Chartbook Section 9
Minnesota Statewide Quality Reporting
and Measurement System
Background
Minnesota’s Health Reform Law, enacted in 2008, requires the
Commissioner of Health to establish a standardized set of
quality measures for health care providers across the state.
 This set of measures is known as the Minnesota Statewide
Quality Reporting and Measurement System.
 MDH updates the measure set every year, after seeking
public comments and recommendations from the
community.
 Physician clinics and hospitals are required to report
quality measures annually. Statewide data collection
began in 2010.
 At this point, more than 1,200 clinics report on 12 quality
metrics; 133 hospitals report on a number of hospital
measures.
2
Contents

Selected Clinic Quality Measures

Optimal Diabetes Care

Optimal Vascular Care

Optimal Asthma Control – Adult and Child

Asthma Education and Self-Management – Adult
and Child

Colorectal Cancer Screening

Depression Remission at Six Months

Adolescent Mental Health and/or Depression
Screening
3
Contents

Selected Clinic Quality Measures, Continued

Spinal Surgery: Lumbar Fusion

Spinal Surgery: Lumbar Discectomy
Laminotomy

Total Knee Replacement: Primary

Patient Experience of Care
4
Contents



Selected Hospital Quality Measures

Hospital Value-Based Purchasing Total
Performance Score

Hospital Acquired Condition Reduction Program
Score

Hospital Readmissions Reduction Program
Excess Readmission Score

Emergency Department Transfer Communication
Composite

Hospital Patient Experience of Care
Measure List
Resources
5
Clinic Quality Measures
6
Optimal Diabetes Care
The percentage of diabetes patients,
ages 18-75, who met ALL of the
following five goals:
1)
2)
3)
4)
5)
Blood sugar control
Blood pressure control
Statin use, if needed
Daily aspirin use, if needed
No tobacco use
Measure steward: MN Community Measurement
National Quality Forum #0729
7
Optimal Diabetes Care
Statewide Rate
4 ½ out of every 10
diabetic patients received optimal care
The 2015 statewide optimal care rate was 46%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
8
Optimal Diabetes Care
Component Rates
The percentage of diabetes patients that met all five goals was 46%. A greater share of patients
met individual goals. Patients had a very high rate of daily aspirin use and high rates of statin use,
blood pressure control, and not using tobacco.
99%
100%
90%
87%
84%
84%
Percent of patients
80%
72%
70%
60%
Statewide Optimal Rate is 46%
50%
40%
30%
20%
10%
0%
Statin use
Blood pressure
control
Daily aspirin use
No tobacco use
To be included in the statewide optimal rate, patients had to meet all five goals.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
Summary of graph
Blood sugar
control
9
Optimal Diabetes Care, Patients Without
Optimal Care by Component
# of patients who did not receive optimal care
The statewide optimal diabetes care rate is lower than individual component rates because
patients had to meet all five goals to have optimal diabetes care. As shown, many patients did not
meet one or more optimal diabetes care goals.
70,000
65,526
60,000
50,000
36,746
40,000
30,000
36,624
29,695
20,000
10,000
0
1,492
Statin use
Blood pressure
control
Daily aspirin use
No tobacco use
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
Summary of graph
Blood sugar
control
10
Optimal Diabetes Care
Stratified by Health Insurance Type
Medicare patients had the highest optimal care rate in 2013 and 2015, followed by patients with
commercial insurance. Note that measure specifications have changed over time and 2013 and
2015 optimal care rates are not directly comparable.
100%
2015
2013
90%
Percent of patients
80%
70%
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
Commercial
Medicare
MHCP
Self-Pay/Uninsured
In 2013, this measure included a cholesterol control component; in 2015 this was replaced with a statin use component.
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and
community-based waiver programs, and Medicare Savings Programs.
Service year: January 1 through December 31.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
11
Optimal Diabetes Care
Clinic Performance
In 2015, compared to 2013, the share of clinics that delivered optimal diabetes care to more than
50% of their patients increased by 18 percentage points. Note that measure specifications have
changed over time and 2013 and 2015 optimal care rates are not directly comparable.
50%
Percent of clinics
40%
30%
2013
2015
20%
10%
0%
0-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients receiving optimal care
In 2013, this measure included a cholesterol control component; in 2015 this was replaced with a statin use component.
