2019-10-15 concussion measurement set · aravind ganesh, md lauren green, do, rd michael jaffee,...

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Concussion

Quality Measurement Set

Approved by the Concussion Quality Measurement Work Group on [DATE]. Approved by the

AAN Quality and Safety Subcommittee on [DATE]. Approved by the AAN Practice Committee on [DATE]. Approved by the American Academy of Neurology Institute Board of Directors on

[DATE].


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Disclaimer

Quality Measures published by the American Academy of Neurology and its affiliates are assessments of current scientific and clinical information provided as an educational service. The information: 1) should not be considered inclusive of all proper treatments, methods of care, or as a statement of the standard of care; 2) is not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); 3) addresses only the question(s) or topic(s) specifically identified; 4) does not mandate any particular course of medical care; and 5) is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary.

AAN provides this information on an “as is” basis, and makes no warranty, expressed or implied, regarding the information. AAN specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. AAN assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions. © 2017 American Academy of Neurology Institute. All rights reserved.

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary coding sets should obtain all necessary licenses from the owners of these code sets. The AAN and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications. ICD-10 copyright 2012 International Health Terminology Standards Development Organization

CPT ® is a registered trademark of the American Medical Association and is copyright 2017. CPT® codes contained in the Measure specifications are copyright 2004-2016 American Medical Association.


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Table of Contents Work Group Participants ..............................................................................................................4

Importance and Measure Purpose ................................................................................................5

Measure Development Process ....................................................................................................5

Importance and Prevalence of Concussion ..................................................................................7

2019 Concussion Measures ..........................................................................................................7

Other Concussion Measures .........................................................................................................7

Harmonization ..............................................................................................................................8

Concussion symptoms evaluation ........................................................................................9

Appropriate neurological exam ..........................................................................................13

Exercise plan after concussion ...........................................................................................16

Documentation of return to play strategy or protocol ........................................................19

Individualized counseling for return to school, other learning environment, or work ......22

Depression outcome ...........................................................................................................27

Counseling on medication overuse headache ....................................................................30

Repeat imaging for concussion ..........................................................................................35

Contact Information ...................................................................................................................38

Appendix A ................................................................................................................................39

Appendix B ................................................................................................................................40

References ..................................................................................................................................41


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Work Group Participants

American Academy of Family Physicians

Deepak Patel, MD, FAAFP, FACSM

American Academy of Neurology

Wayne Anderson, DO, FAAN, FAHS

Daniel Feinberg, MD, FAAN

Aravind Ganesh, MD

Lauren Green, DO, RD

Michael Jaffee, MD, FAAN, FANA

Matthew Lorincz, MD, PhD

Sean C. Rose, MD

Jack Tsao, MD, DPhil, FAAN, FANA

American Academy of Physical Medicine & Rehabilitation

Arthur De Luigi, DO, MHSA, FAAPMR, CAQSM, CAQBIM, DABPM, RMSK

Brain Injury Association of America

Michael Kaplen, Esq.

Facilitator

Adam Webb, MD, FAAN

Staff

Amy Bennett, JD

Erin Lee

Karen Lundgren, MBA

Becky Schierman, MPH


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Improving Outcomes for Patients with Concussion

Rationale for Measures

In 2018, the American Academy of Neurology formed the Concussion Work Group to review existing guidelines, current evidence, and gaps in care in order to develop a measurement set for neurologists that promotes quality improvement and drives better outcomes for patients with concussion.

Measure Development Process

The AAN develops quality measures based on the belief that specialists should play a leading role in selecting and creating measures that will drive performance improvement and possibly be used in accountability programs in the future. All members of the Work Group were required to disclose financial relationships with industry and other entities to avoid actual, potential, or perceived conflicts of interest.

The Quality and Safety Subcommittee (QSS) approved a new measure set concept around concussion. The QSS commissioned a work group comprised of AAN members as well as members of other specialty societies that care for patients with concussion. A facilitator from QSS was appointed to oversee the methodology. This Work Group was tasked with reviewing literature and proposing draft concepts for concussion management.

A series of virtual meetings was held to discuss and refine the measure concepts. The Work Group voted to approve or not approve each proposed measure.

Following the virtual meetings, measures were further refined and posted for public comment. The Work Group reviewed and responded to all of the public comments and refined the measures when feasible, and additional evidence was requested from respondents based upon their suggestions when not feasible. After the measures have been finalized, the Work Group votes to approve or not approve the whole measurement set. If approved by the Work Group, AAN staff facilitate internal AAN approvals. The Work Group drafts a manuscript which is an executive summary of the measurement set that is submitted for potential publication in Neurology. AAN measures undergo a maintenance review every three years.


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Below is an illustration of the measure development process from proposals, discussion, research, evaluation, to approval.

Medical librarian search

19 Measure Concepts

Proposed

Data Review

6 new concepts removed ‐ lack of evidence ‐ not feasible ‐ little impact on care

13 concepts advanced

[x] measures approved

Public comment and

Refinement

Group Discussions

5 measures removed ‐ Lack of evidence ‐ Existing measures available

8 measures advanced


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Importance and Prevalence of Concussion

Concussion represents the immediate and transient symptoms of a mild traumatic brain injury, 1 and is defined as a clinical syndrome of biomechanically induced alteration of brain function2. The term “concussion” is often used interchangeably with “mild traumatic brain injury”, and clear distinctions between the two are not widely agreed upon1.

1.1-1.9 million sports and recreation-related concussions occur in children each year in the United States, although many are not seen in a health care setting3. Approximately 1 million outpatient clinic and emergency department visits for minor head injury in children occur annually in the United States, with an additional 1 million adults4. Concussion can occur in any age group, from early childhood through late adulthood, with the highest incidence in children age 10-195. Much of the existing research on concussion has focused on sports-related concussion. Indeed, most of the published guidelines and consensus statements pertain specifically to sports-related concussion1,2,6-8. However, only half of pediatric ED visits for concussion are sport-related9. There appear to be sex differences in concussion incidence and recovery. In sports with similar rules between sexes (e.g., basketball, soccer), females have a higher risk of concussion than males10. Additionally, females have higher risk of prolonged symptoms1,11.

