PRMR MUC List

To the Centers for Medicare & Medicaid Services (CMS): 

I support the adoption of the American Society of Hematology’s (ASH) new quality measure titled “Median Time to Pain Medication for Patients with Sickle Cell Disease with Vaso-Occlusive Episode” in the Hospital Outpatient Quality Reporting Program and Rural Emergency Hospital Quality Reporting Program. This measure is crucial in addressing the timely management of pain during vaso-occlusive episodes (VOEs), a significant challenge in sickle cell disease (SCD) care. Vaso-occlusive episodes in SCD are excruciating and often lead to emergency visits, hospitalization, and prolonged suffering. Timely pain medication alleviates pain, reduces hospital length of stay, and improves patient outcomes. Published data supports a 60-minute benchmark for this measure. The National Heart, Lung, and Blood Institute (NHLBI) recommended pain management for vaso-occlusive crises within 60 minutes of presentation in 2014. ASH endorsed this benchmark in 2020 to improve clinical outcomes for sickle cell disease patients. Several quality improvement (QI) studies support this national benchmark: 

- A 2015 study in Blood found hospitals that met the 60-minute benchmark had shorter hospitalizations and better pain control. 

- A 2019 ACEP project showed timely pain medication administration reduced delayed pain relief and subsequent hospitalizations. 

- A 2020 study in The Journal of Pain and Symptom Management demonstrated a 15% reduction in readmission rates for sickle cell patients who achieved the 60-minute pain medication target. These studies align with expert consensus and emphasize the necessity of adhering to the 60-minute benchmark. Delays in pain treatment can worsen crises, leading to longer stays, higher healthcare costs, and worse outcomes. ASH’s Quality Measure supports this adoption. Given the overwhelming evidence supporting the 60-minute benchmark and its potential to improve patient outcomes, ASH’s quality measure is essential to ensure hospitals and rural emergency healthcare facilities meet the highest standards of care for sickle cell disease patients. Implementing this measure provides hospitals with an evidence-based framework to evaluate performance, identify areas for improvement, and ensure timely and effective care. It will also foster awareness of sickle cell patients’ unique needs and enhance healthcare providers’ training and preparedness to manage pain associated with vaso-occlusive crises effectively. I strongly encourage the Centers for Medicare & Medicaid Services to adopt the ASH quality measure for “Median Time to Pain Medication for Patients with a Diagnosis of Sickle Cell Disease with Vaso-Occlusive Episode” in the Hospital Outpatient Quality Reporting Program and the Rural Emergency Hospital Quality Reporting Program. This measure, grounded in solid scientific evidence and expert consensus, will significantly improve the quality of care for sickle cell disease patients nationwide. Thank you for considering this important issue. 

Respectfully,

W. Andrés Vásconez-Samaniego, MD.

The problem with just using the time factor for administration of pain medication is concerning. ED providers seeing the patient are not always familiar with prior clinical course of the patient. They need a bit of time to complete their assessment and to determine if this is VOC vs acute on chronic pain, or if patient has hypertension or renal disease ( relative contraindication for iv ketorolac). By putting pressure on the ED  providers to give pain medication ASAP, we are circumventing the process of assessment and plan. A better approach could be rapid triage and assessment of patients with SCD presenting to ED presenting with pain. 

I applaud having a measure for timeliness of treatment for sickle cell pain. Please note, however, that the QUALITY of treatment is also important, and the best practices would be:

1. rapid appropriate assessment that this is sickle cell pain and not another medical problem
2. using an individualized pain plan or weight-based dosing of pain medications, 

3. following guidelines from American College of Emergency Physicians and American Society of Hematology                                                               

                      Sickle Cell | ACEP   

    

   American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain | Blood Advances | American Society of Hematology

I am writing to support American Society of Hematology’s (ASH) new quality measure titled “Median Time to Pain Medication for Patients with Sickle Cell Disease with Vaso-Occlusive Episode” in the Hospital Outpatient Quality Reporting Program and Rural Emergency Hospital Quality Reporting Program.   As a pediatric hematologist, I have witnessed firsthand the severe pain episodes, known as vaso-occlusive crises, that these patients endure. Prompt and effective pain management is not just a matter of comfort; it is a crucial aspect of their care that can significantly impact their overall health outcomes. These pain episodes often require immediate medical attention, and delays in treatment can exacerbate the situation, leading to prolonged hospital stays and increased risk of complications.

The National Institutes of Health (NIH) and the American Society of Hematology (ASH) recommend that patients with sickle cell disease receive prompt pain management upon presentation to the emergency department. Implementing protocols to achieve this can significantly reduce the duration and severity of pain episodes, minimize the risk of acute chest syndrome, and improve patient satisfaction and quality of life.

Best practices to achieve this would include:

1. Implement Rapid Triage Protocols: Ensure that patients with sickle cell disease are quickly identified and triaged to receive timely pain assessments and interventions.

2. Educate Staff: Provide regular training for all emergency department personnel on the unique needs of sickle cell patients and the importance of timely pain management.

3. Streamline Pain Management Processes: Develop and utilize standardized order sets for pain management that facilitate rapid medication administration.

4. Continuously Evaluate and Improve: Regularly review treatment protocols and patient outcomes to identify areas for improvement and ensure adherence to best practice guidelines.

Timely intervention is crucial in managing sickle cell crises effectively. By working together to address these needs, we can enhance the care and support we provide to our patients, reducing their pain and improving their overall health outcomes.