There were 574 reporting clinics in 2013 and 595 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
12
Optimal Diabetes Care Patients
The number of patients receiving optimal care for diabetes increased by 23,000 between 2013
and 2015. In 2013, the statewide optimal rate was 39% and in 2015 it was 46%. Note that
measure specifications have changed over time and 2013 and 2015 optimal care rates are not
directly comparable.
250,000
Number of patients
200,000
83,959
106,958
150,000
# of patients who
received optimal
care
100,000
50,000
0
# of patients who
did not receive
optimal care
129,613
123,257
2013
2015
In 2013, this measure included a cholesterol control component; in 2015 this was replaced with a statin use component.
There were 574 reporting clinics in 2013 and 595 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
13
Optimal Vascular Care
The percentage of ischemic vascular
disease patients, ages 18-75, who met
ALL of the following four goals:
1)
2)
3)
4)
Blood pressure control
Statin use, if needed
Daily aspirin use, if needed
No tobacco use
Measure steward: MN Community Measurement
National Quality Forum #0076
14
Optimal Vascular Care
Statewide Rate
6 ½ out of every 10
vascular patients received optimal care
The 2015 statewide optimal care rate was 66%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
15
Optimal Vascular Care
Component Rates
The percentage of vascular patients who met all five goals is 66%. A greater share of patients met
individual goals. Patients had very high rates of daily aspirin use and statin use.
100%
97%
95%
90%
85%
83%
Percent of patients
80%
Statewide Optimal Rate is 66%
70%
60%
50%
40%
30%
20%
10%
0%
Statin use
Blood pressure control
Daily aspirin use
To be included in the statewide optimal rate, patients had to meet all of the above goals.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
Summary of graph
No tobacco use
16
Optimal Vascular Care, Patients Without
Optimal Care by Component
# of patients who did not receive optimal care
The statewide optimal vascular care rate is lower than individual component rates because
patients had to meet all four goals to have optimal vascular care. As shown below, many patients
did not meet one or more optimal vascular care goals.
16,000
14,958
13,715
14,000
12,000
10,000
8,000
6,000
4,924
4,000
3,101
2,000
0
Statin use
Blood pressure control
Daily aspirin use
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
Summary of graph
No tobacco use
17
Optimal Vascular Care
Stratified by Health Insurance Type
Optimal care rates for patients with commercial insurance and Medicare were notably higher
than rates for MHCP and self-pay/uninsured patients. Note that measure specifications have
changed over time and 2013 and 2015 optimal care rates are not directly comparable.
100%
2013
2015
Percent of patients
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
Commercial
Medicare
MHCP
Self-Pay/Uninsured
In 2013, this measure included a cholesterol control component; in 2015 this was replaced with a statin use component.
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Service year: January 1 through December 31.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
18
Summary of graph
Optimal Vascular Care
Clinic Performance
In 2015, compared to 2013, the share of clinics that delivered optimal vascular care to more than
50% of their patients increased by 31 percentage points. Note that measure specifications have
changed over time and 2013 and 2015 optimal care rates are not directly comparable.
50%
Percent of clinics
40%
2013
2015
30%
20%
10%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients who received optimal care
In 2013, this measure included a cholesterol control component; in 2015 this was replaced with a statin use component.
There were 570 reporting clinics in 2013 and 583 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
19
Optimal Vascular Care Patients
The number of patients receiving optimal vascular care increased by nearly 15,000 between 2013
and 2015. In 2013, the statewide optimal rate was 50% and in 2015 it was 66%. Note that
measure specifications have changed over time and 2013 and 2015 optimal care rates are not
directly comparable.
100,000
90,000
Number of patients
80,000
70,000
60,000
44,402
59,326
50,000
# of patients who
did not receive
optimal care
40,000
30,000
20,000
43,532
10,000
0
# of patients who
received optimal
care
2013
30,537
2015
In 2013, this measure included a cholesterol control component, in 2015 this was replaced with a statin use component.
There were 571 reporting clinics in 2013 and 583 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
20
Optimal Asthma Control
The percentage of asthma patients, ages 18-50 or