While the majority of adults with concussion will return to pre-injury levels of symptoms and functioning within 14 days, considerable variability in recovery exists. Children often take longer than adults to recover1. Approximately 20-30% of children continue to have symptoms longer than 1 month11,12. Persistent post-concussion symptoms are associated with significant morbidity; children with persistent symptoms report lower quality of life than many other childhood chronic diseases including cancer, end-stage renal disease, and cerebral palsy13.

Concussion remains a clinical diagnosis, inevitably involving some degree of subjectivity and uncertainty. An objective biomarker has not been established for the diagnosis or management of concussion. While the objective evidence regarding most aspects of concussion care is quite limited, several consensus statements and evidence-based guidelines are available to guide management1,2,6-8,14.

2019 Concussion Measurement Set

The following measures were approved by the work group. There is no requirement that all measures in the measurement set be used. Providers are encouraged to identify the one or two measures that would be most meaningful for their patient populations and implement these measures to drive performance improvement in practice.

Concussion symptoms evaluation Appropriate neurological exam Exercise plan after concussion Documentation of return to play strategy or protocolIndividualized counseling for return to school, other learning environment, or work Depression outcome Counseling on medication overuse headache Repeat imaging for concussion

Other Potential Measures

The measures developed are a result of a consensus process. Work Group members are given an opportunity to submit new measures in advance of virtual meetings where all measures are reviewed and edited individually. The Work Group felt the following concepts were not ready for development at this time due to lack of strong evidence in a neurology population, difficulty locating data elements needed for measurement, existence of similar measures, or lack of known gaps in treatment. The Work Group recommends these concepts be revisited when this measurement set is updated in 3 years.


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Pediatric patients evaluated by use of PECARN algorithm prior to CT imaging Patients evaluated with New Orleans or Canadian CT rules prior to CT brain for concussion Patients that were symptom free without medication for 24 hours before starting return to play strategy Patients counseled to rest for first 48-72 hours then begin gradual return to cognitive and physical activity Patients offered supervised exercise Patients completing supervised exercise and given exercise guidance Referral to multi-disciplinary concussion clinic Patients screened for depression with a validated tool Patients screened for depression with a validated tool at initial visit Patients who received a CT scan at initial visit Patients with headache who were offered a guideline recommended therapy

Measure Harmonization

The Work Group searched for existing measures on concussion and found no existing measures. The AAN advocates for reducing duplicative measures when possible.


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Measure Title Concussion symptoms evaluation completed

Description Percentage of patients 5 years of age and older diagnosed with concussion who had a symptom evaluation completed at the initial visit

Measurement Period

January 1, 20xx to December 31, 20xx

Eligible Population

Eligible Providers

Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurse (APRN)

Care Setting(s) Outpatient

Ages > 5 years of age

Event Office visit

Diagnosis Concussion

Denominator All patients > 5 years of age diagnosed with concussion

Numerator Patients who had a symptom evaluation^ completed at initial visit ^Evaluations:

Acute Concussion Evaluation (ACE) Concussion Symptom Inventory (CSI) Graded Symptom Checklist (GSC) and Graded Symptom Scale (GSS) Health and Behavior Inventory (HBI) Post-concussion Symptom Inventory (PCSI) Post-concussion Symptom Scale (PCSS) Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ)

Required Exclusions

None

Allowable Exclusions

Patient and/or caregiver unable to report symptoms (non-verbal) Patient and/or caregiver refusal

Exclusion Rationale

Patients and/or their caregivers need to be able to communicate symptoms. Patients and their caregivers have the right to refuse.

Measure Scoring

Percentage

Interpretation of Score

Higher Score Indicates Better Quality

Measure Type Process

Level of Measurement

Provider

Risk Adjustment

N/A


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For Process Measures Relationship to Desired Outcome

Opportunity to Improve Gap in Care

McCrory et al. state that “SRC is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage.”1 Symptom evaluations assist a provider in identifying and subsequently managing the symptoms of concussion as they arise so the patient can return to baseline and resume regular activity.

Harmonization with Existing Measures

No existing measures known

References and Supporting Evidence

1. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Jun;51(11):838-47.

2. Lumba-Brown A, Yeates K, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatrics 2018; 172(11): e182853.

3. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology 2013; 80:2250-2257.

4. The Management of Concussion-mild Traumatic Brain Injury Working Group. VA/DoD Clinical Practice Guideline for the Management of Concussion-Mild Traumatic Brain Injury.


6. Purcell L, Canadian Paediatric Society, Healthy Active Living and Sports Medicine Committee. Sport-related concussion: Evaluation and management. Paediatr Child Health 2014; 19:153-158.

7. Marshall S, Bayley M, McCullagh S, et al. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Injury 2015; 29:688-700.

8. Halstead M, Walter K, Moffatt K, and Council on Sports Medicine and Fitness. Sport-related concussion in children and adolescents. Pediatrics 2018; 142: e20183074.

