quality measures in orthopaedics...total hip replacements hoos harris hip no specific tool vr-12...
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Quality Measures in Orthopaedics Appendix III: Tools Used
American Association of Orthopaedic Executives Quality Measures Task Force
Quality Measures in Orthopaedics. Published by the American Association of Orthopaedic Executives, 6602 E. 75th St. Suite 112, Indianapolis, IN, 46250 © 2016 by the American Association of Orthopaedic Executives. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of the American Association of Orthopaedic Executives.
Contents Tools Used .................................................................................................... 2
Data Collection Tools Used ........................................................................... 2
American Association of Orthopaedic Executives
1
This appendix shows the tools, in order of popularity, that respondents stated they use to collect data for the measure. The most popular measure is shown in column one (1) with the least popular measure shown in column ten (10).
Quality Measures in Orthopaedics
2
Tools Used Data Collection Tools Used
# Measure 1 2 3 4 5 6 7 8 9 10
1
Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older
HOO
S
Oxf
ord
Knee
KOO
S
VR-1
2
DASH
EHR/
EMR
Harr
is Hi
p
ODI
Ow
n th
e Bo
ne
WO
MAC
2
Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy
VR-1
2
HER/
EMR
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
3
Osteoarthritis (OA): Function and Pain Assessment HO
OS
KOO
S
Oxf
ord
Knee
Pain
Ass
essm
ent
Scal
e
VR-1
2
Activ
ities
of
Daily
Liv
ing
Harr
is Hi
p Sc
ore
Knee
Soc
iety
Sc
ore
WO
MAC
PRO
MIS
4
Rheumatoid Arthritis (RA): Tuberculosis Screening
Tube
rcul
osis
Scre
enin
g
HER/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
5
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity EH
R/EM
R
HAQ
-DI
In-H
ouse
De
velo
ped
Asse
ssm
ent
Oxf
ord
Knee
VR-1
2
N/A
N/A
N/A
N/A
N/A
6
Rheumatoid Arthritis (RA): Functional Status Assessment VR
-12
Activ
ities
of
Daily
Liv
ing
EHR/
EMR
KOO
S
Oxf
ord
Knee
Rapi
d 3
Asse
ssm
ent
N/A
N/A
N/A
N/A
7
Rheumatoid Arthritis: Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy
EHR/
EMR
HOO
S
KOO
S
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
3
# Measure 1 2 3 4 5 6 7 8 9 10 8
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis EH
R/EM
R
HOO
S
KOO
S
Oxf
ord
Knee
Rapi
d 3
Asse
ssm
ent
VR-1
2
N/A
N/A
N/A
N/A
9
Rheumatoid Arthritis (RA): Glucocorticoid Management
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
10
Functional status change for patients with Knee impairments
KOO
S
Oxf
ord
Knee
LEFS
HOO
S
Knee
Soc
iety
Sc
ore
Prom
is
WO
MAC
Activ
ities
of
Daily
Liv
ing
Fall
Risk
As
sess
men
t
IDKC
11
Functional status change for patients with Hip impairments HO
OS
Harr
is Hi
p Sc
ore
VR-1
2
Activ
ities
of
Daily
Liv
ing
Fall
Risk
As
sess
men
t
LEFS
Oxf
ord
Knee
PRO
MIS
WO
MAC
No
Spec
ific
Tool
12
Functional status change for patients with Foot and Ankle impairments
AOFA
S
LEFS
SF-1
2
VR-1
2
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
13
Functional status change for patients with lumbar impairments
ODI
SF-1
2
Pain
As
sess
men
t Sc
ale
VR-1
2
N/A
N/A
N/A
N/A
N/A
N/A
14
Functional status change for patients with Shoulder impairments
DASH
SF-1
2
ASES
SPAD
I
VR-1
2
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
15
Functional status change for patients with elbow, wrist or hand impairments
DASH
SF-1
2
VR-1
2
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
16
Functional status change for patients with General orthopaedic impairments
VR-1
2
Activ
ities
of
Daily
Liv
ing
KOO
S
PRO
MIS
SF-1
2
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
