Outpatient Imaging Efficiency Measures: Dry Run Based on Medicare CY 2007 Outpatient Hospital Claims Data

February 2010

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Plan for Today Introduction  Outpatient Imaging Efficiency (OIE) Measures 

 Purpose of

Measures  Outpatient Hospital Reporting 

Overview of Measures and CY 2007 Results  OP-8:

MRI Lumbar Spine for Low Back Pain  OP-9: Mammography Follow-up Rates  OP-10: Abdomen CT – Use of Contrast Material  OP-11: Thorax CT – Use of Contrast Material 

Overview Dry Run 2

Overview OIE Measures

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Public Comments

Technical Expert Panel

Centers for Medicare & Medicaid Services

The Lewin Group

Imaging Measures Developers

L&M Policy Research, LLC

National Imaging Associates

Dobson | DaVanzo & Associates, LLC

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Purpose of OIE Measures 

Promote high-quality efficient care  Reduce

unnecessary exposure to contrast materials and / or radiation  Adhere to evidence-based medicine and practice guidelines  Efficiency defined as “absence of waste” 

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Institute of Medicine (2001) defines efficiency as avoiding the use of resources that do not provide any benefit to patients, and classifies such use of resources as “waste” RAND Corporation (2009) defines “clinical waste” as the provision of clinical services for which the cost of the service outweighs the benefit “Waste” can vary across individuals; i.e., services appropriate and beneficial for one patient may be wasteful for another patient, depending on clinical circumstances 5

Outpatient Hospital Reporting 

OPPS final rule for CY 2010 included public reporting for OIE measures on Hospital Compare as soon as June 2010  OIE Measures are Medicare claims-based

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To educate patients and increase awareness  Informed decisions

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Involved health risks  Exposure to unnecessary radiation and / or contrast materials  Care not consistent with guidelines

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To assess outpatient hospital care for Medicare beneficiaries  Examine hospital protocols 6

OIE Measure Set I

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Measure Set 

OP-8: MRI Lumbar Spine for Low Back Pain

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OP-9: Mammography Follow-up Rates

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OP-10: Abdomen CT – Use of Contrast Material

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OP-11: Thorax CT – Use of Contrast Material

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Data Source 

Relies on outpatient hospital Medicare final claims data, no additional data submission needed

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Dry Run: Medicare fee-for-service outpatient claims data for CY 2007

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Public Reporting: Medicare fee-for-service outpatient claims data for CY 2008

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Dry Run Data 

The data results used in the dry-run will not be publicly reported.

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Data calculations based on all hospitals with claims data for an OIE measure procedure.

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Decision by CMS has not yet been made on minimum case count requirements for public reporting purposes.

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Data presented in dry run HSR are calculated as raw/observed rates, and have not been subjected to statistical reliability testing.

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OIE measures are not risk adjusted. 10

OP-8: MRI Lumbar Spine for Low Back Pain

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OP-8: MRI Lumbar Spine for Low Back Pain 

Definition:  This

measure calculates the percentage of patients who had an MRI of the Lumbar Spine with a diagnosis of low back pain without Medicare claims-based evidence of antecedent conservative therapy.

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OP-8: MRI Lumbar Spine for Low Back Pain Numerator/Denominator Patients who had an MRI of the Lumbar Spine with a diagnosis of low back pain without claims based evidence of antecedent conservative therapy ____________________________________ Patients with a diagnosis of low back pain who had an MRI of the Lumbar Spine

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OP-8: Exclusions and Interpretation 

Denominator exclusions  Lumbar

Spine MRI studies without a diagnosis related to low back pain or having an excluded condition (cancer, trauma, neurological impairment, IV drug abuse, HIV, unspecified immune deficiencies, intraspinal abscess).

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Interpretation of measure  Higher

values towards the higher end of percentile distribution may indicate facilities are less compliant with medical guidelines for treating low back pain.

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OP-8: MRI of Lumbar Spine without evidence of prior conservative therapy Statistic

2007 Data

Number of Facilities

3,845

National Average

32.2%

Standard Deviation

13.3%

Distribution 5th percentile

14.8%

10th percentile

20.8%

25th percentile

26.9%

Median

32.3%

75th percentile

38.7%

90th percentile

47.1%

95th percentile

53.8%

Rates

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OP-8: MRI of Lumbar Spine without evidence of prior conservative therapy Percentage of Total Facilities

30% 25% 20% 15% 10%

% of Facilities

5% 0%

Rate

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OP-9: Mammography Follow-up Rates

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OP-9: Mammography Follow-up Rates 

Definition:  This

measure calculates the percentage of patients with mammography screening studies done in the outpatient hospital setting that are followed within 45 days by a diagnostic mammography or ultrasound of the breast study in an outpatient or office setting.