Code System Code Code Description ICD-10 S06.0X0A Concussion without loss of consciousness, initial encounter ICD-10 S06.0X0D Concussion without loss of consciousness, subsequent encounterICD-10 S06.0X0S Concussion without loss of consciousness, sequela ICD-10 S06.0X1A Concussion with loss of consciousness of 30 minutes or less, initial encounterICD-10

S06.0X1D Concussion with loss of consciousness of 30 minutes or less, subsequent encounter

Process

•Concussion sympoms assessed

Intermediate outcome

•Treatment plan adherence

Outcomes

•Improved quality of life

•Reduction of concussion symptoms


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ICD-10 S06.0X1S Concussion with loss of consciousness of 30 minutes or less, sequelaICD-10

S06.0X9A Concussion with loss of consciousness of unspecified duration, initial encounter

ICD-10 S06.0X9D

Concussion with loss of consciousness of unspecified duration, subsequent encounter

ICD-10 S06.0X9S Concussion with loss of consciousness of unspecified duration, sequelaCPT 99201-99205

99211-99215

Office or other outpatient visit 10, 20, 30, 45, or 60 minutes for the evaluation and management of a new patient Office or other outpatient visit 5, 10, 15, 25, or 40 minutes for the evaluation and management of an established patient


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Yes

No

No

Yes

No

Yes

No or N/A

No or N/A

Yes

Yes

No

No or N/A

Flow Chart Diagram: Concussion symptoms evaluated

Did patient have a diagnosis of concussion

during the measurement period?

Patient

INCLUDED in

Eligible

Population

Yes

Was patient 5 years of age or older during

the measurement period? Patient NOT

Included in

Eligible

Population

Patient

INCLUDED in

Denominator

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, did patient have a symptoms evaluation completed at the initial visit?

Did the patient have at least one new or

established patient visit with an eligible

provider during the measurement period?

On the date of the encounter, were the patient and/or caregiver unable to report symptoms?

On the date of the encounter, did patient and/or caregiver refuse to answer?

Remove from

denominator*

*Do not remove/exclude

if patient meets the

numerator


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Measure Title Appropriate neurological exam

Description Percentage of patients aged 5 years and older diagnosed with concussion seen for an initial visit who had a neurological exam performed that included all components: 1) cervical assessment, 2) cognitive function, 3) vestibular function, 4) extraocular movements, 5) gait, 6) balance, and 7) coordination.

Measurement Period


Eligible Population

Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurse (APRN)

Care Setting(s) Outpatient, Inpatient, Emergency Department


Event Office visit, admission to inpatient unit, emergency department visit


Denominator Patients > 5 years of age diagnosed with concussion seen for an initial visit

Numerator Patients who had a neurological exam that included all components: 1) Cervical assessment 2) Cognitive function 3) Vestibular function 4) Extraocular movements 5) Gait 6) Balance 7) Coordination

Required Exclusions

None


Patient and/or caregiver refusal Patients unable to participate in a neurological exam

Exclusion Rationale

Certain patients might not be able to undergo an aspect of a neurological exam. Patients and/or their caregivers have the right to refuse a neurological exam.

Measure Scoring Percentage


Higher Score Indicates Better Quality



Provider

Risk Adjustment N/A


Process

•Neurological exam

Outcomes

•Confirm diagnosis of concussion

•Referral to additional therapy when needed


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Concussion is a clinical diagnosis. It is important to conduct a neurologic exam in patients with concussion to look for more severe brain or neck injury. If exam abnormalities are consistent with concussion, they should be tracked over time to monitor for resolution. McCrory et al. recommend that the key features of an exam should include a neurological examination which should encompass “mental status, cognitive functioning, sleep/wake disturbance, ocular function, vestibular function, gait and balance.”1


No existing measures known



2. Harmon K, Clugston J, Dec K, et al. American Medical Society for Sports Medicine position statement on concussion in sport. British Journal of Sports Medicine 2019; 53:213-225.







ICD-10 S06.0X9D



99211-99215


CPT 99221-99223 Initial hospital care 30, 50, or 70 minutes, per day, for the evaluation and management of a patient;

CPT 99231-99233 Subsequent hospital care 15, 25, or 35 minutes, per day, for the evaluation and management of a patient

CPT 99291, 99292 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, each additional 30 minutes


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Yes

No

No

Yes

No

Yes

No or N/A

No or N/A

Yes

Yes

No

No or N/A

Flow Chart Diagram: Appropriate neurological exam



Patient

INCLUDED in

Eligible

Population

Yes



Included in

Eligible

Population

Patient

INCLUDED in

Denominator

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, did patient have a neurological exam that included all components: 1. Cervical assessment 2. Cognitive function 3. Vestibular function 4. Extraocular movements 5. Gait 6. Balance 7. Coordination




On the date of the encounter, was the patient unable to participate in a neurological exam?

On the date of the encounter, did patient and/or caregiver refuse?

Remove from

denominator*



numerator


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Measure Title Exercise plan after concussion

Description Percentage of patients 5 years of age and older diagnosed with concussion who were given an exercise plan at every visit

Measurement Period


Eligible Population


Care Setting(s) Outpatient, Urgent Care, Inpatient, Emergency Department


Event Office visit, urgent care visit, inpatient admission, ED visit

Diagnosis Concussion and post-concussion syndrome

Denominator Patient > 5 years of age with concussion or post-concussion syndrome

Numerator Patients who were given exercise counseling^ at every visit ^Counseling should include recommendations on appropriate physical activity

Required Exclusions

None


Patient and/or caregiver decline counseling

Exclusion Rationale

Patients always have the right to refuse a service.



Higher score indicates better quality



Provider

Risk Adjustment None



Patients should take a slow stepwise approach when returning to physical activity.1 After an initial period of rest, providers should counsel patients on developing an appropriate exercise regime to acclimate the patient’s body and brain to cognitive and physical exertion. The exact exercise program will be individualized for each patient.


No known measures exist.

Process

•Exercise counseling at every visit

Intermediate Outcomes

•Adherence to exercise plan

Outcomes

•Quicker recovery

•Resumption of everyday activities


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3. King D, Brughelli M, Hume P, Gissane C. Assessment, Management and Knowledge of Sport-related Concussion: Systematic Review. Sports Medicine 2018: 44:449-471.