17
Use of Imaging Studies for Low Back Pain
X-Ra
y
MRI
EHR/
EMR
ODI
PACS
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
4
# Measure 1 2 3 4 5 6 7 8 9 10 18
Back Pain: Appropriate Imaging for Acute Back Pain X-
Ray
MRI
EHR/
EMR
Oxf
ord
Knee
ODI
VR-1
2
CPT
Code
HOO
S
WO
MAC
N/A
19
Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
20
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
No
Spec
ific
Tool
KOO
S
HOO
S
VR-1
2
WO
MAC
EHR/
EMR
In-H
ouse
De
velo
ped
Asse
ssm
ent
LEFS
Oxf
ord
Knee
N/A
21
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
No
Spec
ific
Tool
In-H
ouse
De
velo
ped
Asse
ssm
ent
EHR/
EMR
KOO
S
Char
lest
on C
o-M
orbi
dity
Inde
x
N/A
N/A
N/A
N/A
N/A
22
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
Hosp
ital
Trac
ked
No
Spec
ific
Tool
In-H
ouse
De
velo
ped
Asse
ssm
ent
N/A
N/A
N/A
N/A
N/A
N/A
N/A
23
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
Hosp
ital
Trac
ked
No
Spec
ific
Tool
In-H
ouse
De
velo
ped
Asse
ssm
ent
Oxf
ord
Knee
Prom
is
N/A
N/A
N/A
N/A
N/A
24
Functional Status Assessment for Knee Replacement KO
OS
Knee
Soc
iety
Sc
ore
No
Spec
ific
Tool
VR-1
2
WO
MAC
EHR/
EMR
Func
tiona
l As
sess
men
t
HOO
S
Prom
is
SF-1
2
25
Functional Status Assessment for Hip Replacement
HOO
S
No
Spec
ific
Tool
Harr
is Hi
p
Prom
is
Fall
Risk
As
sess
men
t
Func
tiona
l As
sess
men
t
HSS
LEFS
Oxf
ord
Knee
SF-1
2
American Association of Orthopaedic Executives
5
# Measure 1 2 3 4 5 6 7 8 9 10 26
Back Pain Condition Episode for CMS Episode Grouper VA
S
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
27
Back Pain: Advice Against Bed Rest
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
28
Back Pain: Advice for Normal Activities
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
29
Back Pain: Initial Visit
ODI
X-Ra
y
EHR/
EMR
VAS
N/A
N/A
N/A
N/A
N/A
N/A
30
Back Pain: Physical Exam
EHR/
EMR
X-Ra
y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
31
Back Pain: Repeat Imaging Studies
MRI
X-Ra
y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
32
Functional Status Assessment and Goal Setting in Patients with Rheumatoid Arthritis
EHR/
EMR
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
33
Hip Osteoarthritis Condition Episode for CMS Episode Grouper N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
34
Hip Replacement/Revision Clinical Episode-Based Payment Measure
Oxf
ord
Knee
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
35
Hip Replacement/Revision Treatment Episode for CMS Episode Grouper
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
6
# Measure 1 2 3 4 5 6 7 8 9 10 36
Hip/Femur Fracture Condition Episode for CMS Episode Grouper
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
37
Hip/Femur Fracture Repair Treatment Episode for CMS Episode Grouper
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
38
Knee Osteoarthritis Condition Episode for CMS Episode Grouper
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
39
Knee Replacement/Revision Clinical Episode-Based Payment Measure
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
40
Lumbar Spine Fusion/Refusion Clinical Episode-Based Payment Measure
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
41
Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications
EHR/
EMR
No
Spec
ific
Tool
KOO
S
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
42
Non-steroidal/Anti-inflammatory (NSAID) Risk Assessment N
o Sp
ecifi
c To
ol
EHR/
EMR
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
N/A
43
Osteoporosis: Counseling for Vitamin D, Calcium Intake, and Exercise EH
R/EM
R
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
44
Shoulder Osteoarthritis Condition Episode for CMS Episode Grouper
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