I agree that this rule establishes a bare minimum comparative metric. It will take much more than rapid administration of "a dose of pain medication" to provide excellent care in the emergency department, but this initial measure will provide an explicit report that something is being done, and how long it takes. The definition of acceptable pain medication is quite broad and allows for personalization and flexibility, and implicit in the idea of 'medication administration' is the idea that someone was appropriately triaged and received the most appropriate medication for their situation. We cannot assess these aspects of care delivery with this metric, but this is an appropriate starting point.

I strongly support the adoption of the American Society of Hematology’s (ASH) new quality measure, “Median Time to Pain Medication for Patients with Sickle Cell Disease with Vaso-Occlusive Episode,” in the Hospital Outpatient Quality Reporting Program and Rural Emergency Hospital Quality Reporting Program.

Timely pain management is a critical component of care for individuals with sickle cell disease (SCD) experiencing vaso-occlusive episodes (VOEs). Delayed treatment not only prolongs patient suffering but also increases the risk of complications, including hospital admissions and longer recovery times; ultimately increasing health care resource utilization overall. By tracking and improving the median time to pain medication, this measure prioritizes evidence-based, patient-centered care, ultimately leading to better clinical outcomes.

Additionally, the implementation of this measure addresses longstanding disparities in SCD care, as patients with SCD—many of whom belong to historically underserved populations—often face stigmatization and inadequate treatment in healthcare settings. This measure promotes health equity by establishing accountability and standardizing care for a condition that disproportionately impacts marginalized communities.

Incorporating this measure into quality reporting programs is a vital step toward ensuring that all patients with SCD receive timely, equitable, and effective care. This initiative underscores the importance of aligning healthcare practices with the principles of justice, equity, and evidence-based care.

It is IMPERATIVE that individuals with SCD receive pain medication within 60 min of arrival to the ED to optimize pain management and potentially reduce hospital admissions. Beyond this first level of treatment, healthcare systems need to focus on standardizing inpt pain management AND individualizing pain management with input from patients, families, and providers. 

I endorse sickle cell  guidelines from ASH providing early less than 1 h pain management for patients with sickle cell disease in the ED admitted with Vasoocclusive crisis

One thing to note is that I would suggest the ‘home safety’ question not refer to the beginning of care only.  Just as in the medication proposed question, it should refer to during care under the agency did team members discuss home safety with you.   

Hello,

I am a pediatric hematologist at a large freestanding children's hospital in Houston, Texas. The sickle cell program at our center provides care to over 1200 infants, children, and adolescents with sickle cell disease. I write to provide my strong support for the adaption of this new measure that aims to improve the care provided to individuals with sickle cell disease. A metric that addresses timely pain medication administration to individuals with sickle cell disease would allow for a critically important patient outcome to be recognized and tracked. I acknowledge that some advocates argue against the measure due to its lack of specificity around the type of medication administered (i.e. does no specify opioid administration). However, I believe that by including this measure as written, it will allow for both buy in from a key stakeholder (Emergency Department providers) and consistent tracking and monitoring of pain medication administration for the first time. Doing so would provide solid data from which to build upon in the effort toward more equitable care for these patients. I applaud the team that worked to develop and validate the measure. 

Thank you.

This metric is very concerning and allows for emergency rooms to utilize non opioid therapy such as ibuprofen and acetaminophen as first line. I am very concerned this will not make meaningful change and allow for emergency rooms to just treat initially with ibuprofen or acetaminophen.  Acetaminophen and ibuprofen are not only ineffective for the management of acute vaso-occulsive event (VOE) but also could be dangerous and contraindicated in people with renal and liver disease.  Opioids are the standard for the management of acute VOE based on the NHLBI Guidelines and ASH 2020 sickle cell guidelines. I am highly concerned that this metric not only falls short but could delay the first dosage of opioid and could be dangerous.

I write to support the adoption of the Equity of Emergency Care Capacity and Quality (ECCQ) measure. The emergency department (ED) represents the safety net for patient care in this country, and is often the only point of access for some of our most disadvantaged patients. Emergency departments are required under EMTALA to provide a medical screening exam and stabilizing treatment, but too often now the emergency department is not an environmen that is conducive to providing quality care or to long term staff longevity. This is in particular because hospitals are boarding admitted patients in the ED, limiting available space for care provision. There is strong evidence that this compromises patient care, increases staff burnout, and promotes workplace violence. It is essential that there is a quality measure that ensures these patients are evaluated reasonably promptly and do not remain in the ED longer than necessary, particularly after the decision to admit.

This measure represents a critical step forward in addressing the diabetes epidemic. Incentivizing providers to screen for abnormal glucose levels among high-risk adults aged 35–70 is evidence-based and will likely lead to earlier diagnoses and better management of prediabetes and type 2 diabetes. I strongly support its inclusion in MIPS.

However, I urge CMS to prioritize equitable implementation of this measure to ensure that populations disproportionately affected by diabetes, including racial and ethnic minorities, are effectively reached. This could involve providing guidance on culturally tailored outreach and screening strategies.

Additionally, I encourage future efforts to expand screening measures to include populations not currently covered, such as younger individuals and those without overweight or obesity, to broaden early intervention opportunities.

Finally, I recommend that CMS address potential implementation challenges, such as reducing provider burden and improving access to care in underserved communities, to ensure the measure achieves its intended impact without exacerbating existing disparities.