4. Schneider, K. J., et al. (2017). "Rest and treatment/rehabilitation following sport-related concussion: a systematic review." Br J Sports Med 51(12): 930-934.


Code System Code Code Description Denominator ICD-10 S06.0X0A Concussion without loss of consciousness initial encounter ICD-10 S06.0X0D Concussion without loss of consciousness, subsequent encounterICD-10 S06.0X0S Concussion without loss of consciousness, sequela ICD-10 S06.0X1A Concussion with loss of consciousness of 30 minutes or less, initial encounterICD-10




ICD-10 S06.0X9D


ICD-10 S06.0X9S Concussion with loss of consciousness of unspecified duration, sequelaICD-10 F07.81 Post-concussion syndromeCPT 99201-99205

99211-99215


Numerator ICD-10 Z71.82 Exercise counseling


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Yes

No

No

Yes

No

Yes

No or N/A

Yes No

No or N/A

Flow Chart Diagram: Exercise counseling

Did patient have a diagnosis of concussion or

post‐concussion syndrome during the

measurement period?

Patient

INCLUDED in

Eligible

Population

Yes



Included in

Eligible

Population

Patient

INCLUDED in

Denominator

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, was the patient given exercise counseling at every visit?




On the date of the encounter, did patient and/or caregiver decline counseling?

Remove from

denominator*



numerator


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Measure Title Documentation of Return to Play Strategy or Protocol

Description Percentage of patients aged 5 years of age and older diagnosed with concussion who were cleared for full participation in sports that had documentation of a return to play strategy or protocol

Measurement Period


Eligible Population


Care Setting(s) Outpatient, Urgent Care


Event Office visit, urgent care visit


Denominator Patients > 5 years of age diagnosed with concussion who were cleared for full participation in sports

Numerator Patients who had documentation of a return to play strategy or protocol

Required Exclusions

Patients with post-concussion syndrome


Patient and/or caregivers who refuse return to play strategy Patients who are currently participating in sports without symptoms

Exclusion Rationale

Patients have the right to refuse a service. Patients who have already returned to their sport prior to receiving clearance should be excluded.






Provider

Risk Adjustment N/A



Returning to a sport after a concussion is a difficult decision which is hampered by the many guidelines providing varying recommendations. Getting a patient back playing their sport safety should be done by using a return to play strategy or protocol that outlines the types of physical activities that the patient tolerated prior to clearance.


No existing measures are known.

Process

•Return to play strategy or protocol documented


•Adhere to return to play strategy

Outcomes

•Return to activity with no symptoms of concussion


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3. Ontario Neurotrauma Foundation. Guidelines for Diagnosing and Managing Pediatric Concussion. 2014.



Code System Code Code Description ICD-10 S06.0X0A Concussion without loss of consciousness initial encounter ICD-10 S06.0X0D Concussion without loss of consciousness, subsequent encounterICD-10 S06.0X0S Concussion without loss of consciousness, sequela ICD-10 S06.0X1A Concussion with loss of consciousness of 30 minutes or less, initial encounterICD-10




ICD-10 S06.0X9D



99211-99215



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Yes

No

No

Yes

No

Yes

No or N/A

No or N/A

No

No or N/A

No or N/A

Yes

Yes

Flow Chart Diagram: Documentation of Return to Play Strategy or Protocol



Patient

INCLUDED in

Eligible

Population

Yes


the measurement period?

Patient NOT

Included in

Eligible

Population




On the date of the encounter, did the patient have a diagnosis of post‐concussion syndrome?

Remove from

denominator*



numerator

Was the patient cleared for full participation

in sports?

Yes

On the date of the encounter, did the patient and/or caregiver refuse a return to play strategy or protocol?

On the date of the encounter, was the patient currently participating in sports without symptoms?


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Yes No

Patient

INCLUDED in

Denominator

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, did the patient have documentation of a return to play strategy or protocol?


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Measure Title Individualized counseling for returning to school, other learning environment, or work

Description Percentage of patients 5 years of age and older diagnosed with concussion who were provided individualized counseling for returning to school, other learning environment, or work

Measurement Period


Eligible Population


Care Setting(s) Outpatient, Urgent Care, Emergency Department, Inpatient


Event Office visit, urgent care visit, inpatient admission, ED visit


Denominator Patients > 5 years of age diagnosed with concussion

Numerator Patients who were provided individualized counseling for returning to school, other learning environment, or work

Required Exclusions

Patients with suspected concussion (not diagnosed)


Patients already tolerating regular participation in school and/or work without symptoms

Patients not in an academic setting Patients not currently working Patient and/or caregiver decline counseling

Exclusion Rationale

Patients who have already returned to school do not need additional help returning. Patients who are not currently in school and those that are on summer break do not need counseling to return to school. Patients that are not currently working do not need counseling to return to work. Patients and/or caregivers have the right to decline counseling.






Provider

Risk Adjustment N/A



Recovery time from concussion is different for every patient. Many patients experience symptom exacerbation in a school, learning, or work environment. As such, an individual

Process

•Individual counseling for returning to school, learning environment, or work


•Adherence to counseling

Outcomes

•Return to school/learning environment/work without concussion symptoms returning


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should be provided with counseling on how and when to return to a learning environment and/or work to mitigate concussion symptoms.


No other existing measures known.



2. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports. Neurology. 2013 Jun 11;80(24):2250-7.



5. Ontario Neurotrauma Foundation. Guidelines for Diagnosing and Managing Pediatric Concussion. 2014.



8. Halstead M, McAvoy K, Devore C, et al. Returning to learning following a concussion. Pediatrics 2013; 132:948.

9. Iverson G, Gioia G. Returning to school following sport-related concussion. Phys Med Rehabil Clin N Am 2016; 27:429-436.