7
# Measure 1 2 3 4 5 6 7 8 9 10 45
Shoulder Replacement/Repair Treatment Episode for CMS Episode Grouper
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
46
Steroid Use - Osteoporosis Screening
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
47
Lumbar Fusion: Average change in functional status O
DI
SF-1
2
VAS
VR-1
2
X-Ra
y
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
48
Lumbar Fusion: Average change in health related quality of life O
DI
VR-1
2
SF-1
2
No
Spec
ific
Tool
HOO
S
Prom
is
N/A
N/A
N/A
N/A
49
Lumbar Fusion: Average change in back pain O
DI
VAS
VR-1
2
SF-1
2
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
50
Lumbar Fusion: Average change in leg pain O
DI
VAS
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
51
Lumbar Discectomy Laminotomy: Average change in functional status
ODI
SF-1
2
No
Spec
ific
Tool
VAS
VR-1
2
N/A
N/A
N/A
N/A
N/A
52
Lumbar Discectomy Laminotomy: Average change in health related quality of life
ODI
SF-1
2
VR-1
2
No
Spec
ific
Tool
VAS
N/A
N/A
N/A
N/A
N/A
53
Lumbar Discectomy Laminotomy: Average change in back pain
VAS
ODI
No
Spec
ific
Tool
SF-1
2
VR-1
2
N/A
N/A
N/A
N/A
N/A
54
Lumbar Discectomy Laminotomy: Average change in leg pain
VAS
ODI
No
Spec
ific
Tool
SF-1
2
VR-1
2
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
8
# Measure 1 2 3 4 5 6 7 8 9 10 55
Total Knee Replacement: Average change in functional status
KOO
S
Oxf
ord
Knee
Prom
is
No
Spec
ific
Tool
HOO
S
IDKC
LEFS
SF-1
2
VR-1
2
WO
MAC
56
Total Knee Replacement: Average change in health related quality of life
HOO
S
KOO
S
VR-1
2
SF-1
2
Oxf
ord
Knee
Harr
is Hi
p
WO
MAC
Oxf
ord
Hip
Prom
is
Arth
rex
SOS
57
Functional Status Outcomes for Patients Receiving Primary Total Hip Replacements
HOO
S
Harr
is Hi
p
No
Spec
ific
Tool
VR-1
2
LEFS
Oxf
ord
Knee
Prom
is
WO
MAC
N/A
N/A
58
Functional Status Outcomes for Patients Receiving Primary Total Knee Replacements
KOO
S
Knee
Soc
iety
Sc
ore
Oxf
ord
Knee
Prom
is
VR-1
2
HOO
S
IDKC
LEFS
SF-1
2
WO
MAC
59
ETG Based HIP/KNEE REPLACEMENT cost of care measure
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
60
Osteopenia and Chronic Steroid Use - Treatment to Prevent Osteoporosis
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
61
Osteoporosis - Use of Pharmacological Treatment
EHR/
EMR
In-H
ouse
De
velo
ped
Asse
ssm
ent
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
62
Osteoporosis Management in Women Who Had a Fracture
EHR/
EMR
In-H
ouse
De
velo
ped
Asse
ssm
ent
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
63
Counseling for physical activity among persons with arthritis.
EHR/
EMR
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
9
# Measure 1 2 3 4 5 6 7 8 9 10 64
Counseling for weight loss among overweight/obese persons with arthritis
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
65
Carpal tunnel syndrome (CTS): Avoidance of Carpal Tunnel Surgery During Pregnancy
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
66
Carpal tunnel syndrome (CTS): percentage of eligible visits for which there is documentation in the medical record of the specific job duties or non-occupational activities that are associated with the CTS symptoms
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
67
Carpal tunnel syndrome (CTS): percentage of eligible visits for which the progress notes documented that the patient was asked about changes in at least one of the following: pain, paresthesias in the first through third digits, or symptoms of hand weakness
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
10
# Measure 1 2 3 4 5 6 7 8 9 10 68
Carpal tunnel syndrome (CTS): percentage of eligible visits for which notes documented whether or not the patient was currently working.
