MEASURING OUTCOMES IN ORTHOPEDICS ROUTINELY (MOOR) STUDY - CMS
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MEASURING OUTCOMES IN ORTHOPEDICS ROUTINELY (MOOR) STUDY Technical Expert Panel Summary Report Virtual Conference Microsoft Teams Meetings March 22 and March 24, 2021 Prepared by: Brigham and Women’s Hospital This material was prepared by BWH under funding from the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. Cooperative Agreement #: 2018A008621, 1V1CMS331637-01-00 The materials within this document do not represent final measure specifications for six measures being developed under the MOOR Study.
Table of Contents Executive Summary ....................................................................................................................................... 2 Background .................................................................................................................................................... 3 MOOR Study Mission ................................................................................................................................. 3 MOOR Study Goals .................................................................................................................................... 3 Measure Development Team .................................................................................................................... 4 TEP Objectives and Purpose ...................................................................................................................... 5 TEP Members ............................................................................................................................................. 5 Pre-work......................................................................................................................................................... 6 Detailed Summary of TEP Meetings (March 22nd and March 24th, 2021) ..................................................... 7 Summary of Key Points ................................................................................................................................11 Conclusion and Next Steps ..........................................................................................................................11 Appendices ..................................................................................................................................................12 Meeting Attendees & Agenda .................................................................................................................13 Attendees.................................................................................................................................................13 Agenda .....................................................................................................................................................13 Care Goal Achievement PowerPoint .......................................................................................................14 CMS Measure Development Plan Technical Expert Panel 1 March 22 and March 24, 2021, Meeting Summary
Executive Summary The Patient Reported Outcome Measures (PROMs) team met with technical expert panel (TEP) members in three separate meetings in March 2021 to update them on the measure specification feedback from the Public Comment period. Separate meetings were held due to scheduling, but the agenda was the same for each meeting. The PROMs team’s purpose was to review the comments from the Public Comment period with the TEP members and obtain their feedback on the proposed measure specification changes. The summaries of the 3 meetings are detailed, along with the overall key findings. This TEP report summarizes the feedback and recommendations received from the TEP members during the March 22nd and March 24th, 2021 virtual TEP meetings focused on the Patient Reported Outcome Performance Measure (PRO-PM). These are the second round of TEP meetings held in year 3 of this agreement for the PRO-PM. The previous TEP meetings to discuss the PRO-PM were held in years one and two, in April 2019, September 2019, January 2020, and October 2020 in year 3. The aim of these meetings was to give TEP members an update on the overall progress of the Care Goal Achievement (CGA) measure and to discuss the overall feedback gathered during the Public Comment period. Specifically, the PROMs team sought TEP input on the measure numerator statement, measure denominator statement, and the inclusion and exclusion criteria. One of the main aims of these meetings was for the TEP members to endorse the measure specification changes for use in the remaining phases of testing. Overall feedback from TEP members was very positive to the public commenter’s and other key stakeholder’s suggestions regarding the measure specification and the PROMs team response rationale. The TEP members continued to see value in the measure, provided excellent feedback, and were positive about the progress made to date. TEP members endorsed the measure specification changes for use in the remaining phases of testing. The PROMs team will utilize their feedback to include in the Public Comment Summary Report and to use in the remaining phase of testing. CMS Measure Development Plan Technical Expert Panel 2 March 22 and March 24, 2021, Meeting Summary
Background
MOOR Study Mission
The Centers for Medicare & Medicaid Services (CMS) has contracted with Brigham and Women’s Hospital
(BWH) to develop quality measures related to orthopedics. The project name is Measuring Outcomes in
Orthopedics Routinely (MOOR). The cooperative agreement number is 1V1CMS331637-01-00. Under this
project, The BWH Center for Patient Safety, Research, and Practice will collaborate with Partners
Orthopedic Surgery specialty physicians, Massachusetts Health Quality Partners, the Patient Reported
Outcomes Measurement System (PROMS) team, and a Technical Expert Panel (TEP) to:
• Develop a Patient Reported Outcome-Based Performance Measure (PRO-PM) related to
orthopedic surgery clinical care
• Develop and refine electronic clinical quality measures (eCQMs) in the areas of
orthopedic surgery outcomes and medication safety
BWH is obtaining expert and stakeholder input on the proposed measures. The BWH measure
development team includes experts in quality outcomes measurement. As is standard with all measure
development processes, BWH has convened a TEP of clinicians, patient advocates, and other
stakeholders. Collectively, the TEP members bring expertise in performance measurement, quality and
patient safety, and coding and informatics.