ICD-10 S06.0X9D



99211-99215



25

Yes

No

No

Yes

No

Yes

No or N/A

No or N/A

No or N/A

No or N/A

No or N/A

Yes

Yes

Yes

Yes

Flow Chart Diagram: Individualized counseling for return to school, work, other learning environment



Patient

INCLUDED in

Eligible

Population

Yes



Included in

Eligible

Population




On the date of the encounter, did the patient have suspected concussion (not confirmed)?

Remove from

denominator*



numerator

On the date of the encounter, was the patient already tolerating regular participation in school and/or work?

On the date of the encounter, was the patient not in an academic setting?

On the date of the encounter, was the patient not working?

On the date of the encounter, did the patient and/or caregiver decline counseling?


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Yes No

No or N/A

Patient

INCLUDED in

Denominator

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, was the patient provided individualized counseling for returning to school, other learning environment, or work?


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Measure Title Depression outcome for patients with concussion

Description Percentage of patients 6 years of age and older diagnosed with concussion with at least two visits during the calendar year whose last depression scale score in the calendar year in maintained or improved compared to first depression scale score of the calendar year

Measurement Period


Eligible Population




Event Office visit


Denominator Patients > 6 years and older diagnosed with concussion with at least two visits during the calendar year

Numerator Patients whose last depression scale^ score in the calendar year is maintained or improved compared to first depression scale score of the year. ^Depression scale is defined as a validated scale appropriate for the patient’s age

Required Exclusions

None


Patient and/or caregiver refuse depression screening on the date of the encounter Patient has advance stage dementia, profound psychosis, neurodevelopment disorder

Exclusion Rationale

Patients and/or their caregivers have the right to refuse a screening for depression. Patients that are unable to communicate due to advance stage dementia, profound psychosis, or neurodevelopmental disorder should be excluded.




Measure Type Outcome


Provider

Risk Adjustment See appendix A



Depression is not an uncommon occurrence after concussion. Junn et al. state “There is evidence that depression, anxiety, and posttraumatic stress disorder can lead to symptom exacerbation and impairment after concussion.” Additionally, concussion is associated with an increased risk of suicide. Management of depression is critical in patients with concussion.

Outcomes

•Depression score maintained or improved


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Examples of commonly used depression scales:

Modified PHQ-A (11-17 y) CES-DC (6-17 y) SMFQ (8-16 y) Patient Health Questionnaire (PHQ-9 or PHQ-2) Beck Depression Inventory (BDI) Hamilton Depression Rating Scale


There are many existing measures for the management of depression. Few include a pediatric population, and none specifically target concussion.


1. Junn C, Bell K, Shenouda C, Hoffman J. Symptoms of Concussion and Comorbid Disorders. Curr Pain Headache Rep 2015; 19:46.

2. Yrondi A, Brauge D, LeMen J, Arbus C, Pariente J. Depression and sports-related concussion: a systematic review. La Presse Medicale 2017;46(10):890-902.

3. Yang J, Peek-Asa C, Covassin T, Torner JC. Post-concussion symptoms of depression and anxiety in Division I collegiate athletes. Developmental Neuropsychology 2015;40(1):18-23.

4. Fralick M, Sy E, Hassan A, et al. Association of concussion with the risk of suicide: a systematic review and meta-analysis. JAMA Neurology 2019; 76:144-151.






ICD-10 S06.0X9D



99211-99215



29

Yes

No

No

Yes

No

Yes

No or N/A

Yes No

No or N/A

No or N/A

Yes

Flow Chart Diagram: Depression outcome for concussion



Patient

INCLUDED in

Eligible

Population

Yes



Included in

Eligible

Population

Patient

INCLUDED in

Denominator

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, was the patient’s last depression scale score in the calendar year maintained or improved compared to the first depression scale score of the year?




On the date of the encounter, did patient and/or caregiver refuse depression screening?

Remove from

denominator*



numerator

On the date of the encounter, did patient have advance stage dementia, profound psychosis, or a neurodevelopmental disorder?


30

Measure Title Counseling on medication overuse headache

Description Percentage of patients > 6 years of age diagnosed with concussion and primary headache or patients diagnosed with post traumatic headache who were counseled on the avoidance of medication overuse headache once per year

Measurement Period


Eligible Population




Event Office visit

Diagnosis Post traumatic headache, primary headache and concussion

Denominator Patients > 6 years of age diagnosed with concussion and a primary headache OR Patients > 6 years of age diagnosed with post traumatic headache

Numerator Patients who were counseled on the avoidance of medication overuse headache once per year

Required Exclusions

None


Patient and/or caregiver refuse counseling Patients with intellectual disabilities and no caregiver or informant present

Exclusion Rationale

Patients have the right to refuse counseling. Some patients with intellectual disabilities may not be able to understand counseling without a caregiver or informant present.






Provider

Risk Adjustment N/A



Headache is a common symptom after concussion and can linger for months.1 Patients can obtain over-the-counter medications or be prescribed acute medications to help alleviate headaches, and if taken inappropriately, can lead to medication overuse headache. To combat the development of medication overuse headache, patients using medications to treat their headache should be counseled about this condition and how to avoid it.

Process

•Counsel patients on avoidance of medication overuse headache

Intermediate outcomes

•Adhere to treatment protocol

Outcomes

•Maintain or reduce frequency of headaches


31


No known measures exist for concussion patients.



2. DiTommaso C, Hoffman J, Lucas S, et al. Medication usage patterns for headache treatment after mild traumatic brain injury. Headache. 2014 Mar;54(3):511-9.