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
69
Carpal tunnel syndrome (CTS): percentage of eligible patients with severe CTS who underwent carpal tunnel surgery, or were offered it and declined (part I).
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
70
Carpal tunnel syndrome (CTS): percentage of eligible patients with severe CTS who underwent carpal tunnel surgery, or were offered it and declined (part II).
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
71
Carpal tunnel syndrome (CTS): percentage of eligible patients with severe CTS who underwent carpal tunnel surgery, or were offered it and declined (part III).
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
72
Carpal tunnel syndrome (CTS): percentage of eligible patients with moderate CTS who underwent carpal tunnel surgery, or were offered it and declined (part I).
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
11
# Measure 1 2 3 4 5 6 7 8 9 10 73
Carpal tunnel syndrome (CTS): percentage of eligible patients with moderate CTS who underwent carpal tunnel surgery, or were offered it and declined (part II).
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
74
Carpal tunnel syndrome (CTS): percentage of eligible patients with moderate CTS who did not undergo carpal tunnel surgery during the study period (part I).
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
75
Carpal tunnel syndrome (CTS): percentage of eligible patients with moderate CTS who did not undergo carpal tunnel surgery during the study period (part II).
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
76
Carpal tunnel syndrome (CTS): percentage of eligible patients with moderate CTS who did not undergo carpal tunnel surgery during the study period (part III).
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
77
Carpal tunnel syndrome (CTS): percentage of eligible patients with moderate CTS who did not undergo carpal tunnel surgery during the study period (part IV).
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
12
# Measure 1 2 3 4 5 6 7 8 9 10 78
Carpal tunnel syndrome (CTS): percentage of eligible patients with mild CTS who underwent carpal tunnel surgery, or were offered it and declined
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
79
Carpal tunnel syndrome (CTS): percentage of eligible patients with mild CTS who did not undergo carpal tunnel surgery during the study period (part I)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
80
Carpal tunnel syndrome (CTS): percentage of eligible patients with mild CTS who did not undergo carpal tunnel surgery during the study period (part II)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
81
Carpal tunnel syndrome (CTS): percentage of eligible patients whose medical record for the visit at which the splint was first prescribed documented that the splint was adjusted so that the wrist was in neutral position
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
13
# Measure 1 2 3 4 5 6 7 8 9 10 82
Carpal tunnel syndrome (CTS): percentage of eligible patients whose CTS symptoms worsened after the closed reduction of a wrist fracture or immobilization of the wrist and who underwent carpal tunnel surgery within 48 hours, or for whom refusal of surgery was documented within 48 hours, of the reduction or immobilization
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
83
Carpal tunnel syndrome (CTS): percentage of eligible patients who have either four or fewer injections in the study hand before the end of the study period or five or more injections in the study hand before the end of the study period and documented refusal of surgery during the six months before the fifth injection
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
14
# Measure 1 2 3 4 5 6 7 8 9 10 84
Carpal tunnel syndrome (CTS): percentage of eligible patients who have documentation in the medical record by the second CTS-related visit after the diagnosis indicating a provider's opinion of the probability that the CTS is work associated and a rationale for that judgment
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
85
Carpal tunnel syndrome (CTS): percentage of eligible patients who had a follow-up visit to a provider who treats musculoskeletal disorders within four weeks of returning to work and for whom the provider's note for this visit documented the presence or absence of occupational functional limitations
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
15
# Measure 1 2 3 4 5 6 7 8 9 10 86
Carpal tunnel syndrome (CTS): percentage of eligible patients who are off work for four or more weeks for CTS-related symptoms for whom the visit note documented the presence or absence of one or more of the following: 1) alcohol or substance abuse, 2) depression or anxiety, or 3) other barriers to return to work
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
87
Carpal tunnel syndrome (CTS): percentage of eligible patients having documentation in the six weeks before or at the visit, by the provider who prescribed/administered the steroids, that he or she discussed surgery with the patient
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
16
# Measure 1 2 3 4 5 6 7 8 9 10 88
Carpal tunnel syndrome (CTS): percentage of eligible patients having documentation in the medical record that activity modification was discussed with the patient at the visit at which the exposures to mechanical force, vibration, or frequent repetitive wrist movements were first documented
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
89
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom there is documentation in the medical record of at least one of the specified pieces of history from the time of the initial evaluation of the CTS symptoms through the two subsequent CTS-related visits
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
17
# Measure 1 2 3 4 5 6 7 8 9 10 90
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the presence or absence of at least one of the specified occupational exacerbating factors is documented from the time of the initial evaluation of the CTS symptoms through the two subsequent CTS-related visits
