September 12, 2011 Janet M. Corrigan, PhD, MBA President and Chief Executive Officer National Quality Forum 601 13th Street, NW Suite 500 North Washington, D.C. 20005 Re: Measure Applications Partnership Report Coordination Strategy for Healthcare-Acquired Conditions and Readmissions Across Public and Private Payers Dear Dr. Corrigan: The American Association of Orthopaedic Surgeons (AAOS) appreciates the opportunity to comment on the report entitled, Coordination Strategy for Healthcare-Acquired Conditions and Readmissions Across Public and Private Payers submitted by the Measure Applications Partnership (MAP). The AAOS represents approximately 18,000 board-certified orthopaedic surgeons and has been a committed partner to the National Quality Forum (NQF) in patient safety and quality health care. We look forward to providing input on the MAP recommendations for coordinating strategies to reduce healthcare-acquired conditions (HACs) and readmissions. General Comments The AAOS commends MAP on the immense effort of formulating the proposed
recommendations and drafting the report, which provides a coordination strategy on alignment of performance measurement and other approaches for addressing HACs and readmissions across public and private payers. The AAOS supports quality measures that are actionable and help align and coordinate care in all settings by all providers. We support the measurement and reduction of complications and readmissions. We have concerns, however, with the ability of an overall performance rate on a measure or set of measures to inform a hospital/provider of its specific needs for quality and patient safety improvement. Core Set of Safety Measures The first recommendation urges development and maintenance of a national core set of safety measures that are applicable to all patients. The AAOS agrees that measurement information should be evidence-based and clinically relevant to providers to support quality improvement. The AAOS believes aligning quality reporting measures across all settings of care is a complicated task, and the AAOS asks that NQF/MAP take a cautious approach and start by focusing on the HACs and readmissions that can be adequately measured, have evidence-based guidelines and are able to be accurately risk-adjusted. The recommendation states that the core measures should be consistent across the care continuum promoting shared accountability among providers across settings. The AAOS agrees that creating a healthcare system that supports shared accountability is essential to improving patient outcomes and reducing HACs and readmissions. The AAOS would like to highlight that there is shared accountability in delivering preventive services and in a patient s treatment and diagnosis. Typically, a team of providers care for the patient. In our fragmented system, however, a shared team approach to healthcare is not well established. We would encourage caution in developing policy that may hurt the team approach to care through inequitable attribution. Accurate attribution should be an element of performance assessment and quality improvement initiatives. This recommendation suggests that public reporting of performance on the core measure set should include understandable information and be disseminated broadly. The AAOS urges that safety information be made available to purchasers and consumers only after the providers have had an opportunity to review reports related to their performance and have had an opportunity to correct any misinformation or incorrect information in the report. NQF/MAP must take into consideration the negative impact that an unfavorable report could have on providers, and every effort must be made to provide accurate, verified reports.
Data Elements Collection The second recommendation states that data elements needed to calculate the measures in the safety core set should be collected on all patients. The AAOS agrees that developing a national safety data strategy within the context of a broader national data strategy is essential for coordination of safety measurement and improvement efforts. The AAOS, however, is concerned about the overall quality of data collection. Differences in data collection mechanisms and processes introduce variation in results unrelated to actual performance. In addition, the AAOS encourages NQF/MAP to be cognizant of the fact that administrative claims may not give the information that is needed to fully and accurately assess providers performance or properly characterize readmissions. Considerations in the selection of measures for a quality reporting program must be applied with an appreciation for factors that distinguish each provider or facility from others. In order to promote broad participation in the quality reporting system, this diversity, which has important implications for the development of data completeness standards, must be considered in the selection of the measure set. The AAOS supports harmonization of the reporting processes for current databases maintained by federal agencies, including those of the Agency for Healthcare Research and Quality s Healthcare Cost and Utilization Project, the Centers for Disease Control and Prevention s National Healthcare Safety Network, CMS s Hospital Compare, and the U.S. Food and Drug Administration s Sentinel Initiative. The AAOS, however, questions whether a goal of 100 percent reporting is realistic, or even feasible, given the nascency of electronic health record technology. Another key component of the data platform is that it would enable collection of patient-reported information, which can be particularly important for reducing readmissions, by understanding problems that arise during care transitions. The AAOS suggests that patient-reported information could also require patients to document their compliance with discharge plans/instructions. Public-Private Sector Coordination The AAOS shares NQF s goal of promoting high quality, safe and effective care. The AAOS generally supports the MAP s third recommendation, which supports coordination of public-and private-sector entities in efforts to make care safer, and urges development and implementation of standardized discharge plan elements incorporating best practices for care transitions. The AAOS, however, cautions NQF/MAP to proceed slowly in developing coordinated incentive
