Acute and Sub-Acute Low Back Pain Functional Status Outcome Measure 2015 Direct Data Submission (04/01/2015 to 06/30/2015 Dates of Service)

Transcription

1 (04/01/2015 to 06/30/2015 Dates of Service) Pilot Measure Specifications

2 Description Methodology Rationale Acute and Sub-Acute Low Back Pain The average change in functional status within 12 weeks of a treatment start date for adult patients experiencing acute or sub-acute low back pain. Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Full population data is required. In the United States, the lifetime prevalence for back pain is approximately 80%, with a 3 month prevalence rate of 28%. According to the CDC, the National Health Interview Survey in 2012 showed the highest 3 month prevalence is in adults ages (32.3%). In 2005, the CDC study based on census data reported that 7.6 million Americans had a disability related to back pain, making back pain the second leading cause of disability in the country. Back pain comes to a great expense to our country. Back pain is the sixth most costly health condition in the United States. According to the CDC, in 2010, back pain was in the top five acute principal reasons for a primary care office visit. The healthcare costs associated with back pain account for more than $12 billion per year in the United States. Americans spend approximately $50 to $100 billion on back pain each year. This total represents the more readily available costs for medical care, workers compensation payments and time lost from work. Measurement Period Pilot Testing measurement period for treatment start dates will be a fixed 3- month period: 04/01/2015 to 06/30/2015 with allowance for subsequent follow up to occur through 09/21/2015.

3 Initial Patient Population Acute and Sub-Acute Low Back Pain Patients who meet each of the following criteria are included in the population: Patient aged 18 years or older at the start of the measurement period. Patient had an outpatient face to face encounter (Table 1) with an eligible provider in an eligible specialty with a low back pain related ICD-9 diagnosis code (Table 2) in the primary position. Treatment Start Date: The earliest date of service for an outpatient face to face encounter during the measurement period with a principal diagnosis of low back pain. Eligible specialties: Chiropractic Medicine [Specialties not eligible for this period but with potential future applicability if tested: Family Medicine, Geriatric Medicine, Internal Medicine, Occupational Medicine, Orthopedic Medicine/Surgery, Neurosurgery, Physiatry, Physical Therapy/Rehabilitation Medicine, Acupuncture and Oriental Medicine] Eligible providers: Doctor of Chiropractic (DC) Exclusions [Providers not eligible for this period but with potential future applicability if tested: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN), Physical Therapist, Acupuncturist (LAc)] Exclusions from eligible population definition (allowed prior to submission): Patients with any same-specialty encounter in the 180 days prior to the treatment start date that included a low back pain related ICD-9 diagnosis code (Table 2) in any position. Patients with a diagnosis of cancer, trauma or infection related to the spine; drug abuse; or neurologic impairment (Table 3) any time during the previous or current measurement year. Patients who were pregnant (Table 4) during the measurement period. Calculated exclusion (based on data submission): Patients who report that current symptoms began more than 3 months prior to the treatment start date.

4 Measure Calculation Functional Status Change within 12 weeks Outcome measure Measure Calculation ODI Administration at Treatment Start Supporting process measure Measure Calculation Follow Up ODI Administration within 12 weeks Supporting process measure Measure Calculation ODI Administration at BOTH Treatment Start AND within 12 weeks Supporting process measure Acute and Sub-Acute Low Back Pain Measures the average change in functional status within the first 12 weeks of treatment for patients experiencing acute or sub-acute low back pain Step 1: For each eligible patient, obtain the ODI v2.1a result from the treatment start date Step 2: For each eligible patient, obtain the most recent ODI v2.1a result occurring on or prior to 12 weeks after the treatment start date. Step 3: For each eligible patient, calculate the change in functional status o ODI start ODI 12weeks Step 4: Sum the change in functional status for all eligible patients Step 5: Divide by the number of eligible patients The percentage of eligible patients with an Oswestry Disability Index (ODI) v2.1a result recorded in the medical record on the treatment start date. The percentage of eligible patients with an Oswestry Disability Index (ODI) v2.1a result recorded in the medical record on or prior to 12 weeks after the treatment start date. The percentage of eligible patients with an Oswestry Disability Index (ODI) v2.1a result recorded in the medical record on BOTH the treatment start date AND on or prior to 12 weeks after the treatment start date.