This report summarizes the feedback and recommendations received from the TEP during the March
22nd and March 24th, 2021 virtual TEP meetings focused on the PRO-PM. These are the second round
of TEP meetings held in year 3 of this agreement for the PRO-PM. The previous TEP meetings to discuss
the PRO-PM were held in years one and two, in April 2019, September 2019, January 2020, and October
2020 in year 3.
MOOR Study Goals
To ensure alignment with CMS’s Quality Payment Program (QPP), specifically the Merit-based
Incentive Payment System (MIPS), the goals of the MOOR project are as follows:
1) Develop a new PRO-PM:
a. Care goal achievement (CGA) following total hip arthroplasty (THA) or total knee
arthroplasty (TKA)
2) Convert one existing National Quality Foundation- (NQF-) approved measure for
complication following total hip arthroplasty and total knee arthroplasty (THA/TKA) to
an electronic clinical quality measure (eCQM):
a. Risk-standardized complication rate (RSCR) following elective primary total hip
arthroplasty (THA) and/or total knee arthroplasty (TKA)
3) Develop three new eCQMs to address THA/TKA orthopedic surgery patient safety
practice and measurement gaps:
a. Prolonged opioid prescribing (POP) rate following elective primary total hip
arthroplasty (THA) and/or total knee arthroplasty (TKA)
b. Inpatient respiratory depression (IRD) rate following elective primary total hip
arthroplasty (THA) and/or total knee arthroplasty (TKA)
CMS Measure Development Plan Technical Expert Panel 3
March 22 and March 24, 2021, Meeting Summaryc. Risk-standardized major bleeding and venous thromboembolism (VTE) rate
following elective primary total hip arthroplasty (THA) and/or total knee
arthroplasty (TKA)
In addition, we will explore the anticipated efficacy, costs, and benefits of our proposed PRO-PM and
eCQMs to our study population. In the process of developing and refining the PRO-PM and eCQMs, we
will use existing electronic data to automate workflow and to minimize burden of the measures we
develop.
Brigham and Women’s Hospital is collaborating with Massachusetts Health Quality Partners (MHQP), a
stakeholder engagement organization, and with Brigham and Women’s Hospital Department of
Orthopedic Surgery specialty physicians and the Partners Healthcare Patient Reported Outcomes
Measurement System (PROMS) team to develop a PRO-PM related to orthopedic surgery clinical care
and eCQMs in the areas of orthopedic surgery outcomes and medication safety. The collaboration is
enhanced by the mutual interests, shared by the participating organizations, that include focusing on
patient engagement to improve safety and outcomes using innovative patient-centered technologies.