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
91
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the presence or absence of at least one of the specified non-occupational exacerbating factors is documented in the medical record from the time of the initial evaluation of the CTS symptoms through the two subsequent CTS-related visits
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
18
# Measure 1 2 3 4 5 6 7 8 9 10 92
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the physician administering or prescribing steroids documented a follow-up call or visit with the patient within four weeks.
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
93
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the medical record for the visit at which splints were first prescribed, or any subsequent visits occurring within six weeks, documented that the splint was prescribed for at least six weeks.
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
94
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom one or more risks of steroids (or prior receipt of steroids) were documented in the medical record as having been discussed within six weeks before the steroids were administered or prescribed
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
19
# Measure 1 2 3 4 5 6 7 8 9 10 95
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom one or more of the specified criteria regarding MRI or CT testing is documented in the medical record.
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
96
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom no provider has documented that they prescribed or administered laser therapy as treatment for CTS symptoms
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
97
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom no provider documented that they prescribed or recommended NSAIDs as treatment for CTS symptoms
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
98
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom no provider documented that they prescribed opiates (opioids) as treatment for CTS symptoms
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
20
# Measure 1 2 3 4 5 6 7 8 9 10 99
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom no provider documented that they prescribed muscle relaxants as treatment for CTS symptoms.
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
100
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom no provider documented that they prescribed diuretics as treatment for CTS symptoms.
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
101
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom height and weight or a clinical judgment about presence or absence of obesity/overweight are documented in the medical record for the initial evaluation visit.
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
102
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom at least two of the following were documented in the medical record for the initial evaluation visit: location, quality, duration, and onset.
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
21
# Measure 1 2 3 4 5 6 7 8 9 10 10
3
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom a suspicion of CTS was explicitly documented in the medical record at or before the visit at which a provider first evaluated the finger symptoms
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
104
Adult acute and subacute low back pain: percentage of patients with radicular pain for whom the clinician ordered imaging studies during the six weeks after pain onset
EHR/
EMR
X-Ra
y
VR-1
2
No
Spec
ific
Tool
ODI
SF-1
2
N/A
N/A
N/A
N/A
105
Adult acute and subacute low back pain: percentage of patients with non-specific back pain diagnosis who received inappropriate repeat imaging studies in the absence of "red flags" or progressive symptoms
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
22
# Measure 1 2 3 4 5 6 7 8 9 10 10
6
Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have their pain status assessed using the Visual Analog Scale, pain diagram or other assessment tool
VAS
Prom
is
No
Spec
ific
Tool
AII
ODI
VR-1
2
N/A
N/A
N/A
N/A
107
Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have their functional status assessed using the Oswestry Disability Questionnaire or other assessment tool
ODI
No
Spec
ific
Tool
VR-1
2
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
23
# Measure 1 2 3 4 5 6 7 8 9 10 10
8
Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have all of the following at the initial visit with the physician: pain assessment using the Visual Analog Scale, pain diagram or other assessment tool; functional status using the Oswestry Disability Questionnaire or other assessment tool; patient history, including notation of presence or absence of "red flags"; assessment of prior treatment and response; job and activity association; and psychosocial screening that includes depression and chemical dependency screening
ODI
Prom
is
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
24
# Measure 1 2 3 4 5 6 7 8 9 10 10
9
Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who have a reassessment at each follow-up visit that includes: pain assessment using the Visual Analog Scale, pain diagram or other assessment tool; functional status using the Oswestry Disability Questionnaire or other assessment tool; clinician's objective assessment; and psychosocial screening that includes depression and chemical dependency screening
ODI
Prom
is
VAS
N/A
N/A
N/A
N/A
N/A
N/A
N/A
110
Adult acute and subacute low back pain: percentage of patients with low back pain diagnosis who are prescribed opioids
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
25
# Measure 1 2 3 4 5 6 7 8 9 10 11
1
Adult acute and subacute low back pain: percentage of patients with a diagnosis of non-specific back pain for whom the physician ordered imaging studies during the six weeks after pain onset, in the absence of "red flags."
