The measure focuses on resources used to deliver episodes of care for patients with pneumonia. Pneumonia episodes are 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 pneumonia. A number of resource use measures are defined for pneumonia 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 pneumonia episodes and will cover both measures at the pneumonia base and severity level and also a pneumonia composite measure where pneumonia episode results are combined across pneumonia severity levels. At the most detailed level, the measure is defined as the base condition of pneumonia and an assigned level of severity (e.g., resources per episode for pneumonia, 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 pneumonia is derived by combining pneumonia episode results across pneumonia severity levels. Appropriate risk adjustment is applied to support comparisons (e.g., for physician measurement, adjusting for a physician’s mix of pneumonia episodes by severity level when supporting a pneumonia composite comparison).
The focus of this measure is on pneumonia. However, pneumonia episode results could also be included in a “pulmonary” or other clinical composite for a physician, combining episodes in clinical areas similar to pneumonia. Further, an “overall” composite for a physician can be created, again by aggregating episode results across appropriate conditions and severity levels and applying proper risk adjustment when making comparisons.
- Measure TypeElectronic Clinical Quality Measure (eCQM)Level Of AnalysisCare SettingTesting Data Sources
- Measure StructureResource Use Measure TypeClinical Condition Topic AreaNon Condition SpecificBrief Description Of Measure Clinical Logic
This measure identifies patients with pneumonia and creates pneumonia episodes of care using the ETG methodology described in the ETG Construction Logic attached in our response to S.2. Each episode of pneumonia is characterized by an ETG Base class ID that specifies the type of condition; the ETG Base class ID representing pneumonia is 437400.
An episode of pneumonia will contain all clinically relevant information related to the condition. In addition to this information, certain diagnoses are considered co-morbidities or condition status factors for pneumonia. For example, for pneumonia, Streptococcal pneumonia is a condition status factor and Septicemia is a comorbidity.
Each episode is assigned a severity level based on age, gender and the observed comorbidity and condition status factors. The severity level is an indicator of the relative resources expected to be required for the given episode of pneumonia.
The pneumonia episode clinical framework is defined by the services, or claim lines, that can begin an episode, the primary and incidental diagnosis relationships involved, how records group to an episode, including relative strength of relationship, and the severity logic employed.Target PopulationNational Quality Strategy PrioritiesAffordable Care
- Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Cost and Resource Use Endorsement Maintenance ProjectInitial EndorsementEndorsement StatusLast UpdatedRemoval Date
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