Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Appendix B. ACEP CEDR QCDR Measure Information Registry CEDR CEDR CEDR CEDR CEDR # 1 2 3 Measure Title/Description Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding Numerator Emergency department visits for patients who have an indication for a head CT Emergency department visits for patients who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury Emergency department visits during which coagulation studies (PT, PTT, or INR tests) were ordered by an emergency care provider 4 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism Emergency department visits for patients with either: 1. Moderate or high pre-test clinical probability for pulmonary embolism OR 2. Positive result or elevated Ddimer level 5 ED Median Time from ED arrival to ED departure for discharged ED patients – Overall Rate Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for discharged patients Denominator All emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider Denominator Exclusions Patients with any of the following: Ventricular shunt Brain tumor Multisystem trauma Pregnancy Currently taking antiplatelet medications All emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma (non-penetrating injuries) with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider Patients with any of the following: • Ventricular shunt • Brain tumor • Coagulopathy • Thrombocytopenia All emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain Patients with any of the following clinical indications for ordering coagulation studies: End stage liver disease Coagulopathy Thrombocytopenia Currently taking or newly prescribed anticoagulant meds Pregnancy Pulmonary or gastrointestinal hemorrhage Atrial fibrillation Inability to obtain medical history All emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition All ED encounters Pregnant patients; Medical reason for ordering a CTPA without moderate or high pre-test clinical probability for PE AND no positive result or elevated Ddimer level (eg, CT ordered for aortic dissection) Patients who expired in the emergency department Measure Type Process Process Process Process Outcome Rationale Evidence Risk Adjustment or Stratification Notes Efficiency & Cost Reduction About 2.5 million traumatic brain injuries occur each year, where 75% of these are considered mild. 3 There is data to suggest that 70% of head injury patients receive a head CT 4, and it is estimated that 1035% of head CTs obtained in head injury patients do not follow recognized guidelines 5 Some estimate that as many as 55,000-194,000 CT scans are possibly avoidable annually. 6 Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy (ACEP, 2008).1 N/A NON-PQRS ACEP Update NQF #0668 Efficiency & Cost Reduction About 2.5 million traumatic brain injuries occur each year, where 75% of these are considered mild. 2 There is data to suggest that 70% of head injury patients receive a head CT 3, and it is estimated that 1035% of head CTs obtained in head injury patients do not follow recognized guidelines 4 Some estimate that as many as 55,000-194,000 CT scans are possibly avoidable annually. 5 Pediatric Emergency Care Applied Research Network (PECARN): Suggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores of 14–15 after head trauma N/A NON-PQRS ACEP Coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient. Ensuring that clinicians are purposefully ordering these studies may lead to significant reduction in resource utilization without any decrease in value of healthcare provided to the patient. In the United States, it is estimated that $114 million are spent annually on coagulation testing for patients presenting with chest pain and without any other indications in the Emergency Department. 1 Across laboratory testing overall 15% to 56% of tests are considered to have been ordered inappropriately; in a study of coagulation studies specifically, it was found that 81% of coagulation tests were ordered inappropriately. 1 N/A NON-PQRS ACEP Suspected non-high risk PE: Plasma D-dimer measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably using a highly sensitive assay (Class I Level A recommendation) N/A NON-PQRS ACEP Update NQF #0667 ED crowding may result in delays in the administration of medication such as antibiotics for pneumonia and has been associated with ED volume, acuity mix, trauma center level, teaching status, patient age, patient gender, NQS Domain Efficiency & Cost Reduction Efficiency & Cost Reduction Patient Experience of Care The goal of this measure is to reduce the inappropriate ordering of CTPA for pulmonary embolism based on pre-test probability estimation. This measure does not require utilization of a structured clinical prediction rule such as the Wells Score or Geneva Score, however the measure aims to improve efficiency by guiding clinical practice towards use of initial d-dimer testing rather than immediate CTPA in low or intermediate probability patients as indicated. Reducing the time patients remain in the emergency department (ED) can improve access to treatment and NON-PQRS NQF #0496 OP-18: a. Overall Rate Page 1 Appendix B. ACEP CEDR QCDR Measure Information Registry CEDR # 6 CEDR 7 CEDR 8 CEDR CEDR CEDR CEDR 9 10 11 12 Measure Title/Description ED Median Time from ED arrival to ED departure for discharged ED patients – General Rate = (Overall Rate – Psych Pts– Transfer Pts) ED Median Time from ED arrival to ED departure for discharged ED patients – Psych Mental Health Patients ED Median Time from ED arrival to ED departure for discharged ED patients – Transfer Patients Door to Diagnostic Evaluation by a Qualified Medical Personnel Anti-coagulation for Acute Pulmonary Embolism Patients Pregnancy Test for Female Abdominal Pain Patients Three day return rate ED Numerator Denominator Denominator Exclusions • • Transfers