CMS Core Measures Evidencebased Performance Measurement

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CMS Core MeasuresEvidence-based Performance
Measurement
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Learning Objectives

• Describe evidence-based medicine.
• Identify CMS core measures and the purpose for
  measuring performance.
• Describe the core measures for each clinical
  topic.

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What is evidence-based medicine?

• Patient care that research has shown to result in
  better outcomes for patients, such as lower
• Mortality and morbidity
• Disability
• Length of stay
• Readmissions

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What is a core measure?

• The percentage of eligible patients that receive
  care represented by the measure.
• Example Percentage of AMI patients that
  receive aspirin on arrival.

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Why are we here today?

• 1 Reason The PATIENT
• It isnt just about the numbers.
• it is about the right care every time.

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Other reasons to improve your core measure rates

• Assure your community and your Board of
  Directors that you are providing high quality
  care.
• Receive higher reimbursement from Medicare and
  other payers.

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National Clinical Focus Areas

• Heart Failure (HF)
• Acute Myocardial Infarction (AMI)
• Pneumonia (PN)
• Surgical Care Improvement Project (SCIP)

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Heart Failure

• Heart failure accounts for more than 700,000
  hospitalizations every year.
• Heart Failure is associated with high rates of
  mortality and morbidity.

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Heart Failure, contd

• It is a common disease in the elderly, accounting
  for more hospital admissions than any other
  diagnosis in patients over the age of 65. 
• The prevalence of heart failure is rising
  dramatically with the aging of the US population.

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Acute Myocardial Infarction

• Cardiovascular disease is America 's biggest
  killer. 
• Each year approximately 1.1 million people have a
  heart attack. 
• Almost two-thirds of heart attack patients do not
  make a complete recovery.
• People who survive the acute phase have a chance
  of related illness and death that is 2 to 9 times
  higher than that of the general population.

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Pneumonia

• Pneumonia and influenza are the fifth leading
  causes of death in the United States in patients
  age 65 years and older. 
• Pneumonia accounts for nearly 600,000 Medicare
  patient hospitalizations utilizing more than 4.5
  million inpatient days each year. 

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Pneumonia, continued

• Pneumonia also is the principal reason for more
  than 500,000 emergency department visits by
  Medicare patients each year. 
• The incidence of pneumonia increases with age,
  and more than 90 percent of deaths due to this
  condition are in the population aged 65 and
  older.

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Impact of Surgical Care Complications

• 22 of preventable deaths attributed to
  postoperative complications
• Approximately 500,000 surgical site
  infections(SSI) occur annually in the United
  States
• Patients that develop SSI have twice the
  mortality and are
• 60 more likely to spend time in ICU
• 5 times more likely to be readmitted

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Surgical Care Complications, contd

• Surgical patients are 20 times more likely to
  have venous thromboembolism (VTE)
• Deep vein thrombosis (DVT) and/or
• Pulmonary embolism (PE)
• PE causes 300,000 deaths per year and is the
  third leading cause of hospital death

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Heart Failure Measures

• Complete discharge instructions
  (six components)
• Left ventricular function assessment
• ACE Inhibitor or ARB prescribed at discharge for
  left ventricular systolic dysfunction
• Adult smoking cessation counseling

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Acute MI Measures

• Aspirin at arrival
• Aspirin prescribed at discharge
• ACE Inhibitor/ARB prescribed at discharge for
  left ventricular systolic dysfunction
• Adult smoking cessation counseling

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Acute MI Measures contd

• Beta Blocker prescribed at discharge
• Beta Blocker at arrival
• Thrombolysis within 30 minutes
• Percutaneous coronary intervention within 90
  minutes

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Pneumonia Measures

• Oxygenation assessment
• Blood cultures performed within 24 hours Prior to
  or after Hospital Arrival (ICU patients)
• Blood cultures performed before 1st antibiotic
  received in hospital

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Pneumonia Measures

• Adult smoking cessation counseling
• Antibiotic timing (w/in 6 hrs of arrival)
• Initial antibiotic selection for community
  acquired pneumonia (CAP) in immunocompetent
  patients
• Influenza vaccination
• Pneumococcal vaccination

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Surgical Care Improvement Project Measures

• Infection prevention
• Antibiotic given within one hour prior to surgery
• Recommended antibiotic given
• Antibiotic dcd within 24 hours after surgery
• Appropriate hair removal
• Normothermia (colon patients)
• Glucose control (cardiac patients)

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Surgical Care Improvement Project Measures

• Venous thromboembolism prophylaxis
• Ordered
• Received
• Cardiovascular
• Patients on Beta Blockers prior to admission
  receive Beta Blockers in hospital

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• Evidence Supporting
• the Core Measures

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Evidence Aspirin

• Use of aspirin for AMI patients results in a
  reduction of adverse events and mortality
  equivalent to thrombolytic therapy.
• Aspirin provides an additive effect when used in
  combination with thrombolytics.