5 Data elements of clinical importance for analysis and/or potential risk adjustment Acute and Sub-Acute Low Back Pain Data elements determined to be useful for assessing risk and predicting future outcomes will be collected as part of the data submission. Proposed elements include: Data elements submitted as part of MNCM standard demographic data elements: Age Gender Health plan product Data elements specific to this patient population: Functional status at Treatment Start Date Duration of low back pain at Treatment Start Date Active or pending motor vehicle accident, worker s compensation and/or personal injury claim Presence or absence of radicular pain Table 1: CPT Codes for Identifying Eligible Face to Face Encounters CPT Codes Code Description Physical therapy evaluation Acupuncture, without electrical stimulation Acupuncture, with electrical stimulation Office or other outpatient visit, New patient, Level I Office or other outpatient visit, New patient, Level II Office or other outpatient visit, New patient, Level III Office or other outpatient visit, New patient, Level IV Office or other outpatient visit, New patient, Level V Office or other outpatient visit, Established patient, Level I Office or other outpatient visit, Established patient, Level II Office or other outpatient visit, Established patient, Level III Office or other outpatient visit, Established patient, Level IV Office or other outpatient visit, Established patient, Level V

6 Table 2: ICD-9 Diagnosis Codes for Identifying Low Back Pain ICD-9 ICD-9 Diagnosis Code Description Diagnosis Code Lumbosacral plexus lesions Lumbosacral root lesions, not elsewhere classified Lesion of sciatic nerve Sacroiliitis, not elsewhere classified Unspecified inflammatory spondylopathy Lumbosacral spondylosis without myelopathy Spondylosis of unspecified site without mention of myelopathy Displacement of lumbar intervertebral disc without myelopathy Degeneration of lumbar or lumbosacral intervertebral disc Other and unspecified disc disorder, lumbar region Spinal stenosis, lumbar region, without neurogenic claudication Lumbago Sciatica Thoracic or lumbosacral neuritis or radiculitis, unspecified Backache, unspecified Disorders of sacrum Unspecified disorder of coccyx Disorders of coccyx, hypermobility of coccyx Disorders of coccyx, other Other symptoms referable to back Other unspecified back disorders Nonallopathic lesions, lumbar region Nonallopathic lesions, sacral region Nonallopathic lesions, pelvic region Sprains and strains of lumbosacral (joint) (ligament) Sprains and strains of sacroiliac ligament Sprains and strains of sacrospinatus (ligament) Sprains and strains of sacrotuberous (ligament) Sprains and strains of other specified sites of sacroiliac region Sprains and strains of unspecified site of sacroiliac region Sprains and strains of lumbar Sprains and strains of sacrum Sprains and strains of coccyx Sprains and strains of pelvis

7 Table 3: ICD-9 Diagnosis Codes for Identifying Patients Meeting Exclusion Criteria ICD-9 ICD-9 Diagnosis Code Description Diagnosis Code Malignant neoplasm bone & cartilage vertebral column Malignant neoplasm bone & cartilage pelvic, sacrum, coccyx Malignant neoplasm of other and unspecified parts of nervous system, spinal cord Secondary malignant neoplasm ; bone and bone marrow Benign neoplasm bone & cartilage vertebral column Benign neoplasm bone & cartilage pelvic, sacrum, coccyx Neoplasm uncertain behavior bone & cartilage Neoplasm unspecified nature bone & cartilage 304.0x Opioid type dependence 304.1x Sedative, hypnotic or anxiolytic dependence 304.2x Cocaine dependence 304.4x Amphetamine and other psychostimulant dependence 305.4x Sedative, hypnotic or anxiolytic abuse 305.5x Opioid abuse 305.6x Cocaine abuse 305.7x Amphetamine or related acting sympathomimetic abuse Caudaequina syndrome without mention of neurogenic bladder Caudaequina syndrome with mention of neurogenic bladder Lumbar spondylosis with myelopathy Neuralgia, neuritis, and radiculitis, unspecified 730.x5 Osteomyelitis, periostitis, and other infections involving bone, pelvic region and thigh 730.x8 Osteomyelitis, periostitis, and other infections involving bone, other specified sites 730.x9 Osteomyelitis, periostitis, and other infections involving bone, multiple sites Fracture, lumbar closed Fracture, lumbar open Fracture, sacrum & coccyx closed Fracture, sacrum & coccyx open Fracture w/spinal cord injury, lumbar closed Fracture w/spinal cord injury, lumbar open Fracture w/spinal cord injury, sacrum, coccyx closed unspecified Fracture w/spinal cord inj, sac/cocc closed caudaequina lesion Fracture w/spinal cord inj, sac/cocc closed caudaequina other Fracture w/spinal cord inj, sac/cocc closed other spinal cord inj Fracture w/spinal cord injury, sacrum, coccyx open unspecified