Psychiatric and mental health pts Patients who expired in the emergency department Measure Type NQS Domain Outcome Patient Experience of Care Time (in minutes) from ED arrival to ED departure for discharged patients All ED encounters (excluding psych and transfers) Time (in minutes) from ED arrival to ED departure for discharged patients All ED psychiatric and mental health patients Patients who expired in the emergency department Outcome Patient Experience of Care Time (in minutes) from ED arrival to ED departure for discharged patients All ED patients transferred to another hospital or facility Patients who expired in the emergency department Outcome Patient Experience of Care • Median time between patient presentation to the ED and the first moment the patient is seen by a qualified medical person for patient evaluation and management. All ED encounters Patients who have orders for anticoagulation All patients, regardless of age, presenting to the emergency department (ED) with a diagnosis of pulmonary embolus Anticoagulation not ordered for reasons documented by clinician All female patients ages 14 through 50 years old who present to the ED with a chief complaint of abdominal pain. Pregnancy test (urine or serum) not ordered for reasons documented by clinician (e.g., documentation of pregnancy or status post hysterectomy) Patients who have had a pregnancy test (urine or serum) ordered All patients who incurred a repeat ED encounter within 3 calendar days All ED Encounters Patients who expired in the emergency department None Outcome Process Process Outcome Rationale Evidence increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. perceptions of compromised emergency care. For patients with non-ST-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised Patient Safety Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. Patient Safety ED patients who have delayed anticoagulation (either on the floor and/or as measured by a delayed therapeutic aPTT) have higher mortality Patient Safety Use of the measure can eliminate the risk of the physician failing to diagnose a patient is pregnancy, thereby reducing the possibility that a patient with ectopic pregnancy is not identified Communication and Care Coordination Hospitalizations occurring shortly after emergency department (ED) discharge, or bounce-back admissions, may signal missed diagnoses of serious illness, incomplete ED care, or insufficient outpatient follow-up after discharge. ED crowding may result in delays in the administration of medication such as antibiotics for pneumonia and has been associated with perceptions of compromised emergency care. For patients with non-ST-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised Several studies demonstrate the importance of timely treatment of pulmonary embolism in the ED. Data from AHRQ’s National Inpatient Sample suggests that about 158,000 patients are admitted to US hospitals with a diagnosis of PE each year, and that 72% of these patients were diagnosed as having a PE in the ED suggesting that the emergency department is an appropriate setting for measurement of this important clinical condition Pregnancy testing is recommended in the Emergency Department for females who might be pregnant because clinical history is unreliable (Ann Emerg Med 1989). The importance of pregnancy diagnosis is particularly true in patients with abdominal pain and/or prior to radiologic procedures where failure to diagnose pregnancy is a risk to the woman and her unborn child. A review of the literature suggests that the rate of return visits to EDs ranges from 0.39% to 5.8% in adults. Reported risk factors for return admissions include older age, living alone, insurance status, and certain diagnoses such as mental disorders, genitourinary disorders, Risk Adjustment or Stratification payer, hospital case mix adjustment factor of the hospital where the service was provided (if provided in a hospital vs. free-standing facility) ED volume, teaching status, acuity mix, trauma center level, patient age, patient gender, payer, hospital case mix adjustment factor of the hospital Notes b. Reporting Measure c. Psych Pts d. Transfer Pts NON-PQRS OP-20 NQF #0498 N/A Former PQRS #252; Former NQF #0503 N/A Former PQRS #253; Former NQF #0502 ED volume, acuity mix, trauma center level, teaching status, patient age, patient gender, payer mix, hospital case mix adjustment factor of the hospital Adapted 72 hour return rate Page 2 Appendix B. ACEP CEDR QCDR Measure Information Registry # Measure Title/Description Numerator Denominator Denominator Exclusions Measure Type NQS Domain Rationale Understanding the factors associated with return visits may inform the design of ED quality improvement interventions for improved care coordination. CEDR CEDR CEDR CEDR CEDR 13 Three day return rate UC 14 tPA Considered: Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for t-PA administration 15 16 17 Tobacco Screening and Cessation Intervention: Percentage of asthma and COPD patients aged 18 years and older who were screened for tobacco use AND who received cessation counseling intervention if identified as a tobacco user. Antibiotic Prescribed for Adult Acute Sinusitis: Percentage of patients, aged 18 years and older, with acute sinusitis for less than 10 days who were prescribed an antibiotic Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis All patients who incurred a repeat UC encounter within 3 calendar days Patients who were considered for t-PA administration Patients who were screened for tobacco use during the ED encounter AND who received tobacco cessation counseling intervention if identified as a tobacco user Antibiotic regimen prescribed within 10 days of onset of symptoms Patients who were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis All UC Encounters None All patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours All asthma and COPD patients aged 18 years and older All patients aged 18 years and older with a diagnosis of acute sinusitis All patients aged 18 years and older with a diagnosis of acute bacterial sinusitis Ischemic stroke symptom onset ≥ 3 hours prior to arrival at emergency department Other medical reason documented Current tobacco non-user Documented medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reasons) Patients who present with sinusitis which has lasted greater than 10 days Patients without assurance of follow-up Documented medical reason (e.g., cystic fibrosis, immotile cilia disorders, ciliary dyskinesia, immune deficiency, prior history of sinus surgery within the past 12 months, and anatomic abnormalities, such as deviated nasal septum, resistant organisms, allergy to medication, recurrent sinusitis, chronic sinusitis, or other reasons) Outcome Process Process Process Process Evidence Risk Adjustment or Stratification Notes Acuity mix, patient age, patient gender, payer mix Adapted 72 hour return rate N/A Formerly PQRS #34 NQF# 0242 N/A NON-PQRS Adapted PQRS # 226 NQF #0028 symptom based diagnoses such as abdominal pain and chest pain, dehydration, and septicemia. Monitoring unscheduled return visits is important for quality assurance in the Emergency Department (ED). Communication and Care Coordination Understanding the factors associated with return visits may inform the quality improvement interventions for improved care coordination. Monitoring unscheduled return visits is important for quality assurance and care coordination. Effective Clinical Care Patients who arrive at the hospital within 3 hours of stroke symptom onset should be considered for t-PA therapy. Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is strongly recommended for carefully selected patients who can be treated within 3 hours of onset of ischemic stroke. (Adams, ASA, 2003) (Grade A) CommunityPopulation Health There is good evidence that tobacco screening and brief cessation intervention (including counseling and/or pharmacotherapy) is successful in helping high-risk tobacco users quit. Tobacco users who are able to stop smoking lower their risk for acute exacerbations of their lung disease. The USPSTF recommends that clinicians ask adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) (U.S. Preventive Services Task Force, 2009) Efficiency & Cost Reduction Antibiotic treatment for Sinusitis is indicated for some patients, but overtreatment of acute sinusitis with antibiotics is common and often not indicated. Further, treatment with antibiotics may increase patient harm and can lead to antibiotic resistance. AAO-HNS Sinusitis Guideline (2007): Observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness (mild pain and temperature < 38.3°C or 101°F) and assurance of follow-up (based on double-blind randomized controlled trials). Antibiotics are not recommended for treating viral rhinosinusitis (VRS) because they are ineffective and do not relieve symptoms directly. Efficiency & Cost Reduction The use of broad-spectrum antibiotics as first line treatment has contributed to the rising incidence of drugresistant strains of bacteria and to increased costs. Once antibiotics therapy is initiated, the goal is to choose a first-line antibiotic treatment that is efficacious, cost-effective and results in minimal side effects. Amoxicillin is first-line therapy for most patients with ABRS relates to its favorable adverse effect profile, efficacy, low cost, AAO-HNS Sinusitis Guideline (2007) If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin as first-line therapy for most adults (based on RCTs). N/A N/A NON-PQRS Adapted PQRS # 331 NON-PQRS Adapted PQRS # 332 Page 3 Appendix B. ACEP CEDR QCDR Measure Information Registry # Measure Title/Description Numerator Denominator Denominator Exclusions Measure Type NQS Domain Rationale Evidence Risk Adjustment or Stratification Notes Clinical guidelines do not support antibiotic treatment of otherwise healthy adults with acute bronchitis due to the viral origin of acute bronchitis. Patients with chronic bronchitis, COPD or other chronic comorbidity may be treated with antibiotics and are therefore excluded from the measure denominator. (Gonzales R., D.C. Malone, J.H. Maselli, et al, 2001) N/A Adapted PQRS# 116 NQF #0058 and narrow microbiologic spectrum. CEDR 18 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis: Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed an antibiotic prescription within 3 days of onset of symptoms Patients who were not prescribed or dispensed antibiotics on or within 3 days of the onset of symptoms. All patients aged 18 through 64 years of age with an outpatient or emergency department (ED) visit with a diagnosis of acute bronchitis at the visit Patients who presented with symptoms of bronchitis for more than 3 days Documentation of medical reason(s) for prescribing or dispensing antibiotic (another infection), cystic fibrosis, disorders of the immune system, malignancy, lung diseases (asthma, COPD, chronic bronchitis), other diseases of the respiratory system, and tuberculosis Process Efficiency & Cost Reduction Antibiotics are commonly misused and overused for a number of viral respiratory conditions where antibiotic treatment is not clinically indicated. In adults, antibiotics are most often (65–80 percent) prescribed for acute bronchitis, despite its viral origin. The misuse and overuse of antibiotics contributes to antibiotic drug resistance, which is of public health concern due to the diminished efficacy of antibiotics against bacterial infections, particularly in sick patients and the elderly. Legend: NQS Domains Clinical Effectiveness Efficiency & Cost Reduction Patient Safety Community-Population Health Communication and Care Coordination Patient Experience of Care Page 4