ETG Based HIP/KNEE REPLACEMENT cost of care measure

The measure focuses on resources used to deliver episodes of care for patients who have undergone a Hip/Knee Replacement. Hip Replacement and Knee Replacement episodes are initially defined using the Episode Treatment Groups (ETG) methodology and describe the unique presence of the condition for a patient and the services involved in diagnosing, managing and treating the condition. The Procedure Episode Group (PEG) methodology uses the ETG results and further logic to creating a procedure episode that focuses on the Hip Replacement and Knee Replacement component of the care. Procedure episodes identify a unique procedure event as well as the related services performed before and after the procedure including workup and therapy prior to the procedure as well as post-op activities such as repeated surgery and patient follow-up. Together, the ETG and PEG methodologies identify the services involved in diagnosing, managing and treating patients with Hip/Knee Replacements. A methodology to assign a severity level to each episode is employed to group Hip and Knee Replacement episodes by level of risk.

A number of resource use measures are defined for Hip/Knee Replacement episodes, including overall cost of care, cost of care by type of service, and the utilization of specific types of services. Each resource use measure is expressed as a cost or a utilization count per episode and comparisons with internal and external benchmarks are made using risk adjustment to support valid comparisons.
As requested by NQF, the focus of this submission is for Hip/Knee Replacement procedure episodes and will cover both measures at the Hip Replacement and Knee Replacement PEGs and severity level and also a Hip/Knee Replacement composite measure where Hip and/or Knee Replacement procedure episode results are combined across severity levels. At the most detailed level, the measure is defined as a Hip Replcement or Knee Replacement episode and an assigned level of severity (e.g., resources per episode for Knee Replacement, severity level 1 episodes). Composite measures can then be created using these measurement units to meet a specific need. For example, a composite measure for Hip/Knee Replacement is derived by combining episode results across Hip and Knee Replacements and severity levels. Appropriate risk adjustment is applied to support comparisons (e.g., for physician measurement, adjusting for a physician’s mix of Hip and Knee Replacement episodes by severity level when supporting a composite comparison).