Measure Development Team
BWH Team Key Personnel
• David Bates, MD, MSc: Principal Investigator
• Patricia Dykes, RN, PhD: Co-Investigator
• Ronen Rozenblum, PhD, MPH: Co-Investigator
• Alexandra Businger, MPH: Senior Project Manager
• Stuart Lipsitz, ScD, PhD: Senior Statistician
• Francois Bastardot, MD: Research Fellow
• Antonia Chen, MD, MBA: Ortho Co-Investigator
• Jeffrey Katz, MD, MS: Ortho Co-Investigator
• Richard Iorio, MD: Ortho Contributor
• Andrew Schoenfeld, MD, MSc: Ortho Contributor
• Todd O’Brien, MD: Ortho Contributor
• Christopher Melnic, MD: Ortho Contributor
• David Boardman, MD: Ortho Contributor
• David Halsey, MD: Ortho Contributor
• Rachel Clark, MD: PROMs Medical Director, PHS
BWH Team Personnel
• Stephanie Singleton, BA: PROMs Project Coordinator
• Tien Thai, BS: Software Engineer
• Brianna Ericson, MPH: PROMs Data Analyst
• Amanda Norton, MPH: PROMs Data Analyst
• Michael Sainlaire, MS: eCQM Data Analyst
• Mica Bowen, BS: Research Assistant
• Avery Pullman, BS: Research Assistant
• Tyler Oliver, BS: Research Assistant
CMS Measure Development Plan Technical Expert Panel 4
March 22 and March 24, 2021, Meeting SummaryMassachusetts Health Quality Partners (MHQP)
• Barbra Rabson, MPH: President and CEO
• Jim Courtemanche, MPH: Vice President of Programs and Analytics
• Nathalie McIntosh, PhD: Director of Programs
• Ola Szczerepa, MA: Project Manager
• Natalya Martins, BSc: Project Specialist
BWH MOOR Team Consultants
• Rosemary Kennedy, PhD
• Lisa Kern, MD
• Calvin Franz, PhD
• Kate Miller, PhD
TEP Objectives and Purpose
The objectives of the TEP meetings of the second quarter of year three of the cooperative agreement
were to gain TEP member input on measure specification, (i.e., brief measure description, numerator
statement, denominator statement, inclusion, and exclusion criteria), specifically comments from the
Public Comment period.
TEP Members
Table 1. TEP Member Names and Organizations
Potential Attendance on Attendance on
Name Organization Conflicts 3/22/21 3/24/21
of Interest Meeting Meeting
(4:00 p.m.) (3 p.m. and 5 p.m.)
Bonnie B. Blanchfield, CPA, Brigham and None Present Absent
SM ScD Women’s Hospital
Senior Scientist Harvard Medical
Assistant Professor in School
Medicine
Kevin Bozic, MD, MBA Dell Medical School None Absent Present (3p.m.)
Department Chair - Surgery
and Perioperative Care
Martha Carnie Brigham and None Present Absent
Senior Patient Engagement Women’s Hospital
Advisor
Co-Chair of BWH Patient
and Family Advisory Council
Steering Committee
CMS Measure Development Plan Technical Expert Panel 5
March 22 and March 24, 2021, Meeting SummaryAttendance on Attendance on
Potential 3/22/21 3/24/21
Name Organization Conflicts Meeting Meeting
of Interest (4:00 p.m.) (3 p.m. and 5 p.m.)
Aileen Davis, PhD Division of None Absent Present (3 p.m.)
Senior Scientist Healthcare and
Outcomes Research,
Toronto Krembil
Research Institute
*Lisa Hines, PharmD Pharmacy Quality None Absent Absent
Senior Director – Measure Alliance (PQA)
Operations and Analytics
William Jiranek, MD Department of None Absent Present (5 p.m.)
Professor and Vice Chair Orthopaedic
Surgery, Duke
University
Jay Lieberman, MD Department of None Absent Present (5 p.m.)
Chair and Professor Orthopaedic Surgery
– Keck School of
MOOR Study TEP Chair Medicine, University
of Southern
California
* Lisa Hines did not participate in these series of meetings, but the PROMs team will reach out to her to
review the same materials as the others reviewed and get her feedback.
Pre-work
TEP members were sent a PDF of the PowerPoint presentation prepared by the BWH MOOR
PROMs team prior to the meeting. The PowerPoint presentation included the agenda for the
meeting and details on the measure under development’s Public Comment measure specification
feedback. A copy of the PowerPoint presentation is available in the Appendix at the end of this
document.