structures designed to prevent adverse safety events. The AAOS is concerned about programs that may penalize providers who are not actually responsible for the safety event. Applying a healthcare-associated condition policy requires analysis and discretion, as well as accurate attribution. The AAOS urges that only events or conditions that are immediately or irrefutably attributable to the service being provided lead to penalties or other reduction or elimination of payment/reimbursement. This third recommendation advocates providing resources to patients to help ensure patients fully understand the role they should play in maintaining their health and determining their healthcare needs. The report espouses a delivery system with better and more information for consumer decision making and heightened accountability for clinicians and providers. The AAOS believes the report falls short on acknowledging the critical role patients play in determining their own healthcare outcomes. Successful surgical outcomes, particularly those in the outpatient and ambulatory settings, are heavily reliant on patient responsibility and accountability. Patients are not merely consumers making decisions about healthcare purchases. They must be seen as sharing the responsibility for their own outcomes. The AAOS believes that providers and purchasers in collaboration with medical communities can take actions to improve health care delivery and reduce readmissions by ensuring that patients are clinically ready at discharge, reducing the risk of infection, reconciling medications, and improving communications among providers involved in transition of care. The AAOS recognizes, however, that there are many factors beyond the providers /hospitals control that may impact rates of readmission, including the patient s own behavior. We are committed to patient-centered care, yet we are concerned that our current health care system has a minimal culture of patient accountability. Before proceeding with implementation of readmissions measures, NQF should consider the necessary resources, structure, and cultural changes necessary to reasonably implement a meaningful policy. Hospital-Acquired Conditions The AAOS is very supportive of NQF s efforts to encourage the adoption of evidence-based treatment guidelines which could improve the quality of care for our patients. However, we are concerned with the presumption that all of the HACs cited in the report could be reasonably prevented through the use of evidence-based guidelines. The AAOS believes there is an important distinction between reduction and preventability. While evidence-based
guidelines can reduce incidence, they cannot completely eliminate the risk of certain hospital-acquired adverse events. To be reasonably preventable a HAC should have solid evidence published in peer-reviewed literature that by following certain guidelines the occurrence of an event can be reduced to zero or near zero among a typically broad and diverse patient population including high-risk patients. The MAP and the Partnership for Patients initiative focus on nine HACs, including surgical site infections and venous thromboembolism. Surgical Site Infections The AAOS agrees that surgical site infection is a serious patient safety concern. Infection, however, is a multidimensional condition with many contributing factors. Patients have varying degrees of susceptibility to infection. Prior open surgical procedures, immunosuppressive therapy, poor nutrition, hypokalemia, diabetes mellitus, obesity, current or historical nicotine use, prior incidence of infection, corticosteroid use, extremes of age, rheumatoid arthritis, and prolonged perioperative hospitalizations are some of the factors that increase the risk of surgical site infection in orthopaedic procedures. An all-or-nothing policy can punish providers even if they follow evidence-based guidelines. Moreover, appropriate guidelines do not exist for surgical site infection. Generic guidelines that cannot possibly take into account differences in procedure type and length are not suitable. For example, it would be devastating if we applied one guideline to the treatment of all cancers, each type requires different mechanisms of treatment. Even when following the best evidence-based medicine, including administration of appropriately selected pre-operative antibiotics and discontinuation of antibiotics within 24 hours post-operatively, certain patients who undergo orthopaedic procedures will still develop a surgical site infection. Risk factors for surgical site infections after skeletal trauma are most strongly determined by nonmodifiable factors such as patient co-morbidities and injury complexity. Therefore, it is important to recognize this level of unavoidability and apply a method of risk adjustment that can adequately encompass the relevant risk factors. We believe that without risk adjustment the system creates a disincentive to treat patients with the co-morbidities listed above. We would strongly recommend that prevalence measures include a risk adjustment component. It would be inequitable to compare facilities such as large academic centers that often see the sickest and most vulnerable patients. Policy should not create an incentive for any provider to deselect sicker patients.