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OP-9: Mammography Follow-up Rates Numerator/Denominator Number of patients who had a diagnostic mammography study or an ultrasound of the breast study following a screening mammography study (within 45 days) ____________________________________ The number of patients who had received a screening mammography study 19

OP-9: Exclusions and Interpretation 

Denominator exclusions  None

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Interpretation of measure  Low

values near zero or values above 14 percent may indicate unusual patterns of follow-up.

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OP-9: Mammography Follow-up Rates Statistic

2007 Data

Number of Facilities

3,825

National Average

8.5%

Standard Deviation

6.4%

Distribution 5th percentile

2.8%

10th percentile

3.8%

25th percentile

5.6%

Median

8.0%

75th percentile

11.0%

90th percentile

14.6%

95th percentile

17.9%

Rates

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OP-9: Mammography Follow-up Rates

Percentage of Total Facilities

50% 40% 30% 20%

% of Facilities

10% 0%

Rate

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OP-10: Use of Contrast Material – Abdomen CT

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OP-10: Abdomen CT – Use of Contrast Material 

Definition:  This

measure calculates the ratio of CT abdomen studies that are performed both with/without contrast out of all CT abdomen studies performed (those with contrast, those without contrast, and those with both).

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OP-10: Abdomen CT – Use of Contrast Material Numerator/Denominator The number of Abdomen CT studies both with/without contrast (combined studies). ____________________________________ The number of Abdomen CT studies performed (with contrast, without contrast or with/without contrast). 25

OP-10: Exclusions and Interpretation 

Denominator exclusions  Patients with

diagnoses related to unspecified disorder of kidney and ureter, hematuria, pancreatic disorders, adrenal mass, malignant neoplasms of liver and intrahepatic bile ducts, and neoplasms of the pancreas, kidney, and liver.

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Interpretation of measure  Lower

values are better.  A high value indicates a high use of combination studies and raises the question of inefficient examination protocols.

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OP-10: Use of Contrast – Abdomen CT Statistic

2007 Data

Number of Facilities

4,497

National Average

0.200

Standard Deviation

0.248

Distribution 5th percentile

0.008

10th percentile

0.023

25th percentile

0.052

Median

0.108

75th percentile

0.379

90th percentile

0.666

95th percentile

0.750

Ratios

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OP-10: Use of Contrast – Abdomen CT

Percentage of Total Facilities

25% 20% 15% 10%

% of Facilities

5% 0%

Ratio

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OP-11: Use of Contrast Material – Thorax CT

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OP-11: Thorax CT – Use of Contrast Material 

Definition:  This

measure calculates the ratio of CT thorax studies that are performed with and without contrast out of all CT thorax studies performed (those with contrast, those without contrast, and those with both).

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OP-11: Use of Contrast Material – Thorax CT Numerator/Denominator The number of thorax CT studies with and without contrast (combined studies) ____________________________________ The number of thorax CT studies performed (with contrast, without contrast or both with/without contrast) 31

OP-11: Exclusions and Interpretation 

Denominator exclusion  None

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Interpretation of Measure  Lower

values are better  High value indicates high use of combination studies and raises the question of inefficient examination protocols

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OP-11: Use of Contrast – Thorax CT Statistic

2007 Data

Number of Facilities

4,493

National Average

0.057

Standard Deviation

0.171

Distribution 5th percentile

0.000

10th percentile

0.000

25th percentile

0.005

Median

0.025

75th percentile

0.102

90th percentile

0.293

95th percentile

0.517

Ratios

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OP-11: Use of Contrast – Thorax CT 45%

Percentage of Total Facilities

40% 35% 30% 25% 20% % of Facilities

15% 10% 5% 0%

Ratio

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OP-11: Exclusions and Interpretation 

Denominator exclusion  None



Interpretation of Measure  Lower

values are better  High value indicates high use of combination studies and raises the question of inefficient examination protocols.

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Overview Dry Run Hospital Specific Report for OIE Measure Set I

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Dry Run Overview 

Before public reporting the CMS is conducting a dry run similar to those conducted for other hospital measures.

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Dry run provides Hospital-Specific Report (HSR) for review by hospitals.