8 ICD-9 ICD-9 Diagnosis Code Description Diagnosis Code Fracture w/spinal cord inj, sac/coccyx open caudaequina lesion Fracture w/spinal cord inj, sac/coccyx open caudaequina other Fracture w/spinal cord inj, sac/coccyx open other spinal cord inj Pathologic fracture of vertebrae Non-union of fracture (pseudoarthrosis) Late effect fracture of the spine and trunk without mention of spinal cord lesion

9 Table 4: It is acceptable to use both set of codes to identify pregnancy, depending on coding practices in the medical group. If ICD-9 V-Codes are used consistently, it is acceptable to use these codes for populating an exception for pregnancy. If ICD-9 V-Codes are not used, or not used consistently, it is recommended to use the ICD-9 diagnosis code ranges that indicate pregnancy. Table 4a: ICD-9 V-Codes that Indicate Pregnancy ICD-9 V-Code ICD-9 V-Code Description V22.0 Supervision of normal first pregnancy V22.1 Supervision of other normal pregnancy V22.2 Pregnant state, incidental V23.0 Pregnancy with history of infertility V23.1 Pregnancy with history of trophoblastic disease V23.2 Pregnancy with history of abortion V23.3 Grand multiparity V23.41 Pregnancy with history of pre-term labor V23.42 Pregnancy with history of ectopic pregnancy V23.49 Pregnancy with other poor obstetrical history V23.5 Pregnancy with other poor reproductive history V23.7 Insufficient prenatal care V23.81 Elderly primigravida V23.82 Elderly multigravida V23.83 Young primigravida V23.84 Young multigravida V23.85 Pregnancy resulting from assisted reproductive technology V23.86 Pregnancy with history of in utero procedure during previous pregnancy V23.87 Pregnancy with inconclusive fetal viability V23.89 Other high risk pregnancy Table 4b: ICD-9 Diagnosis Codes that Indicate Pregnancy ICD-9 Code Start End of Range Description of Range 630 to 639.x Ectopic and Molar Pregnancy and Other Pregnancy with Abortive Outcome 640.xx to 649.xx Complications Mainly Related to Pregnancy 650 to 659.xx Normal Delivery and Other Indications for Care in Pregnancy, Labor and Delivery 660.xx to 669.xx Complications Occurring Mainly in the Course of Labor and Delivery 670.xx to 677 Complications Of the Puerperium 678.xx to 679.xx Other Maternal and Fetal Complications

10 Acute and Sub-Acute Low Back Pain Measure Flow Chart Was the patient born on or prior to 04/01/1997 No PATIENT NOT INCLUDED IN DATA SUBMISSION Yes Did the patient have an outpatient face to face encounter (Table 1) with an eligible provider during the measurement period (4/1/2015 6/30/2015)? (Treatment Start) Yes No No Was an ICD-9 diagnosis code (Table 2) for low back pain in the primary position for the encounter? Yes Yes Did the patient have any samespecialty encounters for low back pain in the 180 days prior? No Yes Did the patient have an exclusion diagnosis (Table 3) any time between 4/1/2014 9/21/2015? No Yes Was the patient pregnant (Table 4) any time between 4/1/2015 9/21/2015? No Change in ODI calculated. Result included in outcome measure. Yes Did the patient complete a follow up ODI v2.1a within 12 weeks of Treatment Start? Yes Did the patient complete an ODI v2.1a at Treatment Start? Patient included in process measure denominators No Does the patient report that current symptoms began more than 3 months prior to Treatment Start? PATIENT INCLUDED IN DATA SUBMISSION No No Yes Patient NOT included in outcome measure Patient NOT included in Measure Set