5-17, who met the following two goals:
1)
2)
Asthma under control
Asthma at low risk of worsening
Measure steward: MN Community Measurement
21
Adult Optimal Asthma Control
Statewide Rate
5 ½ out of every 10
adult asthma patients had optimal control
The 2015 statewide optimal control rate was 56%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
.
22
Adult Optimal Asthma Control
Component Rates
The percentage of adult asthma patients that met both goals was 56%, and a greater share of
patients met individual goals. Three-quarters of patients were at low risk of their asthma
worsening.
100%
90%
Percent of patients
80%
75%
70%
60%
58%
Statewide Optimal Rate is 56%
50%
40%
30%
20%
10%
0%
Under control
Low risk of worsening
To be included in the statewide optimal rate, patients had to meet both of the above goals.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
Summary of graph
23
Adult Optimal Asthma Control
Stratified by Health Insurance Type
Optimal care rates for patients with commercial insurance were notably higher than rates for
patients with other insurance types.
100%
90%
Percent of patients
80%
2014
70%
2015
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Service year: July 1 through June 30.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
24
Summary of graph
Adult Optimal Asthma Control
Clinic Performance
In 2015, compared to 2014, the share of clinics that delivered optimal asthma control to more
than 50% of their patients increased by 6 percentage points.
50%
Percent of clinics
40%
2014
2015
30%
20%
10%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients who had optimal control
There were 614 reporting clinics in 2014 and 613 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
25
Adult Optimal Asthma Control Patients
The number of patients in the adult asthma control measure decreased by approximately 5,700
between 2014 and 2015. In 2014, the statewide optimal rate was 54% and in 2015 it was 56%.
70,000
60,000
# of patients
who received
optimal care
Number of patients
50,000
40,000
32,863
31,080
30,000
# of patients
who did not
receive optimal
care
20,000
10,000
0
28,085
2014
There were 614 reporting clinics in 2014 and 613 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
24,105
2015
26
Child Optimal Asthma Control
Statewide Rate
6 ½ out of every 10
child asthma patients had optimal control
The 2015 statewide optimal control rate was 67%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
27
Child Optimal Asthma Control
Component Rates
The percentage of child asthma patients that met both goals was 67%, and a greater share of
patients met individual goals. Over 80% of patients were at low risk of their asthma worsening.
100%
90%
Percent of patients
80%
70%
81%
70%
Statewide Optimal Rate is 67%
60%
50%
40%
30%
20%
10%
0%
Under control
Low risk of worsening
To be included in the statewide optimal rate, patients had to meet all of the above goals.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
Summary of graph
28
Child Optimal Asthma Control
Stratified by Health Insurance Type
Patients with commercial insurance had the highest optimal control rate in 2014 and 2015.
100%
90%
2014
Percent of patients
80%
2015
70%
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and
community-based waiver programs, and Medicare Savings Programs.
Service year: July 1 through June 30.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
29
Child Optimal Asthma Control
Clinic Performance
The share of clinics that delivered optimal asthma control to more than 50% of their patients
increased by 4 percentage points in 2015.
50%
Percent of clinics
40%
2014
30%
2015
20%
10%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients who received optimal care
There were 568 reporting clinics in 2014 and 561 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
30
Child Optimal Asthma Control Patients
The number of patients in the child asthma control measure decreased by approximately 2,400
between 2014 and 2015. In 2014, the statewide optimal rate was 61% and in 2015 it increased to
67%.
45,000
40,000
Number of patients
35,000
30,000
25,000
# of patients
who received
optimal care
24,136
25,036
# of patients
who did not
receive
optimal care
20,000
15,000
10,000
5,000
0
15,633
2014
There were 568 reporting clinics in 2014 and 561 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
12,337
2015
31
Asthma Education and
Self-Management
The percentage of asthma patients, ages 18-50 or
5-17, who have been educated about their
condition and have a written asthma selfmanagement plan.
32
Adult Asthma Education and SelfManagement, Statewide Rate
4 out of every 10
adult asthma patients had asthma education