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Evidence ACE Inhibitors ARBs

• ACEIs ARBs are medications that reduce
  angiotensin absorption by blood vessels,
  resulting in lower vascular resistance.
• ACEIs ARBs reduce morbidity and mortality in
  patients with left ventricular systolic
  dysfunction.

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Evidence Beta Blockers

• Beta Blockers cause vasodilation and reduce
  peripheral vascular resistance.
• Beta Blockers significantly reduce morbidity and
  mortality in AMI patients.

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Evidence Timing of thrombolytics and
percutaneous coronary interventions

• Early reperfusion of coronary arteries saves
  heart muscle and reduces disability and
  mortality.
• Nearly 2 lives per 1,000 patients are lost per
  hour of delay.

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Evidence Heart Failure Discharge Instructions

• Patients and their families that learn to manage
  heart failure can reduce morbidity and mortality.
• Knowing to contact their physician for
  appointments and medication adjustments can
  prevent readmissions.

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Evidence Blood Cultures

• Pneumonia patients sick enough to be admitted to
  the ICU should have blood cultures drawn.
• Results can be used to optimize antibiotic
  therapy.

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Evidence Timing of Initial Antibiotic

• For patients with community acquired pneumonia,
  studies have shown that giving antibiotics within
  6 8 hours of arrival reduces mortality by 15
  30.

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Evidence Selection of Initial Antibiotic

• Pneumonia patients should be assessed for
  severity of illness, allergies, and pseudomonal
  risk.
• Different combinations of initial (empiric)
  antibiotics are recommended based on patient
  characteristics.
• Patients receiving recommended antibiotics have a
  lower mortality rate.

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Evidence Influenza and Pneumococcal Immunizations

• Over 30,000 people in the U.S. die each year from
  influenza and pneumonia.
• Clinics and physician offices are ineffective in
  immunizing large numbers of eligible patients.
• The most vulnerable patients are hospital
  inpatients.

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Influenza and Pneumococcal Immunizations, contd

• Texas law requires hospitals to assess patients
  and offer these immunizations to patients age 65
  and older.
• The influenza vaccine is made from dead viruses.
  While patients may experience short-term flu-like
  symptoms, they cannot catch the flu from the
  vaccine.

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Influenza and Pneumococcal Immunizations, contd

• The influenza vaccine is highly effective in
  preventing influenza-related pneumonia,
  hospitalization, and death.
• The pneumococcal vaccine is up to 75 effective
  in preventing pneumococcal bacteremia and
  meningitis.

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Evidence Prophylactic Antibiotics for Surgery
Patients

• Antibiotics are most effective when given within
  one hour prior to surgery.
• Short duration antibiotics are as effective in
  preventing infection as long duration
  antibiotics.
• Long duration antibiotics are more likely to
  cause development of drug resistant bacteria.

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Evidence Appropriate Hair Removal

• Shaving with a razor creates small nicks at the
  surgical site that can become infected.
• Hair removal with clippers or depilatories
  results in significantly lower infection rates.

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Evidence Normothermia

• Hypothermia causes vasoconstriction, reducing
  delivery of IV medications.
• Hypothermia suppresses the immune system.
• In one study, colorectal surgery patients that
  maintained normothermia had an infection rate
  two-thirds lower than control patients.

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Evidence Blood Glucose Control

• CABG patients with uncontrolled blood glucose
  have significantly higher infection rates.
• Deep wound infections in diabetic cardiac surgery
  patients were reduced by controlling mean blood
  glucose levels below 200mg/dL.

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Evidence Venous Thromboembolism Prophylaxis (VTE)

• Surgical patients are at high risk of developing
  VTE (deep vein thrombosis or pulmonary embolism).
• Pulmonary embolism is the most common preventable
  cause of hospital death in the U.S.
• Use of anticoagulants and intermittent
  compression devices provides effective
  prophylaxis.

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What is your hospital doing to improve care?

• (List processes implemented or being tested that
  should improve core measure performance.)

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What can nurses do to help?

• (Examples - modify for your hospital)
• Be a part of the processvolunteer to test a
  change or try a new form.
• Documentation Use forms/screens developed.
• Provide smoking cessation counseling administer
  flu and pneumococcal vaccinations.
• Realize you can impact patient outcomes.

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Information Source

• You can find a brief literature review for each
  measure at
• www.qualitynet.org
• Hospitals Inpatient
• Measurement Information
• Measurement Information Form

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Questions?
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This material was prepared by TMF Health Quality
Institute, the Medicare Quality Improvement
Organization for Texas, under contract with the
Centers for Medicare Medicaid Services (CMS),
an agency of the U.S. Department of Health and
Human Services. The contents presented do not
necessarily reflect CMS policy. 8SOW-TX-HOQI-08-03