EHR/
EMR
100
AII
VR-1
2
N/A
N/A
N/A
N/A
N/A
N/A
112
Adult acute and subacute low back pain: percentage of patients who were advised on maintenance or resumption of activities, against bed rest, use of heat, education on importance of active lifestyle and exercise, and recommendation to take anti-inflammatory or analgesic medication in the first six weeks of pain onset in the absence of "red flags."
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
113
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the progress notes from the visit document the presence or absence of at least one of the following: trauma, deformity, and fever.
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
26
# Measure 1 2 3 4 5 6 7 8 9 10 11
4
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the presence or absence of at least one of the following risk factors was documented in the medical record at the initial evaluation or two subsequent CTS-related visits: rheumatoid or other arthritis, diabetes mellitus, hypothyroidism, pregnancy, and chronic renal failure
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
115
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the medical record from the visit documented that at least one diagnosis other than CTS was evaluated
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
27
# Measure 1 2 3 4 5 6 7 8 9 10 11
6
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom the medical record documents that at least one of the following physical examination maneuvers was performed during the visit: testing for sensory abnormalities in median nerve distribution, testing for thenar muscle weakness, and examination for thenar muscle atrophy
EHR/
EMR
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
117
Total knee replacement: percentage of patients undergoing a total knee replacement with radiographic evidence of arthritis within one year prior to the procedure
EHR/
EMR
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
28
# Measure 1 2 3 4 5 6 7 8 9 10 11
8
Total knee replacement: percentage of patients undergoing a total knee replacement who had a physical examination completed within one year prior to the procedure that included all of the following: gait, knee range of motion, presence or absence of deformity of the knee, stability of the knee, neurologic status, vascular status, skin, height, and weight
Oxf
ord
Knee
Prom
is
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
119
Total knee replacement: percentage of patients undergoing a total knee replacement who had a history completed within one year prior to the procedure that included all of the following: onset and duration of symptoms, location and severity of pain, activity limitations
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
29
# Measure 1 2 3 4 5 6 7 8 9 10 12
0
Diagnosis and treatment of osteoporosis: percentage of patients with a low-impact (fragility) fracture who are taking calcium and vitamin D dietary supplementation
In-H
ouse
Dev
elop
ed
Asse
ssm
ent
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
121
Diagnosis and treatment of osteoporosis: percentage of patients with a history of low-impact (fragility) fracture who were assessed for osteoporosis
In-H
ouse
Dev
elop
ed
Asse
ssm
ent
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
122
Diagnosis and treatment of osteoporosis: percentage of patients with a history of low-impact (fragility) fracture assessed for secondary causes of osteoporosis
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
123
Diagnosis and treatment of osteoporosis: percentage of patients with a history of low-impact (fragility) fracture and diagnosed with osteoporosis due to secondary causes offered treatment
In-H
ouse
Dev
elop
ed A
sses
smen
t
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
30
# Measure 1 2 3 4 5 6 7 8 9 10 12
4
Diagnosis and treatment of osteoporosis: percentage of patients diagnosed with osteoporosis who are on pharmacologic therapy
In-H
ouse
Dev
elop
ed
Asse
ssm
ent
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
125
Carpal tunnel syndrome (CTS): percentage of eligible patients having documentation in the medical record that within the first four weeks after the diagnosis of CTS a provider who treats musculoskeletal disorders educated them about CTS
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