3. Heyer G, Idris S. Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients? Pediatr Neurol. 2014 May;50(5):464-8.


5. Lucas S, Blume H. Sport-related Headache. Neurologic Clinics 2017; 35:501-521.





ICD-10 S06.0X9D


ICD-10 S06.0X9S Concussion with loss of consciousness of unspecified duration, sequelaICD-10 G43.1 Migraine with auraICD-10 G43.109 Migraine with aura, not intractable, without status migrainosusICD-10 G43.119 Migraine with aura, intractable, without status migrainosus ICD-10 G43.101 Migraine with aura, not intractable with status migrainosus ICD-10 G43.111 Migraine with aura, intractable with status migrainosus ICD-10 G43.0 Migraine without auraICD-10 G43.009 Migraine without aura, not intractable without status migrainosusICD-10 G43.019 Migraine without aura, intractable without status migrainosus ICD-10 G43.001 Migraine without aura, not intractable with status migrainosus ICD-10 G43.011 Migraine without aura, intractable with status migrainosus ICD-10 G43.9 Migraine, unspecifiedICD-10 G43.909 Migraine, unspecified, not intractable without status migrainosusICD-10 G43.919 Migraine, unspecified, intractable without status migrainosus ICD-10 G43.901 Migraine, unspecified, not intractable with status migrainosus ICD-10 G43.911 Migraine, unspecified, intractable with status migrainosus ICD-10 G43.4 Hemiplegic migraineICD-10 G43.409 Hemiplegic migraine, not intractable without status migrainosusICD-10 G43.419 Hemiplegic migraine, intractable without status migrainosus ICD-10 G43.401 Hemiplegic migraine, not intractable with status migrainosus ICD-10 G43.411 Hemiplegic migraine, intractable with status migrainosus ICD-10 G43.8 Other migraine


32

ICD-10 G43.829 Menstrual migraine, not intractable without status migrainosusICD-10 G43.839 Menstrual migraine, intractable without status migrainosus ICD-10 G43.821 Menstrual migraine, not intractable with status migrainosus ICD-10 G43.831 Menstrual migraine, intractable with status migrainosus ICD-10 G43.5 Persistent migraine aura without cerebral infarction ICD-10 G43.509 Persistent migraine aura without cerebral infarction, not intractable without

status migrainosusICD-10 G43.519 Persistent migraine aura without cerebral infarction, intractable without status

migrainosusICD-10 G43.501 Persistent migraine aura without cerebral infarction, not intractable with status

migrainosusICD-10 G43.511 Persistent migraine aura without cerebral infarction, intractable with status

migrainosusICD-10 G43.7 Chronic migraine without auraICD-10 G43.709 Chronic migraine without aura, not intractable without status migrainosusICD-10 G43.719 Chronic migraine without aura, intractable without status migrainosusICD-10 G43.701 Chronic migraine without aura, not intractable with status migrainosusICD-10 G43.711 Chronic migraine without aura, intractable with status migrainosusICD-10 G43.8 Other migraineICD-10 G43.809 Other migraine, not intractable without status migrainosus ICD-10 G43.819 Other migraine, intractable without status migrainosus ICD-10 G43.801 Other migraine, not intractable with status migrainosus ICD-10 G43.811 Other migraine, intractable with status migrainosus ICD-10 G43.9 Migraine, unspecifiedICD-10 G43.909 Migraine unspecified, not intractable without status migrainosusICD-10 G43.919 Migraine unspecified, intractable without status migrainosus ICD-10 G43.901 Migraine, unspecified, not intractable with status migrainosus ICD-10 G43.911 Migraine, unspecified intractable with status migrainosus ICD-10 G44.1 Vascular headache, not elsewhere classifiedICD-10 R51 HeadacheICD-10 G44.001 Cluster headache syndrome, unspecified, intractable ICD-10 G44.009 Cluster headache syndrome, unspecified, not intractable ICD-10 G44.011 Episodic cluster headache, intractableICD-10 G44.019 Episodic cluster headache, not intractableICD-10 G44.021 Chronic cluster headache, intractableICD-10 G44.029 Chronic cluster headache, not intractableICD-10 G44.031 Episodic paroxysmal hemicrania, intractableICD-10 G44.039 Episodic paroxysmal hemicrania, not intractable ICD-10 G44.041 Chronic paroxysmal hemicrania, intractableICD-10 G44.049 Chronic paroxysmal hemicrania, not intractableICD-10 G44.051 Short lasting unilateral neuralgiform headache with conjunctival injection and

tearing, intractableICD-10 G44.059 Short lasting unilateral neuralgiform headache with conjunctival injection and

tearing, not intractableICD-10 G44.091 Other trigeminal autonomic cephalgias, intractable ICD-10 G44.099 Other trigeminal autonomic cephalgias, not intractable ICD-10 G44.201 Tension-type headache, unspecified, intractableICD-10 G44.209 Tension-type headache, unspecified, not intractable ICD-10 G44.211 Episodic tension-type headache, intractableICD-10 G44.219 Episodic tension-type headache, not intractableICD-10 G44.221 Chronic tension-type headache, intractable


33

ICD-10 G44.229 Chronic tension-type headache, not intractableICD-10 G44.52 New daily persistent headacheICD-10 G44.59 Other complicated headache syndromeICD-10 G44.81 Hypnic headacheICD-10 G44.85 Primary stabbing headacheICD-10 G44.89 Other headache syndromeICD-10 G44.301 Post-traumatic headache, unspecified, intractable ICD-10 G44.309 Post-traumatic headache, unspecified, not intractable ICD-10 G44.311 Acute post-traumatic headache, intractableICD-10 G44.319 Acute post-traumatic headache, not intractableICD-10 G44.321 Chronic post-traumatic headache, intractableICD-10 G44.329 Chronic post-traumatic headache, not intractable CPT 99201-99205 Office or other outpatient visit 10, 20, 30, 45, or 60 minutes for the evaluation

and management of a new patientCPT 99211-99215 Office or other outpatient visit 5, 10, 15, 25, or 40 minutes for the evaluation

and management of an established patient


34

Yes

No

No

Yes

No

Yes

No or N/A

Yes No

No or N/A

Yes

Yes

No

Flow Chart Diagram: Counseling on medication overuse headache


and primary headache during the

measurement period?