and a self-management plan
The 2015 statewide rate was 41%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
33
Adult Asthma Education and SelfManagement, Stratified by Insurance Type
Patients with commercial insurance had the highest optimal control rate, followed by Minnesota
Health Care Programs. Rates for all insurance types decreased between 2014 and 2015.
100%
90%
Percent of patients
80%
70%
2014
2015
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and
community-based waiver programs, and Medicare Savings Programs.
Service year: July 1 through June 30.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
34
Adult Asthma Education and SelfManagement, Clinic Performance
The share of clinics that delivered optimal asthma education and self-management to more than
50% of their patients remained roughly constant from 2014 to 2015 at 35%.
50%
Percent of clinics
40%
2014
30%
2015
20%
10%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients who had asthma education and a self-management plan
There were 614 reporting clinics in 2014 and 613 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
35
Adult Asthma Education and SelfManagement Patients
The number of patients in the adult asthma education measure decreased by approximately
5,700 between 2014 and 2015. In 2014, the statewide optimal rate was 46% and in 2015 it
decreased to 41%.
70,000
60,000
Number of patients
50,000
27,766
40,000
22,634
30,000
20,000
33,182
32,551
2014
2015
10,000
0
There were 614 reporting clinics in 2014 and 613 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
# of patients who
had asthma
education and a
self-management
plan
# of patients who
did not have
asthma education
and a selfmanagement plan
36
Adult Asthma Components
Since 2013, roughly two-thirds of adult asthma patients have had their asthma under control,
with low risk of worsening. However, the rate of asthma patients with asthma education and a
self-management plan has declined since peaking in 2013.
100%
90%
Percent of patients
80%
70%
60%
50%
40%
30%
20%
10%
0%
2011
Under control
2012
2013
2014
2015
Low risk of worsening
Asthma education and self-management plan
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
37
Child Asthma Education and SelfManagement, Statewide Rate
6 ½ out of every 10
child asthma patients had asthma education and
a self-management plan
The 2015 statewide rate was 66%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
38
Child Asthma Education and SelfManagement, Stratified by Insurance Type
Patients with commercial insurance had the highest optimal control rate, followed by Minnesota
Health Care Programs patients.
100%
90%
2014
Percent of patients
80%
2015
70%
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and
community-based waiver programs, and Medicare Savings Programs.
Service year: July 1 through June 30.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
39
Child Asthma Education and SelfManagement, Clinic Performance
The share of clinics that delivered optimal asthma education and self-management to more than
50% of their patients remained roughly constant at 46%.
50%
40%
Percent of clinics
2014
30%
2015
20%
10%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients who had asthma education and a self-management plan
There were 568 reporting clinics in 2014 and 561 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
40
Child Asthma Education and SelfManagement Patients
The number of patients in the child asthma education measure decreased by approximately 2,400
between 2014 and 2015. In 2014, the statewide optimal rate was 65% and in 2015 it was 66%.
45,000
40,000
# of patients who
had asthma
education and a
self-management
plan
Number of patients
35,000
30,000
25,000
25,730
24,654
# of patients who
did not have asthma
education and a
self-management
plan
20,000
15,000
10,000
5,000
0
14,039
12,719
2014
2015
There were 568 reporting clinics in 2014 and 561 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
41
Child Asthma Components
The rates of child asthma patients who have their asthma under control, with low risk of
worsening, rose steadily until 2013. After small decreases in 2014, these rates rose slightly again
in 2015. The rate of child asthma patients with asthma education and a self-management plan
peaked at 79% in 2013, and has since dropped to 66%.
100%
90%
Percent of patients
80%
70%
60%
50%
40%
30%
20%
10%
0%
2011
Under control
2012
Low risk of worsening
2013
2014
2015
Asthma education and self-management plan
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
42
Colorectal Cancer Screening
The percentage of patients ages 50-75 who are
up to date with appropriate colorectal cancer
screening exams, which include ANY of the