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Goal of the dry run:  Educate hospitals about the OIE measures  Test CMS measure production process  Give hospitals an opportunity to ask questions and provide CMS with their feedback

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Hospital Specific Data and National Summary Statistics Table 1: Your Hospital’s Specific Data and National Summary Statistics

Measure # and Description

Your Hospital’s Rate (Mock data)

OP-8: MRI Lumbar Spine for Low Back Pain (Percentage) OP-9: Mammography Follow-up Rates (Percentage) OP-10: Use of Contrast – Abdomen CT (Ratio) OP-11: Use of Contrast – Thorax CT (Ratio)

National Summary Statistics

# Hospitals Average Standard Measure Deviation 25.4% 3,845 32.2% 13.3% 8.5%

3,825

8.5%

6.4%

0.029

4,497

0.200

0.248

0.000

4,493

0.057

0.171

Data source: CY 2007 Medicare Standard Analytical Files

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HHS Regions Crosswalk from HHS Region to States HHS Region

States

1

Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont

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New Jersey, New York, Puerto Rico, Virgin Islands

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Washington D.C., Delaware, Maryland, Pennsylvania, Virginia, West Virginia

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Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

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Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

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Arkansas, Louisiana, New Mexico, Oklahoma, Texas

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Iowa, Kansas, Missouri, Nebraska

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Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

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California, Guam, Hawaii, Northern Mariana Island, Nevada, American Samoa, Arizona

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Alaska, Idaho, Oregon, Washington 39

Detailed Data for Each Measure Hospital Specific Rates and Summary Statistics for OP-8 (Mock Report) Hospital A # Cases in Numerator # Cases in Denominator Calculated Percentage

17 67 25.4%

# Hospitals  National Mean # Cases in Numerator Mean # Cases in Denominator Calculated Percentage  HHS Region Mean # Cases in Numerator Mean # Cases in Denominator Calculated Percentage  State Mean # Cases in Numerator Mean # Cases in Denominator Calculated Percentage

5th

10th

Percentiles 25th

50th

75th

90th

95th

32 99 32.2%

3,845 3,845 3,845

14.8%

20.8%

26.9%

32.3%

38.7%

47.1%

53.8%

39 120 32.6%

307 307 307

21.2%

24.3%

28.0%

32.1%

37.2%

44.4%

48.5%

32 102 31.6%

140 140 140

18.3%

23.2%

27.6%

31.5%

35.6%

41.7%

46.2%

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Patient Level Data 

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Separate report with patient level data on Medicare FFS beneficiaries included in the numerator portion of the measure calculations. Because of large volume of imaging services provided by many hospitals, limiting release of patient level information to patients included in the numerator of measure calculations. Patients in numerator are those likely to be most relevant to hospitals’ interests in examining the charts of patients to look for potential quality improvement efforts.

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Data Variables in Patient Level Data For all measures except OP-9: Mammography Follow-up Rates  Provider  CPT

Identifier (Medicare provider ID)

Code for Imaging Procedure

 Patient

Identifier (HIC-Medicare health insurance claim account number)

 Date

of Service

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Data Variables in Patient Level Data for OP-9: Mammography Follow-up Rates  Provider

Identifier (Medicare provider ID)

 CPT

Code for Screening Mammography Procedure

 Patient

Identifier (HIC-Medicare health insurance claim account number)

 Date

of Service

 Indication of

Diagnostic Mammography Study or an Ultrasound of the Breast Study 43

Privacy of Patient Level Data 

Identifiable patient health information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). E-mailing protected health information poses a security issue, and each HIPAA-covered entity is responsible for ensuring compliance with the security standards.

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It is a violation of HIPAA rules to share these protected patient-level data with other organizations, including the press. This includes e-mailing your patient-level data to CMS or any other organization. The only two secure ways to send your patient-level data are: 1) mailing the data through the U.S. Postal Service, and 2) send it via the government-approved, secure section of the QualityNet website (http://www.qualitynet.org).

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Dry Run Information Relevant information and a mock report posted on Hospital – Outpatient tab / Imaging Efficiency Measures at: www.qualitynet.org  Confidential Hospital-Specific Reports (HSR) for OIE measures available online in the secured section of “MY QualityNet” at: www.qualitynet.org 

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Dry Run Comment Period 

30 day comment period post-release HSRs

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Questions and comments should be sent to [email protected]

This material provided by FMQAI, the Medicare Quality Improvement Organization for Florida, an agency of the U.S. Department of Health and Human Services, was prepared by The Lewin Group, Imaging measure writers under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy. FL2010SS1T111911633

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Questions

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