Patient

INCLUDED in

Eligible

Population

No


the measurement period?

Patient NOT

Included in

Eligible

Population

Patient

INCLUDED in

Denominator Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, was the patient counseled on the avoidance of medication overuse headache once per year?




On the date of the encounter, did patient and/or caregiver refuse counseling?

Remove from

denominator*



numerator

On the date of the encounter, did patient have an intellectual disability and no caregiver or informant was present?

Did patient have a diagnosis of post

traumatic headache during the

measurement period?

Yes


35

Measure Title Repeat imaging for concussion

Description Percentage of all patients diagnosed with concussion who received a repeat CT within 1 month after an initial normal CT or MRI *Note: this is an inverse measure where a lower score is more desirable

Measurement Period


Eligible Population



Ages All patients

Event Office visit


Denominator All patients diagnosed with concussion

Numerator Patients who received a repeat CT within 1 month after an initial normal CT or MRI

Required Exclusions

None


None

Exclusion Rationale

None



Lower score indicates better quality



Provider

Risk Adjustment N/A



The neurological history and exam continue to be the primary tool to diagnose and manage concussion. Almenawer et al. state “…the simple yet important neurological examination is the predictive factor of changing the management and guiding the needs for repeat imaging after mild head injury.”1 Continuing to do repeat imaging is a waste of time and resources and with CT involves unnecessary radiation exposure.


No similar measures known.

Process

•Repeat imaging for concussion within 1 month after an initial normal CT or MRI

Outcomes

•Decrease CT utilization

•Decrease radiation exposure


36


1. Almenawer SA, Bogza I, Yarascavitch B, et al. The value of scheduled repeat cranial computed tomography after mild head injury: Single-Center Series and Meta-analysis. Neurosurgery 2013;72:56-64.




5. Ellis M, Leiter J, Hall T, et al. Neuroimaging findings in pediatric sports-related concussion. J Neurosurg Pediatr 2015; 16:241-247.

Code System Code Code Description ICD-10 S06.0X0D Concussion without loss of consciousness, subsequent encounterICD-10 S06.0X0S Concussion without loss of consciousness, sequela ICD-10



S06.0X9D Concussion with loss of consciousness of unspecified duration, subsequent encounter


99211-99215



37

No

No

Yes

Yes No

Yes

Flow Chart Diagram: Repeat imaging for concussion


curing the measurement period?

Patient

INCLUDED in

Eligible

Population

Patient NOT

Included in

Eligible

Population

Patient

INCLUDED in

Denominator

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

During the measurement period, did the patient receive a repeat CT within 1 month after an initial normal CT or MRI?





38

Contact Information

American Academy of Neurology 201 Chicago Avenue Minneapolis, MN 55415 [email protected]


39

Appendix A AAN Statement on Comparing Outcomes of Patients

Why this statement: Characteristics of patients can vary across practices and differences in those characteristics may impact the differences in health outcomes among those patients. Some examples of these characteristics are demographics, co-morbidities, socioeconomic status, and disease severity. Because these variables are typically not under the control of a clinician, it would be inappropriate to compare outcomes of patients managed by different clinicians and practices without accounting for those differences in characteristics among patients. There are many approaches and models to improve comparability, but this statement will focus on risk adjustment. This area continues to evolve (1), and the AAN will revisit this statement regularly to ensure accuracy, as well as address other comparability methods (2) should they become more common.

AAN quality measures are used primarily to demonstrate compliance with evidence-based and consensus-based best practices within a given practice as a component of a robust quality improvement program. The AAN includes this statement to caution against using certain measures, particularly outcome measures, for comparison to other individuals/practices/hospitals without the necessary and appropriate risk adjustment.

What is Risk Adjustment: Risk adjustment is a statistical approach that can make populations more comparable by controlling for patient characteristics (most commonly adjusted variable is a patient’s age) that are associated with outcomes but are beyond the control of the clinician. By doing so, the processes of care delivered, and the outcomes of care can be more strongly linked.

Comparing measure results from practice to practice: For process measures, the characteristics of the population are generally not a large factor in comparing one practice to another. Outcome measures, however, may be influenced by characteristics of a patient that are beyond the control of a clinician.(3) For example, demographic characteristics, socioeconomic status, or presence of comorbid conditions, and disease severity may impact quality of life measurements. Unfortunately, for a particular outcome, there may not be sufficient scientific literature to specify the variables that should be included in a model of risk adjustment. When efforts to risk adjust are made, for example by adjusting socioeconomic status and disease severity, values may not be documented in the medical record, leading to incomplete risk adjustment.

When using outcome measures to compare one practice to another, a methodologist, such as a health researcher, statistician, actuary or health economist, ought to ensure that the populations are comparable, apply the appropriate methodology to account for differences or state that no methodology exists or is needed.

Use of measures by other agencies for the purpose of pay-for-performance and public reporting programs: AAN measures, as they are rigorously developed, may be endorsed by the National Quality Forum or incorporated into Centers for Medicare & Medicaid Services (CMS) and private payer programs. 14

It is important when implementing outcomes measures in quality measurement programs that a method be employed to account for differences in patients beyond a clinicians’ control such as risk adjustment.

References and Additional Reading for AAN Statement on Comparing Outcomes of Patients

1. Shahian DM, Wolf RE, Iezzoni LI, Kirle L, Normand SL. Variability in the measurement of hospital‐wide mortality rates. N Engl J Med

2010;363(26):2530‐2539. Erratum in: N Engl J Med 2011;364(14):1382.

2. Psaty BM, Siscovick DS. Minimizing bias due to confounding by indication in comparative effectiveness research: the importance of restriction.

JAMA 2010;304(8):897‐898.