11 Data Elements and Field Specifications Use this section to build your data submission. The specifications contain detailed information regarding each column in the submission file that you will need to complete, including column order, definitions, examples, and appropriate formatting. A Clinic ID Enter the MNCM Clinic ID for every patient/row submitted. MNCM assigns the clinic ID at the time of registration. Use the MNCM ID listed in the MNCM Data Portal. Do NOT use the Medical Group ID. Blank values will create ERRORs upon submission. Text 905 B Patient ID Enter a unique patient ID to identify each patient. Keep a crosswalk between patient IDs and the patient names/dobs to help clinic staff locate records during validation audits. Enter clinic-assigned ID (e.g., MRN, account number). Do NOT enter Social Security Numbers. Blank values will create ERRORs upon submission. Text C Patient Date of Birth Enter patient s date of birth. Patient must be 18 years or older at the start of the measurement period. Blank values or values prior to 04/01/1997 will create ERRORs upon submission. Quality Check: Verify each date of birth is within the accepted range. D Patient Gender Enter patient s gender. Female = F Male = M Unknown = U Blank values will create ERRORs upon submission. Quality Check: Verify each cell has one of the accepted codes. Date (mm/dd/yyyy) Text 05/08/1985 F

12 E F G H I J K L M N Patient Zip Code Race/Ethnicity 1 Race/Ethnicity 2 Race/Ethnicity 3 Race/Ethnicity 4 Race/Ethnicity 5 Country of Origin Code Country of Origin Other Description Preferred Language Code Preferred Language Other Description Enter the five-digit zip code of patient s primary residence at the most recent encounter on or prior to 9/21/2015. If EMR query extracts a nine-digit number, submit the nine-digit number. The MNCM Data Portal will remove the last four digits automatically. Blank values will create ERRORs upon submission. Quality Check: Verify the zip code is at least five digits and each cell has data. Please refer to the separate document, REL Data Field Specifications & Codes, for the field specifications in Columns F-N. These are optional fields. For more information about collecting this data from patients, refer to the Handbook on the Collection of REL Data in Medical Groups. Quality Check: Verify each cell has one of the accepted codes. Blank cells (if there is no data available) are acceptable. Text 55111

13 O P Provider NPI Number Provider Specialty Code Enter the 10 digit NPI number of the eligible provider. Blank values will create ERRORs upon submission. Quality Check: Verify each cell has data. Enter the code for the specialty of the eligible provider. TBD = Chiropractic Medicine Text Number 22 Q R S Insurance Coverage Code Insurance Coverage Other Description Insurance Plan Member ID Blank values will create ERRORs upon submission. Quality check: Verify each cell has an accepted code. Please refer to a separate document, 2015 Insurance Coverage Data Field Specifications and Codes, for these field specifications. This should be the patient s most recent insurance on or prior to 9/21/2015. Quality Check: Verify each cell has an accepted code and that all 99 codes have a name entered in Column R. Verify Social Security Numbers are NOT submitted. Number 1 Text Text Assurant Health FBOXZ7969 T Treatment Start Date Enter the earliest date of service for an outpatient face to face encounter during the measurement period with a principal diagnosis of low back pain. Blank values or values outside the measurement period will create ERRORs upon submission. Quality Check: Verify all dates are between 04/01/2015 to 06/30/2015. Date (mm/dd/yyyy) 5/10/2015

14 U Duration of low Enter the value corresponding to the patient s response at treatment start to the back pain at following question: Treatment When did your current symptoms begin? Start Date 0 = Less than 2 weeks ago 1 = 2 6 weeks ago 2 = 6 weeks 3 months ago 3 = More than 3 months ago Leave BLANK if the patient does not answer or if there is no documentation For patients with a 3 in Field U: STOP. For patients with a duration of low back pain at Treatment Start Date of More than 3 months ago, the remaining fields (V AR) are not required. V Claim Type Enter the value that indicates whether the patient has an active or pending motor vehicle accident, worker s compensation or other personal injury claim related to this episode of treatment. 0 = No, the patient does not have an active or pending claim of these types 1 = Yes, the patient has an active or pending claim of these types 1 Blank values will create ERRORs upon submission. W Radicular Pain Enter the value that indicates whether the patient has radicular pain associated with this episode of low back pain. 0 = No, the patient does not have radicular pain 1 = Yes, the patient does have radicular pain 0 Blank values will create ERRORs upon submission.