CMS Measure Development Plan Technical Expert Panel 6
March 22 and March 24, 2021, Meeting SummaryDetailed Summary of TEP Meetings (March 22nd and March 24th, 2021)
The TEP Meetings focused on PRO-PM were held via Microsoft Teams on March 22nd, 2021 4 p.m., and
March 24th, 2021 3 p.m. and 5 p.m. The agenda was as follows:
I. Meetings 1-3: March 22nd – 4 p.m., March 24th – 3 p.m. and 5 p.m.
I. Welcome
II. Project Updates
• Overall Progress since the last TEP meeting in October 2020
III. Public Comment Period
• Goals
• Stakeholder Participation
IV. Public Comment Measure Specification Feedback
• Brief Measure Description
• Numerator Statement
• Denominator Statement
• Inclusion and Exclusion Criteria
V. Discussion
CMS Measure Development Plan Technical Expert Panel 7
March 22 and March 24, 2021, Meeting SummaryDates: March 22nd and March 24th
The TEP meeting/feedback summary listed below was presented to the attendees listed below.
Attendees:
TEP: Jay Lieberman, Bonnie Blanchfield, Kevin Bozic, Martie Carnie, Aileen Davis, William Jiranek
BWH MOOR PROMs: Ronen Rozenblum, Stephanie Singleton, Tyler Oliver, Amanda Norton
Absent: Charles Bragdon (retired), Lisa Hines
The PROMs team grouped the feedback of the 3 TEP meetings into the following areas that are in line
with the main topics covered in the agenda:
1. Project Updates
2. Public Comment Overview
3. Public Comment Measure Specification
• Project Updates
o Overview: The PROMs team provided the latest project updates to the TEP detailing a
high-level overview of testing results, updated project timeline dates, and the public
commenting period.
Current data collection number of paired data sets (PRO-PM)
Testing status and results of data to date
Explained the 75% threshold for the PRO-PM score that is to be submitted to
CMS/MIPS for reimbursement
Reliability and validity testing would be completed for hip and for knee
separately
The updated project timeline was reviewed to reflect data collection changes
per CMS
• MUC List Submission: 5/27/2021
• MUC List Submission – Updated Data: 7/30/2021
• NQF Letter of Intent: 8/3/2021
o Next Steps:
The PROMs team will continue measure testing as planned.
• Public Comment Overview
o Overview: The PROMs team reiterated to the TEP the purpose of the Public Comment
web posting which was to gather feedback on the proposed care goal achievement PRO-
PM in the following areas related to the Measure Specification:
Measure Description Overview
Measure Numerator Statement
Measure Denominator Statement
Inclusion and Exclusion Criteria
PROMs team described the characteristics of the commenters, highlighting the
good variety of stakeholders that responded to the Public Comment period.
o TEP Feedback
TEP members appreciated the constructive and positive comments received
from the public commenters.
CMS Measure Development Plan Technical Expert Panel 8
March 22 and March 24, 2021, Meeting SummaryThe TEP members agreed that the 10 commenters who responded to the online
questionnaire represented a good variety of key stakeholders, coming from the
following areas:
o Healthcare professionals (orthopedic surgeons)
o Healthcare policy/research
o Academic medical centers (PROMs leadership)
o Electronic health record (EHR) vendors
o Specialty societies/medical associations
o Measure developers
TEP members were pleased that all the commenters found value in the measure
under development that aims to assess care goal achievement before and after
THA or TKA.
o Note: For detailed information on all the Measure Specification items, please see the Power
Point presentation on page 14.
Measure Specification - Brief Measure Description Overview
o Overview: The PROMs team reviewed the original version of the brief measure
description with the TEP members, then reviewed the new version with the updates
that had been made based on feedback from public commenters and key stakeholders:
Specified one procedure versus the other by changing ‘and/or’ to ‘or’
Defined the PRO-PM threshold
Included data collection timeframes
o TEP Feedback: The TEP members reviewed the updates made to the brief measure
description and endorsed the updated version.
Measure Specification - Numerator Statement Overview
o Overview: The PROMs team reviewed the original version of the numerator
statement with the TEP members, then reviewed the new version with the updates
that had been made based on feedback from public commenters and key
stakeholders:
Specified one procedure versus the other by changing ‘and/or’ to ‘or’
Defined PRO-PM threshold
Included data collection timeframes
o TEP Feedback: The TEP members reviewed the updates made to the numerator
statement and endorsed the updated version.
