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Quality & Practice

There were 25 quality measures in the Registry in 2017 and new measures were added for the 2018 year, including more patient-reported outcomes. Participating members and practices see their performance rates for each of the measures on their Registry User Dashboard. Below is the list of approved measures for the Registry, all of which can be used for 2017 quality reporting. Click here to access the full non-MIPS measures specifications.

Measures Measure Descriptions
Depression and Anxiety Assessment Prior to Spine-Related Therapies Percentage of patients aged 18 years and older with documentation of depression and/or anxiety assessment through discussion with the patient including the use of a standardized assessment tool prior to therapy(-ies) for treatment of spine-related pain symptoms.
Unplanned Admission to Hospital Following Percutaneous Spine Procedure within the 30-Day Post-Procedure Period Percentage of patients aged 18 years and older who had any unplanned admission following percutaneous spine-related procedure within the 30-day post-procedure period.
Functional Outcome Assessment for Spine Intervention Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) functional outcome assessment.
Narcotic Pain Medicine Management Prior to and Following Spine Therapy Percentage of patients aged 18 years and older with documentation of narcotic use/requirements at baseline (initial encounter) and at 2 +/-1 months following initial assessment and therapy (ies) for treatment of spine-related pain symptoms and documentation of follow-up plan.
Complication Following Percutaneous Spine-Related Procedure Proportion of patients undergoing percutaneous spine-related procedures who have a complication (specifically, CSF leak, deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, procedure related infection or unexpected new neurological deficit) in the 30-day post-procedure period.
Quality-of-Life Assessment for Spine Intervention Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed baseline and 2 +/- 1 month follow-up (patient-reported) quality-of-life assessment.
Patient Satisfaction with Spine Care Percentage of patients aged 18 years and older undergoing spine therapy(-ies) who completed 2 +/- 1 month follow-up (patient-reported) satisfaction with care assessment.
Spine/Extremity Pain Assessment Percentage of patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized back or neck pain tool(s) at baseline and/or leg or arm pain tool(s) at baseline and 2 +/-1 months following initial assessment and therapy(-ies) for treatment of spine-related pain symptoms and documentation of follow-up plan.
QPP #21 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin Percentage of surgical patients aged 18 years or older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis.
QPP #23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (CTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given with 24 hours prior to incision time or within 24 hours after surgery end time.
QPP #47 Care Plan Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision mater or provide an advance care plan.
QPP #109 Osteoarthritis (OA): Function and Pain Assessment Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain.
QPP #110 Preventive Care and Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
QPP #111 Pneumococcal Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
QPP #128 Preventive Care and Screening: Body Mass Index (BMI Screening and Follow-Up Plan Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.
QPP #130 Documentation of Current Medications in the Medical Record Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This listmustinclude ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements ANDmustcontain the medications’ name, dosage, frequency and route of administration.
QPP #131 Pain Assessment and Follow-Up Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan with pain is present.
QPP #182 Functional Outcome Assessment Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
QPP #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
QPP #312 Use of Imaging Studies for Low Back Pain Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
QPP #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
QPP #374 Closing the Referral Loop: Receipt of Specialist Report Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
QPP #402 Tobacco Use and Help with Quitting Among Adolescents The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.
QPP #408 Opioid Therapy Follow-up Evaluation All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record.
QPP #412 Documentation of Signed Opioid Treatment Agreement All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
QPP #414 Evaluation or Interview for Risk of Opioid Misuse All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record.
QPP #431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.