months) postoperatively
+461,discectomyLaminectmy,Percentage of lumbar discectomy/laminectomy procedures for which the patient reports leg pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively
+461,lumbarFusion,Percentage of lumbar fusion procedures for which the patient reports leg painless than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at one year (9 to 15 months) postoperatively after lumbar fusion.
+471,discectomyLaminectmy,Percentage of lumbar discectomy/laminectomy procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at three months (6 to 20 weeks) postoperatively
+471,lumbarFusion,Percentage of lumbar fusion procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool at one year (9 to 15 months) postoperatively
 493,influenza,Percentage of patients (19 years of age and older on the date of the encounter) who received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period
 493,Tdap,"Percentage of patients (19 years of age and older on the date of the encounter) who received at least 1 tetanus and diphtheria (Td) vaccine or 1 tetanus, diphtheria, and pertussis (Tdap) vaccine between 9 years prior to the encounter and the end of the measurement period"
 493,herpesZoster,Percentage of patients (50 years of age and older on the date of the encounter) who received at least 1 dose of the herpes zoster live vaccine or 2 doses of the herpes zoster recombinant vaccine anytime on or after the patients’ 50th birthday
@@ -60,4 +66,4 @@
 503,6points,Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month period.
 503,AveChg,Average change between baseline PAM® score and the second score within 6 to 12 months of a baseline PAM® score.
 504,24hour,"Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician (concurrent or within 24 hours of clinical encounter)"
-504,overall,"Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation."
+504,overall,"Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation."
Original file line number	Diff line number	Diff line change
		@@ -0,0 +1,2 @@
		Category ,Measure Title,CMS eCQM ID,eCQM NQF,NQF,* Quality Number (#) / QCDR #,Primary Measure Steward,Allowed QCDR Vendor ID,Measure Description,* Measure Type ,High Priority,First Performance Year,Year Removed,* Collection Type(s) for Submission,Specialty Measure Sets,* Inverse,* Metric Type,* Calculation Type,Collection Type(s) where Historic Benchmark Removed,Collection Type(s) where Suppressed,Collection Type(s) where Truncated,Is Risk Adjusted
		QCDR,,,,,PP11,,,,,,,2024,,,,,,,,,