126
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom CTS was mentioned in the progress note from a follow-up visit with a provider who treats musculoskeletal disorders within 4 weeks of the visit at which the CTS symptoms were first described as work associated
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
31
# Measure 1 2 3 4 5 6 7 8 9 10 12
7
Carpal tunnel syndrome (CTS): percentage of eligible patients for whom a provider who treats musculoskeletal disorders has not documented that carpal tunnel surgery is contraindicated because the patient has diabetes
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
128
Functional Status Assessment and Improvement for Patients who Received a Total Hip Replacement
HOO
S
Harr
is Hi
p
Oxf
ord
Knee
Prom
is
LEFS
VR-1
2
WO
MAC
AII
Arth
rex
SOS
N/A
129
Functional Status Assessment and Improvement for Patients who Received a Total Knee Replacement
KOO
S
Oxf
ord
Knee
HOO
S
Prom
is
No
Spec
ific
Tool
Knee
Soc
iety
Sc
ore
IDKC
LEFS
WO
MAC
N/A
130
Patient(s) with rheumatoid arthritis taking methotrexate, sulfasalazine, gold, or leflunomide that had a CBC in last 3 reported months
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
131
Patient(s) with Rheumatoid Arthritis Taking Methotrexate or Sulfasalazine that had a Serum Creatinine in Last 6 Reported Months
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
32
# Measure 1 2 3 4 5 6 7 8 9 10 13
2
Patient(s) with Rheumatoid Arthritis Taking Methotrexate, Sulfasalazine, or Leflunomide that had Serum ALT or AST Test in Last 3 Reported Months
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
133
New Rheumatoid Arthritis Baseline ESR or CRP within Three Months N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
134
Rheumatoid Arthritis New DMARD Baseline CBC N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
135
Rheumatoid Arthritis New DMARD Baseline Liver Function Test
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
136
Rheumatoid Arthritis Annual ESR or CRP N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
137
Rheumatoid Arthritis New DMARD Baseline Serum Creatinine N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
138
Methotrexate: LFT within 12 weeks N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
139
Methotrexate: CBC within 12 weeks N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
140
Methotrexate: Creatinine within 12 weeks N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
American Association of Orthopaedic Executives
33
# Measure 1 2 3 4 5 6 7 8 9 10 14
1
Back Pain: Mental Health Assessment
VR-1
2
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
142
Back Pain: Recommendation for Exercise
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
143
Back Pain: Appropriate Use of Epidural Steroid Injections
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
144
Back Pain: Surgical Timing
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
145
Back Pain: Patient Reassessment
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
146
Back Pain: Shared Decision Making
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
147
Osteoarthritis Medication Monitoring
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
148
Appropriate follow-up imaging for non-traumatic knee pain
KOO
S
Oxf
ord
Knee
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
149
Appropriate Use of Imaging for Non-Traumatic Shoulder Pain N
/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
150
LBP: Evaluation of Patient Experience
Pres
s Ga
ney
CAHP
S
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Quality Measures in Orthopaedics
34
151
LBP: Post-surgical Outcomes
ODI
SF-1
2
VAS
N/A
N/A
N/A
N/A
N/A
N/A
N/A
152
LBP: Patient Education
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
153
Therapeutic Exercise for the Involved Joint
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
154
Anti-inflammatory/Analgesic Therapy
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
155
Physical Examination of the Involved Joint
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
156
Rheumatoid Arthritis Medication Monitoring
EHR/
EMR
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
157
Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis
KOO
S
HOO
S
Oxf
ord
Knee
SF-1
2
VR-1
2
No
Spec
ific
Tool
N/A
N/A
N/A
N/A
# Measure 1 2 3 4 5 6 7 8 9 10