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LBP: Post-surgical Outcomes

CBE ID
0311
1.4 Project
National Voluntary Consensus Standards for Ambulatory Care- Part 1 (Phase 3 Cycle 1)
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
Previous Endorsement Cycle
Full Year 2010
Is Under Review
No
1.3 Measure Description

Percentage of post-surgical outcomes examined by a physician's system that includes the following. •Tracking specific complications of back surgery; •Periodic analysis of surgical complications data and a plan for improving outcomes. Note: This standard is assessed as a process that applies to all patients. Evaluation is not based on documentation in individual medical records. This standard is applicable only for physicians who perform surgery.

    • 1.14 Numerator

      ELEMENT A: TRACKS BACK SURGERY COMPLICATIONS
      Several studies have reported an increase in back surgery rates in the U.S. despite the high rate of complications associated with these surgeries. Rates of post-operative complications following procedures on the lumbar spine are significant; are associated with higher total hospital charges; and are an indication of quality problems
      This requirement applies to physician applicants who perform back surgeries. Back surgery-related complications within 6–12 weeks of surgery may include, but are not limited to, the following.
      – Infection
      – Wound dehiscence
      – Hematoma
      – CSF leak
      – Other
      The 6–12-week period should start the day the patient undergoes the surgical procedure.

      ELEMENT B: ANALYZE SURGICAL OUTCOME DATA
      The physician must demonstrate that there is a process for periodically:
      – analyzing the surgical outcomes data to reduce the number and severity of surgical complications
      – improving surgical outcomes, based on the analysis.
      The requirement applies to physicians who perform back surgeries and should include all patients having back surgery.

    • 1.15 Denominator

      ELEMENT A: TRACKS BACK SURGERY COMPLICATIONS
      Documentation requirements:
      To meet the requirements for this standard, the physician must submit a copy of the tracking tool used to identify the complications of back surgery.

      The physician tracks the following.
      Yes No
      1. Wound infection ? ?
      2. Wound dehiscence ? ?
      3. Hematoma ? ?
      4. CSF leak ? ?
      5. Other ? ?







      ELEMENT B: ANALYZE SURGICAL OUTCOME DATA
      Documentation Requirements:
      To meet the requirements for this standard, the physician must submit a copy of the data analysis and the plan for improving outcomes.
      Scoring:

      Yes No
      1. The physician analyzes surgical outcomes data ? ?
      2. The physician has a plan for improving surgical
      Outcome ? ?

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed National Voluntary Consensus Standards for Ambulatory Care- Part 1 (Phase 3 Cycle 1)
      Initial Endorsement
      Last Updated
      Removal Date
    • Steward
      National Committee for Quality Assurance
      Steward Organization POC Email
      [email protected]