This measure assesses the extent to which health care providers actually involve patients in a decision-making process when there is more than one reasonable option. This proposal is to focus on patients who have undergone any one of 7 common, important surgical procedures: total replacement of the knee or hip, lower back surgery for spinal stenosis of herniated disc, radical prostatectomy for prostate cancer, mastectomy for early stage breast cancer or percutaneous coronary intervention (PCI) for stable angina. Patients answer four questions (scored 0 to 4) about their interactions with providers about the decision to have the procedure, and the measure of the extent to which a provider or provider group is practicing shared decision making for a particular procedure is the average score from their responding patients who had the procedure.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis
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1.14 Numerator
Patient answers to four questions about whether not 4 essential elements of shared decision making (laying out options, discussing the reasons to have the intervention and not to have the intervention, and asking for patient input) were part of the interactions with providers when the decision was made to have the procedure.
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1.15 Denominator
All responding patients who have undergone one of the following 7 surgical procedures: back surgery for a herniated disc; back surgery for spinal stenosis; knee replacement for osteoarthritis of the knee; hip replacement for osteoarthritis of the hip; radical prostatectomy for prostate cancer; percutaneous coronary intervention (PCI) for stable angina, and mastectomy for early stage breast cancer.
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Exclusions
For back, hip, knee, and prostate surgery patients, there are no exclusions, so long as the surgery is for the designated condition.
PCI patients who had a heart attack within 4 weeks of the PCI procedure are excluded, as are those who have had previous coronary artery procedures (either PCI or CABG).
For patients who have mastectomy, patients who had had a prior lumpectomy for breast cancer in the same breast and patients who have not been diagnosed with breast cancer (who are having prophylactic mastectomies) are excluded.
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OLD 1.12 MAT output not attachedAttached
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Most Recent Endorsement ActivityPatient Experience and Function Fall 2022Initial EndorsementLast Updated
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StewardMassachusetts General HospitalSteward Organization POC Email
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Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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6.1.2 Current or Planned Use(s)
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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 #2962, the most recent measure specifications can be found here: https://p4qm.org/sites/default/files/2024-02/2962.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.