Qualis Health analyzed Medicare Fee-for-Service claims data for three of the measures included in reports produced by the state's Choosing Wisely task force and three additional measures that are ongoing priorities at CMS.
Imaging (CT scan or MRI) for simple syncope.
While there may be instances where imaging is required, multiple organizations do not recommend it as a standard practice.
Imaging (CT scan or MRI) for uncomplicated headache.
Imaging may be warranted in some cases, but providers and patients should be familiar with the American College of Radiology's recommendation against it for most situations.
Antibiotics for upper respiratory infection.
Overuse of antibiotics can lead to complications for individual patients as well as the larger public; read the Infectious Diseases Society of America's recommendation on this topic.
Antipsychotic medications for the behavioral symptoms of dementia.
The risks of giving antipsychotic medications to dementia patients generally outweigh any potential benefits; read the recommendations against this practice from AMDA, the American Geriatrics Society, and the American Psychiatric Association.
New Chemotherapy or radiation during the last 30 days of life for patients with solid tumor cancers.
Although this is not a Choosing Wisely measure per se, it is related to three similar ones. (See the statements by the American Society of Clinical Oncology regarding the care of patients for whom additional chemotherapy or radiation is not warranted and the need to define goals with end-stage patients, as well as patient-centered recommendations from the Commission on Cancer.) None of these statements are formulated in such a way that they can be tracked using Medicare claims data. The more straightforward measure that Qualis Health has chosen is included in Hutchinson Institute for Cancer Outcomes Research (HICOR) analyses.
New Hospice, palliative care, or advance planning services during the last 90 days of life for patients with solid tumor cancers.
This is an expansion of a similar Choosing Wisely measure (described by the American Academy of Hospice and Palliative Medicine) and of a similar HICOR metric. Neither of those measures included advance planning services, which became a billable item for Medicare providers in 2016. (Please note that, unlike the other Choosing Wisely measures, higher rates are better. Clinicians are encouraged to order hospice or palliative care, and to provide advance planning services.)
As much as possible, data selection criteria mirrored those used by the state's task force and specified in the national Choosing Wisely guidelines. For the two end-of-life measures, data selection generally aligned with HICOR criteria.
To generate the county- and race-specific rates, Qualis Health divided the denominators by the numerators (both defined below) then calculated the corresponding 90% Wilson confidence intervals.
End-of-life cancer measures
A. Denominator (relevant population)
The denominator is identical for both measures; it includes the population of Medicare beneficiaries who met all of the following criteria:
Exclusions:
B. Numerator (among the denominator population, those who received the treatment of focus)
Chemotherapy or radiation therapy
All those who met both of the following:
Hospice, palliative care, or advance care planning
All those with Medicare Part A or Part B claims related to any of the following:
A. Denominator (population of Medicare beneficiaries with targeted diagnosis) |
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Diagnosis
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Simple Syncope
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Uncomplicated Headache
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Upper Respiratory Infection
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Dementia
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Study Period
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October 2016 - Septemeber 2017
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Enrollment
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Beneficiary must have been enrolled in Part A and B for at least one month during study period
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Beneficiary must have at least one instance of Part D claim during study period
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Location
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Provider must have either a practice location or mailing address in Washington
Beneficiary must have a Washington address; beneficiary’s address used to assign to county
(Please note that because the location designations are dependent upon the address of the beneficiary and not the care provider, data included in the county-specific rates may include some care provided outside the county.)
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Claims Source
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Principal diagnosis codes in Medicare Part B
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Principal diagnosis code in Medicare Part A or B
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Exclusions
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Claim excluded if the provider taxonomy was radiologist, interventional radiologist, ambulance, or laboratory
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Exclude beneficiaries if they had:
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Exclude beneficiaries with schizophrenia, bipolar disorders, Huntington’s Disease, Tourette’s Syndrome
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a)
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comorbid diagnoses within 12 months prior to index case
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b)
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competing diagnoses between 30 days prior, through 7 days after, the index case
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Index Case
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First diagnosis in study period
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All beneficiaries meeting the criteria above
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B. Numerator (among the denominator population, those who received the treatment of focus) |
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Claims Source
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Procedure codes related to CT or MRI in Medicare Part A or Part B, within 30 days following the index case
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National Drug Codes related to antibiotics in Medicare Part D, within three days following the index case
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National Drug Codes related to antipsychotics in Medicare Part D, during measurement period
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