TEP members approved a 75% threshold for reporting
One TEP member suggested shortening the numerator statement for the sake
of simplicity.
o Next Steps: The PROMs team will continue to test the measure and will adjust the
numerator statement if needed.
Measure Specification - Denominator Statement
o Overview: The PROMs team reviewed the original version of the denominator
statement with the TEP members, then reviewed the new version with the updates
CMS Measure Development Plan Technical Expert Panel 9
March 22 and March 24, 2021, Meeting Summarythat had been made based on feedback from public commenters and key
stakeholders:
Specified one procedure versus the other by changing ‘and/or’ to ‘or’.
Specified ‘pre-surgical’ and ‘post-surgical’ regarding the timeframes of
data collection.
The PROMs teams provided information on other relevant CMS
measures to denote alignment in key areas in measure specification.
o TEP Feedback: The TEP members reviewed the updates made to the denominator
statement and endorsed the updated version.
TEP members agreed the statement was clear, concise, and applicable to the
measure specification.
TEP members agreed the timeframes for the measure data collection support
the concept of care goal achievement and are appropriate for assessing the
patient’s main goals and expectations before THA or TKA surgery (i.e., pain,
physical function, and quality of life) and the degree to which the expectations
were met after surgery.
o Next Steps: The PROMs team will continue to test the measure and will adjust the
denominator statement if needed.
• Measure Specification – Exclusion Criteria
o Overview: The PROMs team reviewed the original version of the exclusion criteria with
the TEP members, then reviewed the new version with the updates that had been
made based on feedback from public commenters and key stakeholders.
o The PROMs team provided information on other relevant CMS measures to denote
alignment in key areas in measure specification.
o The PROMs team explained the rationale for the additions and exclusions to the
criteria list, having received feedback from the Public Comment period and from key
stakeholders, resulting in the following exclusion criteria:
Patients who underwent revision THA or TKA
Patients who underwent conversion THA or TKA
Patients with a fracture of the hip or knee at the time of the THA or TKA
Patients with tumors of the hip or knee at the time of the THA or TKA
o TEP Feedback: The TEP members reviewed the updates made to the exclusion criteria,
suggested some changes but overall endorsed the updated version.
TEP members endorsed the criteria regarding THA and TKA revisions and
conversions.
TEP members agreed to remove trauma-specific fractures since the new
fracture exclusion covers traumas.
While all TEP members endorsed excluding patients with tumors at the time of
the THA or TKA, there was a further discussion about tumor criteria being
further clarified by using ICD-10 codes to distinguish malignant versus non-
malignant tumors as well as bone versus soft-tissue tumors.
While most of the TEP members agreed with the public commenters who
suggested not to exclude hospice patients or patients with severe cognitive
CMS Measure Development Plan Technical Expert Panel 10
March 22 and March 24, 2021, Meeting Summaryimpairment, there was a further discussion about whether proxy responses
should be allowed if the patient is unable to complete the survey on their own.
It was determined that given the nature of the measure, using proxy responses
would not be appropriate.
o Next Steps: The PROMs team will reassess the denominator exclusion criteria based on
TEP input and will continue to test the measure exclusions.
Summary of Key Points
Key points from all three TEP meetings related to Measure Specification of the Care Goal Achievement
PRO-PM
• TEP members appreciated the update and were impressed with the progress made since
October 2020.
• TEP members appreciated the constructive and positive comments received from the public
commenters and key stakeholders.
• TEP members endorsed the measure specification changes presented and new changes
brought up in the meetings.
• TEP members endorsed the measure specification for use in the remaining phases of testing.
Conclusion and Next Steps
Based on TEP feedback, the PROMs team will incorporate the updated measure specification, and the
newly added exclusion criteria into their testing, both retrospectively and prospectively in accordance
with the current phase of measure development and testing. The project team will continue to assess
other CMS measures, those in development, and those who have received NQF-endorsement for
alignment and harmonization.
The project team will continue to engage the TEP members leading up to May 27, 2021 MUC List
submission as well as the NQF submission in August 2021.