15 For all Oswestry Disability Index (ODI) Fields; refer to Appendix A for more information about how to implement and score the ODI v2.1a. X Treatment Start ODI Pain Enter the value that corresponds with the patient s selection for ODI Section 1- Pain intensity. 0 = I have no pain at the moment. 1 = The pain is very mild at the moment. 2 = The pain is moderate at the moment. 3 = The pain is fairly severe at the moment. 4 = The pain is very severe at the moment. 5 = The pain is the worst imaginable at the moment. 2 Y Treatment Start ODI Care Enter the value that corresponds with the patient s selection for ODI Section 2- Personal Care (washing, dressing, etc.). 0 = I can look after myself normally without causing additional pain. 1 = I can look after myself normally but it is very painful. 2 = It is painful to look after myself and I am slow and careful. 3 = I need some help but manage most of my personal care. 4 = I need help every day in most aspects of my personal care. 5 = I do not get dressed, I wash with difficulty and stay in bed. 1

16 Z Treatment Start ODI Lifting Enter the value that corresponds with the patient s selection for ODI Section 3- Lifting. 0 = I can lift heavy weights without additional pain. 1 = I can lift heavy weights but it give me additional pain. 2 = Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, e.g. on a table. 3 = Pain prevents me from lifting heavy weights, but I can manage light to medium weights if off they are conveniently positioned. 4 = I can lift only very light weights. 5 = I cannot lift ot carry anything at all. 4 AA Treatment Start ODI Walking Enter the value that corresponds with the patient s selection for ODI Section 4- Walking. 0 = Pain does not prevent me from walking any distance. 1 = Pain prevents me from walking more than one mile. 2 = Pain prevents me from walking more than a quarter of a mile. 3 = Pain prevents me from walking more than 100 yards. 4 = I can only walk using a cane or crutches. 5 = I am in bed most of the time and have to crawl to the toilet. 2

17 AB Treatment Start ODI Sitting Enter the value that corresponds with the patient s selection for ODI Section 5- Sitting. 0 = I can sit in any chair as long as I like. 1 = I can sit in my favorite chair as long as I like. 2 = Pain prevents me from sitting more than one hour. 3 = Pain prevents me from sitting more than half an hour. 4 = Pain prevents me from sitting more than 10 minutes. 5 = Pain prevents me from sitting at all. 1 AC Treatment Start ODI Standing Enter the value that corresponds with the patient s selection for ODI Section 6- Standing. 0 = I can stand as long as I want without additional pain. 1 = I can stand as long as I want but it gives me additional pain. 2 = Pain prevents me from standing more than one hour. 3 = Pain prevents me from standing more than half an hour. 4 = Pain prevents me from standing more than 10 minutes. 5 = Pain prevents me from standing at all. 3

18 AD Treatment Start ODI Sleeping Enter the value that corresponds with the patient s selection for ODI Section 7- Sleeping. 0 = My sleep is never interrupted by pain. 1 = My sleep is occassionally interrupted by pain. 2 = Because of pain I have less than 6 hours of sleep. 3 = Because of pain I have less than 4 hours of sleep. 4 = Because of pain I have less than 2 hours of sleep. 5 = Pain prevents me from sleeping at all. 1 AE Treatment Start ODI Sex, if applicable Enter the value that corresponds with the patient s selection for ODI Section 8- Sex life. 0 = My sex life is normal and causes no additional pain. 1 = My sex life is normal but causes some additional pain. 2 = My sex life is nearly normal but is very painful. 3 = My sex life is severly restricted by pain. 4 = My sex life is nearly nonexistant because of pain. 5 = Pain prevents me from having any sex life at all. 2