Venous Thromboembolism The AAOS suggests that NQF take a cautious, measured approach toward development of venous thromboembolism measures. Even with best practice recommendations from the AAOS or the American College of Clinical Pharmacy (ACCP), the incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) following total knee and hip replacement can at best be reduced but not eliminated. Often the trade-off for lower rates of DVT/PE is more wound complications including surgical site infections. Moreover, there is also recent evidence that some PEs diagnosed in hospitalized patients may prove to be clinically insignificant. Yet treatment of any PE is not without risk. For example, anticoagulation, the current standard of care for all pulmonary emboli, can result in bleeding, and inferior vena cava filters can cause substantial bleeding, and even result in subsequent DVT. Finally, certain patient risk factors, including obesity, history of venous thromboembolism, and cancer, are known to be associated with a higher risk of VTE. Patients with these conditions are at increased risk for VTE even after receiving appropriate, evidence-based, guideline-recommended prophylaxis. Defining VTE as a reasonably preventable HAC would make surgeons and hospitals less likely to offer potentially beneficial, life-altering procedures to patients with these risk factors. The AAOS believes that applying a healthcare-associated condition policy requires analysis and discretion. We urge NQF/MAP to be cautious when selecting specific healthcare-associated conditions. Our current care and payment system is far too disjointed to tackle the concept of attribution with accuracy. Therefore we would encourage NQF/MAP to choose conditions that are immediately or irrefutably attributable to the service being provided. Risk-Adjustment The AAOS supports movement toward developing clinically relevant quality measures which recognize the importance of measuring both process and outcome. We cannot stress enough the importance of risk adjustment when outcome measures are publicly reported and/or used in future value-based purchasing programs. Both of these quality tools rely on accurate, valid, and reliable data to inform stakeholders and improve quality. Without risk adjustment, comparisons are not equitable. Risk adjustment facilitates equitable comparison among providers by accounting for patient s co-morbidities and co-conditions that increase their risk for complications and further treatment. Risk adjustment will significantly vary for acute and chronic conditions and among the individual conditions or procedures. The AAOS, however, urges NQF/MAP to proceed
cautiously to ensure accuracy and reliability of the methodologies as well as the quality of data. The AAOS recommends that NQF/MAP capture as many co-morbidities as possible in its risk-adjustment methodologies. Each condition and/or procedure has different associated co-morbidities, co-conditions, and complications. Chronic conditions have associated acute episodes that may be unavoidable and other associated acute episodes that are avoidable. In addition, chronic conditions will have acute episodes that are unrelated to that condition. Accordingly, postacute care and readmissions will vary in their necessity and preventability based on each specific condition and/or procedure and each patient s severity, comorbidities, and treatment plans. The AAOS believes that risk adjustment must adequately account for a patient s unique risk factors. Moreover, the AAOS advocates that high-risk and co-morbid patients not be placed at a disadvantage for access to high quality, effective healthcare. We are concerned that hospitals will incentivize physicians to deselect patients based on their risk factors or co-morbidities. If patient deselecting occurs, tertiary centers will be further inundated with the most complex, high-risk patients. The AAOS urges NQF/MAP to further develop a means for risk adjusting for the wide range variation in patient characteristics prior to fully implementing the policy. The AAOS believes that risk adjustment is necessary to differentiate and account for patient demographics, co-morbidities, severity of illness, and procedure. NQF/MAP should take into account the condition-specific or procedure-specific risk, and though potentially more difficult, should account for the patient-specific risk factors that affect preventability. Conclusion The AAOS appreciates this opportunity to provide input on the report submitted by MAP addressing coordination strategies for HACs and readmissions, and we invite NQF to call on us as a partner and expert in performance and quality
measurement in musculoskeletal care. Please contact William R. Martin, III, MD, at (202) 546-4430 or martin@aaos.org with any questions on the AAOS comments. Sincerely, Daniel J. Berry, MD President American Association of Orthopaedic Surgeons