CMS Measure Development Plan Technical Expert Panel 11
March 22 and March 24, 2021, Meeting SummaryAppendices
I. Meeting Agendas
o March 22 and March 24, 2021 Meeting Agenda
II. PowerPoint Presentation
CMS Measure Development Plan Technical Expert Panel 12
March 22 and March 24, 2021, Meeting SummaryMeeting Attendees & Agenda
TEP- MOOR PRO-PM Consultation Meeting
Attendees
Monday, March 22, 2021 - 2 p.m.
BWH PROMs Team TEP Members
Ronen Rozenblum, PhD Martie Carnie
Stephanie Singleton Bonnie Blanchfield, CPA, SM, ScD
Wednesday, March 24, 2021 - 3 p.m.
BWH PROMs Team TEP Members
Ronen Rozenblum, PhD, MPH Kevin Bozic, MD, MBA
Stephanie Singleton Aileen Davis, PhD
Tyler Oliver, BS
Amanda Norton, MPH
Wednesday, March 24, 2021 - 5 p.m.
BWH PROMs Team TEP Members
Ronen Rozenblum, PhD, MPH Jay Lieberman, MD
Stephanie Singleton William Jiranek, MD
Tyler Oliver, BS
Amanda Norton, MPH
Agenda
I. Welcome
II. Project Updates
• Overall Progress since the last TEP meeting in October 2020
III. Public Comment Overview
• Goals
• Stakeholder
• Overall Responses
IV. Public Comment Measure Specification Feedback
• Brief Measure Description
• Numerator Statement
• Denominator Statement
• Inclusion and Exclusion Criteria
V. Discussion
CMS Measure Development Plan Technical Expert Panel 13
March 22 and March 24, 2021, Meeting SummaryCare Goal Achievement PowerPoint
Care Goal Achievement
PRO-PM Development
TEP Meetings
March 22 & 24, 2021
• Project Brief Update
• Public Comment – Goals & Stakeholders
• Public Comment – Overall Responses
• Measure Specification
- Brief Measure Description
- Numerator Statement
- Denominator Statement
- Inclusion and Exclusion Criteria
• Discussion
CMS Measure Development Plan Technical Expert Panel 14
March 22 and March 24, 2021, Meeting Summary• In December 2020, we submitted our Public Comment Web Posting.
• We sought feedback for the proposed care goal achievement PRO-PM in
the following areas related to the Measure Specification:
- Measure Numerator Statement
- Measure Denominator Statement
- Inclusion and Exclusion Criteria
CMS Measure Development Plan Technical Expert Panel 15
March 22 and March 24, 2021, Meeting Summary• 10 commenters responded via an online questionnaire.
• Response to our public comment web posting included key
stakeholders representing the following areas:
- Healthcare professionals (orthopedic surgeons)
- Healthcare policy/research
- Academic medical centers (PROMs leadership)
- Electronic health record (EHR) vendors
- Specialty societies/medical associations
- Measure developers
• All 10 of the commenters selected they found value in our proposed
measure that aims to assess care goal achievement before and after
THA and/or TKA.
• One Commenter stated that “Using PROMs before and after surgery to
measure expectations vs perceived outcomes is a good approach for
assessing goal achievement.”
• One Commenter noted that “Capturing and evaluating patient's
expectations before and after procedures are important to improve
patient's care quality.”
CMS Measure Development Plan Technical Expert Panel 16
March 22 and March 24, 2021, Meeting SummaryOriginal Version
The percentage of adult patients 18 years and older who had an elective primary total hip arthroplasty (THA) and/or total knee
arthroplasty (TKA) during the performance period AND who completed both a pre- and post-surgical care goal achievement survey that
generated a care goal achievement score of “x” or higher. “x” = to be determined following the quantitative and qualitative testing
data/information and analysis.
The measure is derived from patient responses to a new instrument that will be developed related to care goal achievement following
THA and/or TKA. The new surveys will assess the patient’s main goals and expectations before surgery (i.e., pain, physical function and
quality of life) and the degree to which the expectations were addressed after surgery.