19 AF Treatment Start ODI Social Enter the value that corresponds with the patient s selection for ODI Section 9- Social Life. 0 = My social life is normal and causes no additional pain. 1 = My social life is normal but increases the degree of pain. 2 = Pain has no significant effect on my social life apart from limiting my more energetic interests. 3 = Pain has restricted my social life and I do not go out as often. 4 = Pain has restricted my social life to home. 5 = I have no social life becasue of pain. 0 AG Treatment Start ODI Travelling Enter the value that corresponds with the patient s selection for ODI Section 10- Travelling. 0 = I can travel anywhere without pain. 1 = I can travel anywhere but it gives me additional pain. 2 = Pain is bad but I m able to manage trips over two hours. 3 = Pain restricts me to trips on less than one hour. 4 = Pain restricts me to short necessary trips of under 30 minutes. 5 = Pain prevents me from travelling except to receive treatment. If a patient selects more than one response to a question, submit the highest (worst) 0

20 AH 12WeekODI Date Enter the most recent date corresponding to an ODI v2.1a administration on or prior to 12 weeks after the treatment start date. Leave BLANK if a follow up ODI v2.1a was not administered on or prior to 12 weeks after the treatment start date. Date (mm/dd/yyyy) 11/12/2013 AI 12 Weeks - ODI Pain Enter the value of the patient s selection for ODI Section 1- Pain intensity. 0 = I have no pain at the moment. 1 = The pain is very mild at the moment. 2 = The pain is moderate at the moment. 3 = The pain is fairly severe at the moment. 4 = The pain is very severe at the moment. 5 = The pain is the worst imaginable at the moment. 2 AJ 12 Weeks - ODI Care Enter the value of the patient s selection for ODI Section 2- Personal Care (washing, dressing, etc.). 0 = I can look after myself normally without causing additional pain. 1 = I can look after myself normally but it is very painful. 2 = It is painful to look after myself and I am slow and careful. 3 = I need some help but manage most of my personal care. 4 = I need help every day in most aspects of my personal care. 5 = I do not get dressed, I wash with difficulty and stay in bed. 1

21 AK 12 Weeks - ODI Lifting Enter the value that corresponds with the patient s selection for ODI Section 3- Lifting. 0 = I can lift heavy weights without additional pain. 1 = I can lift heavy weights but it give me additional pain. 2 = Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, e.g. on a table. 3 = Pain prevents me from lifting heavy weights, but I can manage light to medium weights if off they are conveniently positioned. 4 = I can lift only very light weights. 5 = I cannot lift ot carry anything at all. 4 AL 12 Weeks - ODI Walking Enter the value that corresponds with the patient s selection for ODI Section 4- Walking. 0 = Pain does not prevent me from walking any distance. 1 = Pain prevents me from walking more than one mile. 2 = Pain prevents me from walking more than a quarter of a mile. 3 = Pain prevents me from walking more than 100 yards. 4 = I can only walk using a cane or crutches. 5 = I am in bed most of the time and have to crawl to the toilet. 2

22 AM 12 Weeks - ODI Sitting Enter the value that corresponds with the patient s selection for ODI Section 5- Sitting. 0 = I can sit in any chair as long as I like. 1 = I can sit in my favorite chair as long as I like. 2 = Pain prevents me from sitting more than one hour. 3 = Pain prevents me from sitting more than half an hour. 4 = Pain prevents me from sitting more than 10 minutes. 5 = Pain prevents me from sitting at all. 1 AN 12 Weeks - ODI Standing Enter the value that corresponds with the patient s selection for ODI Section 6- Standing. 0 = I can stand as long as I want without additional pain. 1 = I can stand as long as I want but it gives me additional pain. 2 = Pain prevents me from standing more than one hour. 3 = Pain prevents me from standing more than half an hour. 4 = Pain prevents me from standing more than 10 minutes. 5 = Pain prevents me from standing at all. 3

23 AO 12 Weeks - ODI Sleeping Enter the value that corresponds with the patient s selection for ODI Section 7- Sleeping. 0 = My sleep is never interrupted by pain. 1 = My sleep is occassionally interrupted by pain. 2 = Because of pain I have less than 6 hours of sleep. 3 = Because of pain I have less than 4 hours of sleep. 4 = Because of pain I have less than 2 hours of sleep. 5 = Pain prevents me from sleeping at all. 1 AP 12 Weeks - ODI Sex, if applicable Enter the value that corresponds with the patient s selection for ODI Section 8- Sex life. 0 = My sex life is normal and causes no additional pain. 1 = My sex life is normal but causes some additional pain. 2 = My sex life is nearly normal but is very painful. 3 = My sex life is severly restricted by pain. 4 = My sex life is nearly nonexistant because of pain. 5 = Pain prevents me from having any sex life at all. 2

