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Informed, Patient Centered (IPC) Hip and Knee Replacement Surgery

CBE ID
2958
Endorsed
New or Maintenance
Is Under Review
No
E&M Cycle Comments

Effective March 27, 2023, the National Quality Forum (NQF) is no longer the consensus-based entity (CBE) funded through the Centers for Medicare & Medicaid Services (CMS) National Consensus Development and Strategic Planning for Health Care Quality Measurement Contract. Battelle has been selected to oversee the endorsement & maintenance (E&M) of clinical quality and cost/resource use measures. Since the Fall 2022 cycle launched at NQF, measures submitted to this E&M cycle continued along the prior E&M protocols that were in place at time of the Fall 2022 “Intent to Submit.” Battelle took over the E&M work for the Fall 2022 cycle after developers and/or stewards submitted their full measure information to NQF, which for CBE #2958, the most recent measure specifications can be found here: https://p4qm.org/sites/default/files/2024-02/2958.zip

Battelle took over the E&M work beginning with the public comment period to close the E&M committees for the post-comment meeting, convening the CSAC to render a final endorsement decision, and executing the appeals period.

 

Measure Description

The measure is derived from patient responses to the Hip or Knee Decision Quality Instruments. Participants who have a passing knowledge score (60% or higher) and a clear preference for surgery are considered to have met the criteria for an informed, patient-centered decision.
The target population is adult patients who had a primary hip or knee replacement surgery for treatment of hip or knee osteoarthritis.

  • Electronic Clinical Quality Measure (eCQM)
    Level Of Analysis
    MAT output not attached
    Attached
    Numerator

    The numerator is the number of respondents who have an adequate knowledge score (60% or greater) and a clear preference for surgery.

    Denominator

    The denominator includes the number of respondents from the target population who have undergone primary knee or hip replacement surgery for treatment of knee or hip osteoarthritis.

    Exclusions

    Respondents who are missing 3 or more knowledge items do not get a total knowledge score and are excluded. Similarly, respondents who do not indicate a preferred treatment are excluded. No other exclusions as long as the respondent has the procedure for the designated condition.

    All information required to stratify the measure results
    Off
    All information required to stratify the measure results
    Off
  • Risk adjustment approach
    Off
    Risk adjustment approach
    Off
    Conceptual model for risk adjustment
    Off
    Conceptual model for risk adjustment
    Off
  • Most Recent Endorsement Activity
    Patient Experience and Function Fall 2022
    Initial Endorsement
    Next Planned Maintenance Review
    Fall 2027
    Endorsement Status
    Last Updated
  • Do you have a secondary measure developer point of contact?
    Off
    The measure developer is NOT the same as measure steward
    Off
    Steward Organization Email
    Steward Organization Copyright

    Copyright holder of the Hip and Knee Decision Quality Instruments used to generate the measure is Massachusetts General Hospital (MGH). MGH makes the survey available for use free of charge under the creative commons license agreement, with the provision it is not modified or sold.

  • Detailed Measure Specifications
    No
    Logic Model
    Off
    Impact and Gap
    No
    Feasibility assessment methodology and results
    No
    Address health equity
    No
    Measure’s use or intended use
    No
    508 Compliance
    Off
    If no, attest that all information will be provided in other fields in the submission.
    Off