QUALITY IMPROVEMENT COLUMN by Jeremy Collins, MD, and Jeremy Durack, MD


SIR-stewarded PQRS measures published in Federal Register


Quality Reporting System (PQRS). SIR Foundation has made performance measurement a central focus of its efforts, which include proposing PQRS measures relevant to IR, developing IR registries and streamlining data collection through a structured reporting initiative.


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These efforts are critical to IRs in all practice settings as the Centers for Medicare and Medicaid Services (CMS) have clearly indicated their intent to migrate toward value-based reimbursement schemes, in which a significant proportion of reimbursement will depend on documentation of quality care through participation in PQRS or other value-based measurement programs. In addition, such an infrastructure allows SIR to collect objective outcome data demonstrating to both payers and patients the quality of care we provide.


In June 2014, SIR Foundation sponsored a research consensus panel (RCP) on performance measurement. In the break-out sessions from the RCP, service line representatives discussed and refined PQRS performance measures; 13 measures were later submitted for the 2016 PQRS program. Following review by CMS, the National Quality Forum’s (NQF) Measures Applications Partnership (MAP) and the Physicians Quality


Table 1: SIR-stewarded PQRS measures NQF/PQRS # NQS Domain Measure Title


409 413 420


Effective Clinical Care


Effective Clinical Care


Effective Clinical Care


421


Effective Clinical Care


437


Patient Safety


Clinical Outcome Post Endovascular Stroke Treatment


Door to Puncture Time for Endovascular Stoke Treatment


Varicose Vein Treatment with Saphenous Ablation: Outcome Survey


Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal


Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure


20 IR QUARTERLY | WINTER 2016


he SIR Foundation Performance and Quality Improvement Committee has worked closely with the society’s service lines to propose and refine performance measures for inclusion in the Physician


Measures Management (PQMM) group, five proposed measures were published in the Federal Register on Nov. 16, 2015 (1.usa. gov/1N5Y0wh; see summary table below). SIR has also submitted 22 additional measures for consideration in the 2017 PQRS program.


In addition to SIR-stewarded PQRS efforts, the foundation has worked closely with the American College of Radiology (ACR) to develop a qualified clinical data registry (QCDR), the National IR Quality Registry. Reporting on measures in this registry satisfies PQRS reporting requirements. As additional SIR-stewarded PQRS measures are approved, these measures will be added to the National IR Quality Registry. Led by Rajesh Shah, MD, efforts are ongoing to develop a data dictionary to facilitate the measure specification process for the National IR Quality Registry.


The SIR Foundation-supported structured reporting initiative, led by Jeremy Durack, MD, and Justin P. McWilliams, MD, has recently completed a year-long pilot study of five structured reporting templates deployed at numerous private and academic centers. Use of these structured reporting templates would enable data extraction as part of routine clinical care ensuring accurate data for value-based reimbursement program reporting. Feedback from the pilot has focused the structured reporting group in their efforts to refine (and shorten!) the next generation of templates.


Description


Percentage of patients with a mRS score of 0 to 2 at 90 days following endovascular stroke intervention


Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours


Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease-specific patient reported outcome survey instrument after treatment


Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal, or the inability to contact the patient with at least two attempts


In patients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo an unplanned major amputation or surgical bypass within 48 hours of the index procedure


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