24 AQ AR 12 Weeks - ODI Social 12 Weeks - ODI Travelling Enter the value that corresponds with the patient s selection for ODI Section 9- Social Life. 0 = My social life is normal and causes no additional pain. 1 = My social life is normal but increases the degree of pain. 2 = Pain has no significant effect on my social life apart from limiting my more energetic interests. 3 = Pain has restricted my social life and I do not go out as often. 4 = Pain has restricted my social life to home. 5 = I have no social life becasue of pain. Enter the value that corresponds with the patient s selection for ODI Section 10- Travelling. 0 = I can travel anywhere without pain. 1 = I can travel anywhere but it gives me additional pain. 2 = Pain is bad but I m able to manage trips over two hours. 3 = Pain restricts me to trips on less than one hour. 4 = Pain restricts me to short necessary trips of under 30 minutes. 5 = Pain prevents me from travelling except to receive treatment. 0 0

25 Appendix A: Functional Status (Oswestry Disability Index, v2.1a) Ideally tools are completed by the patient at the time of treatment; however office visits are not required for tool completion. Any provider or office staff may administer the initial and follow-up instruments. Modes of acceptable administration Administration Mode In person/during visit Acceptable Via mail Acceptable Via telephone Not Acceptable* Administer electronically ** Acceptable *Instrument has not been validated for telephone administration. **When administering electronically, the tools must be kept intact including content, order and scoring. Electronic examples: , patient portal, ipad/tablet, patient kiosk. Other Activities Store results in EMR Must seek approval for other uses (examples: Research, publication, use of tool beyond measure population, etc.) Acceptable Yes Regardless of the successful administration of the ODI, all patients who meet the initial patient population criteria after upfront exclusions must be included in the data submission file. For example: A patient who has no initial or follow up functional status score must still be included in the data submission file. A patient who has either an initial or a follow up functional status score must still be included in the data submission file. A patient who has initial and follow up functional status scores must be included in the data submission file. The MNCM Data Portal will calculate process measures based on the submission to determine the rate of administration of the instruments at treatment start date and in follow up.

26 Oswestry Disability Index (ODI) version 2.1a This is a patient completed survey consisting of 10 structured questions asking the patient to describe the impact of their low back pain and function in the following areas: pain, personal care, lifting, walking, sitting, standing, sleeping, sex life (if applicable), social life, and ability to travel. More information can be found at The MNCM Data Portal will evaluate all incoming responses, if eight of the ten questions are completed by the patient, the assessment tool can be used and the MNCM Data Portal will calculate a score. The MNCM Data Portal will score appropriately, recalculating the denominator as recommended by the developer, Jeremy Fairbank. If an ODI was administered and any answers were skipped, leave the correlated fields blank in the data file. Do not replace a blank response with a zero as this is a valid response in the instrument. If a patient selects more than one response to a question, submit the highest (worst) References ODI Jeremy Fairbank, All Rights Reserved. ODI - United States/English - Version of 29 Jul 11 - Mapi Institute. ID6287/ODI_AU2.1a_eng-US.doc Fairbank J, Pynsent PB. The Oswestry Disability Index. Spine 2000; 25(22): Baker DJ, Pynsent PB and Fairbank JCT (1989) The Oswestry Disability revisited. In Roland Jenner JR (eds) Back pain: New approaches to rehabilitation and education. Manchester University Press.pp Fairbank JCT, Couper J, Davies JB, O Brien JP. The Oswestry Low Back Pain Disability Questionnaire.Physiotherapy. 1980; 66: Permissions MNCM obtained permission to make the ODI version 2.1a available on the MNCM Data Portal for use by providers participating in MNCM reporting and improvement efforts. This tool is also available in the public domain and is free of charge for use in clinical practice. For research use, please refer to the MAPI Trust website for more information: The tool developer, Dr. Jeremy Fairbank, has stipulated as a part of the user agreement that for all new studies, version 2.1a of the ODI must be used.