New Version
The percentage of adult patients 18 years and older who had an elective primary total hip arthroplasty (THA) or total knee arthroplasty
(TKA) during the performance period AND who completed both a pre- and post-surgical care goal achievement (CGA) survey and
demonstrated that 75% or more of the patient’s expectations from surgery were met or exceeded.
The new surveys will assess the patient’s main goals and expectations (i.e., pain, physical function and quality of life) before surgery and
the degree to which the expectations were met after surgery.
The pre-surgical data collection timeframe will be 0 to 90 days before surgery and the post-surgical data collection timeframe will be 90 to
180 days after surgery.
Updates – Based on feedback from public commenters and key stakeholders
• Specified one procedure versus the other by changing ‘and/or’ to ‘or’
• Defined PRO-PM threshold
• Included data collection timeframes
Original Version
Total number of patients in the denominator who completed both a pre- and post-surgical care goal achievement survey that generated a
care goal achievement score of “x” or higher. “x” = to be determined following quantitative and qualitative testing data and analysis.
New Version
Total number of patients in the denominator who completed both a pre- and post-surgical care goal achievement (CGA) survey who
demonstrated that 75% or more of the patient’s expectations from surgery were met or exceeded.
• The CGA surveys were developed and defined based on qualitative interviews and focus groups with patients, health care
providers and policy makers, and quantitative testing data and analysis.
• The PRO-PM score [proportion of expectations met or exceeded] and threshold (i.e., 75% or more) was developed based on
qualitative interviews with key stakeholders and quantitative testing data and analysis. A higher score indicates greater care goal
achievement.
• The CGA surveys, PRO-PM score and threshold were vetted by our Technical Expert Panel (TEP), Steering Committee and measure
developers.
Updates – Based on feedback from public commenters and key stakeholders
• Specified one procedure versus the other by changing ‘and/or’ to ‘or’
• Defined PRO-PM threshold
• Included data collection timeframes
CMS Measure Development Plan Technical Expert Panel 17
March 22 and March 24, 2021, Meeting SummaryOriginal Version
Adult patients age 18 and older who undergo an elective, primary THA and/or TKA during the performance period AND who have a
completed care goal achievement survey within 90 days prior to the date of surgery AND between 90-180 days after surgery.
New Version
Adult patients age 18 and older who undergo an elective, primary THA or TKA during the performance period AND who have completed a
pre-surgical care goal achievement (CGA) survey 0 to 90 days before surgery AND a post-surgical CGA survey within 90-180 days after
surgery.
Updates – Based on feedback from public commenters and key stakeholders
• Specified one procedure versus the other by changing ‘and/or’ to ‘or’
• Specified ‘pre-surgical’ and ‘post-surgical’ with regard to the timeframes of data collection
Original Version
• Patients who had a revision THA and/or TKA
• Patients with a fracture of the hip or lower limb indicating trauma at time of the THA or TKA
• Patients with severe cognitive impairment that overlaps the data measurement collection period or THA and/or TKA procedure
• Patients who are/were in hospice care during the measurement period
New Version
• Patients who underwent revision THA or TKA
• Patients who underwent conversion THA or TKA
• Patients with a fracture of the hip or knee at the time of the THA or TKA
• Patients with tumors of the hip or knee at the time of the THA or TKA
Updates – Based on feedback from public commenters and key stakeholders
• Specified one procedure versus the other by changing ‘and/or’ to ‘or’
• Specified knee instead of lower limb for patients with fractures at the time of the THA or TKA
• Included patients who underwent conversion THA or TKA to the exclusion criteria
• Included patients with tumors of hip and knee at the time of the THA or TKA to the exclusion criteria
• Removed patients with trauma-specific fractures from exclusion criteria
• Removed patients who are/were in hospice care during the measurement period from exclusion criteria
• Removed patients with severe cognitive impairment that overlaps the data measurement collection period or THA or TKA procedure from
exclusion criteria
CMS Measure Development Plan Technical Expert Panel 18
March 22 and March 24, 2021, Meeting SummaryCMS Measure Development Plan Technical Expert Panel 19 March 22 and March 24, 2021, Meeting Summary
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