3. National Quality Forum. Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors. August 2014. Available at:

http://www.qualityforum.org/Publications/2014/08/Risk_Adjustment_for_Socioeconomic_Status_or_Other_Sociodemographic_Factors.as px

Accessed on January 8, 2015.

• Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50(12):1109‐1118.

• Pope GC, Kauter J, Ingber MJ, et al. for The Centers for Medicare & Medicaid Services’ Office of Research, Development, and Information.

Evaluation of the CMS‐HCC Risk Adjustment Model. March 2011. Available at: http://www.cms.gov/Medicare/HealthPlans/MedicareAdvtgSpecRateStats/downloads/evaluation_risk_adj_model_2011.pdf [Accessed on January 8, 2015].


40

Appendix B Disclosures

Work Group Member Disclosures Wayne Anderson, DO, FAAN, FAHS Dr. Anderson has been an expert witness in CRPS and catastrophic injury

cases.Steven Broglio, PhD, ATC Dr. Broglio has received funding for travel from the NCAA, NIH, AAN,

and NATA. He serves as an editor for the Journal of Athletic Training, Concussion, British Journal of Sports Medicine, Athletic Training & Sports Health Care. Dr. Broglio has received research support from the NCAA, DoD, NIH, and University of Michigan. He has provided an affidavit for a legal proceeding.

Daniel Feinberg, MD, FAAN Dr. Feinberg has given expert testimony on behalf of defendants and plaintiffs.

Aravind Ganesh, MD Dr. Ganesh receives honoraria from NHS Health Education England and Genome BC. He receives research support from Rhodes Trust, Wellcome Trust, and Murray Speight Foundation. Dr. Ganesh received compensation for serving on a board of directors for Advanced Health Analytics, SnapDx, and TheRounds.ca.

Lauren Green, DO, RD Nothing to disclose.Michael S. Jaffee, MD, FAAN, FANA Dr. Jaffee has received funding for travel to serve as Chair for a DoD

Congressionally Directed Medical Research Program which includes studies on the chronic effects of concussion. He receives research support from Neurorehabilitation, the University of Florida, and the state government of Florida. Dr. Jaffee has received compensation as an evaluating neurologist for the national NFL disability programs and has provided an affidavit regarding clinical care as a paid subject matter expert to the NCAA.

Michael Kaplen, Esq Nothing to disclose.Matthew Lorincz, MD, PhD Dr. Lorincz has received funding for travel to the NCAA to review

concussion protocols, editorial service for Medlink Neurology, and serving on the Xenith Scientific Advisory Board.

Arthur De Luigi, DO, MHSA, FAAPMR, CAQSM, CAQBIM, DABPM, RMSK

Nothing to disclose.

Deepak Patel, MD, FAAFP, FACSM Nothing to disclose.Sean Rose, MD Dr. Rose has received research support from the Abigail Wexner Research

Institute at Nationwide Children’s Hospital, the Dale and Amy Earnhardt Fund, MORE Foundation, Riddell, ElMindA, S Dallas Rowe and Associates.

Jack Tsao, MD, DPhil, FAAN, FANA Dr. Tsao serves as the Navy Reserve representative to the Department of Defense Traumatic Brain Injury Advisory Committee. He receives royalties from Springer for two books: 1) Traumatic Brain Injury: A Clinician’s Guide to Diagnosis, Management, and Rehabilitation, and 2) Teleneurology in Practice: A Comprehensive Clinical Guide. Dr. Tsao holds stock in Biogen and Illumina.

Adam Webb, MD, FAAN Dr. Webb has received compensation for activities with Bard Medical as a consultant.

Steven Broglio, PhD, ATC provided edits to measures on behalf of the National Athletic Trainer’s Association but is not listed as an author of this work.


41

References

1. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017; 51(11):838-847.

2. Giza C, Kutch J, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the guideline development subcommittee of the American Academy of Neurology. Neurology 2013; 80(24):2250-2257.

3. Bryan MA, Rowhani-Rahbar A, Comstock R, Rivara F. Sports- and recreation-related concussions in US youth. Pediatrics 2016; 138(1).

4. Mannix R, O’Brien M, Meehan W, 3rd. The epidemiology of outpatient visits for minor head injury: 2005 to 2009. Neurosurgery 2013; 73(1):129-134; discussion 134.

5. Zhang A, Sing D, Rugg C, Feeley B, Senter C. The rise of concussions in the adolescent population. Orthopaedic Journal of Sports Med 2016; 4(8).

6. Broglio S, Cantu R, Gioia G, et al. National Athletic Trainers’ Association position statement: management of sport concussion. Journal of Athletic Training 2014; 49(2):245-265.

7. Halstead M, Walter K, Moffatt K. Sport-related concussion in children and adolescents. Pediatrics 2018; 142(6).

8. Harmon K, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sports. Br J Sports Med 2013; 47(1):15-26.

9. Bakhos L, Lockhart G, Myers R, Linakis J. Emergency department visits for concussion in young child athletes. Pediatrics 2010; 126(3): e550-556.

10. Lincoln A, Caswell S, Almquist J, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med 2011; 39(5):958-963.

11. Heyer G, Schaffer C, Rose S, et al. Specific factors influence postconcussion symptom duration among youth referred to a sports concussion clinic. J Pediatr 2016; 174:33-38.

12. Grubenhoff J, Currie D, Comstock R, et al. Psychological factors associated with delayed symptom resolution in children with concussion. J Pediatr 2016; 174:27-32.

13. Simpson T, Peterson R, Mason D, et al. Quality of life for youth with persistent postconcussive symptoms following mild traumatic brain injury. Clinical Practice in Pediatric Psychology 2017; 5(3):248-257.

14. Lumba-Brown A, Yeates K, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of mild traumatic brain injury among children. JAMA pediatrics 2018; e182853.

2019-10-15 concussion measurement set · aravind ganesh, md lauren green, do, rd michael jaffee,...

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