following methods:
1)
2)
3)
Colonoscopy within the measurement
period or prior 9 years
Sigmoidoscopy within the measurement
period or prior 4 years
Stool blood test within the measurement
period
Definitions:
(1) Colonoscopy: An exam used to detect changes or abnormalities in the large intestine (colon) and rectum.
(2) Sigmoidoscopy: An exam used to evaluate the lower part of the large intestine (colon).
(3) Stool blood test: A lab test used to check stool samples for hidden blood, which may be an indicator of colon cancer or polyps in the colon or rectum.
The USPSTF recommends regular colorectal cancer screening for adults ages 50-75 using the tests described above.
Measure steward: MN Community Measurement
43
Colorectal Cancer Screening
Statewide Rate
7 out of every 10
adult patients were screened for colorectal cancer
The 2016 statewide screening rate was 72%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
44
Colorectal Cancer Screening
Stratified by Health Insurance Type
Optimal care rates for patients with commercial insurance and Medicare were notably higher
than rates for MHCP and self-pay/uninsured patients.
100%
90%
2013
Percent of patients
80%
2014
2015
70%
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and
community-based waiver programs, and Medicare Savings Programs.
Service year: July 1 through June 30.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
45
Colorectal Cancer Screening
Clinic Performance
The share of clinics that screened more than 50% of their patients for colorectal cancer remained
roughly constant from 2013 to 2015 at 87%.
50%
2013
Percent of clinics
40%
2015
30%
20%
10%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients who received screening
There were 612 reporting clinics in 2013 and 627 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
46
Colorectal Cancer Screening Patients
Approximately 53,000 more patients were screened in 2015 as compared to 2013. In 2013, the
statewide screening rate was 70% and in 2015 it was 72%.
1,200,000
1,000,000
800,000
735,009
787,995
600,000
# of patients
who received
screening
400,000
200,000
0
# of patients
who did not
receive
screening
312,161
299,345
2013
2015
There were 612 reporting clinics in 2013 and 627 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
47
Depression Remission at Six Months
The percentage of patients with Major
Depression or Dysthymia who reached remission
six months (+/- 30 days) after an initial visit
To achieve remission, patients must score below
5 on the Patient Health Questionnaire-9 (PHQ-9)
tool
Patients are not counted as having reached
remission if they do not complete a PHQ-9 six
months (+/- 30 days) after their initial visit
Measure steward: MN Community Measurement
National Quality Forum# 0711
48
Depression Remission at Six Months
Statewide Rate
1 out of every 10
depression patients achieved remission in six months
The 2015 statewide rate was 8%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
49
Depression Remission at Six Months
Stratified by Severity
Patients with moderate depression had the highest remission rate for all three years.
100%
90%
Percent of patients
80%
2013
70%
2014
2015
60%
50%
40%
30%
20%
10%
0%
Moderate
Moderately Severe
Severity is determined by initial PHQ-9 scores.
Index year: January 1 through December 31.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
Severe
50
Depression Remission at Six Months
Clinic Performance
In 2015, compared to 2013, the share of clinics where more than 10% of depression patients
achieved remission at six months increased by 3 percentage points to 20%.
100%
90%
80%
Percent of clinics
70%
2013
2015
60%
50%
40%
30%
20%
10%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients in remission at six months
There were 599 reporting clinics in 2013, and 591 in 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
51
Depression Remission at Six Months
Patients
There were over 10,000 fewer patients in the depression remission measure in 2015 as compared
to 2013. The statewide remission rate remained roughly constant at 8%.
100,000
90,000
Number of patients
80,000
6,705
6,078
70,000
60,000
50,000
40,000
79,710
30,000
69,891
# of patients who
achieved
remission at 6
months
# of patients who
did not achieve
remission at 6
months
20,000
10,000
0
2013
2015
There were 599 reporting clinics in 2013, and 591 in 2015.
In 2015, to be included in this measure, patients had to have a PHQ-9 greater than 9 and a diagnosis of major depression or dysthymia. Previously, this
diagnosis was only required at the first-ever index contact between patient and provider.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
52
Adolescent Mental Health and/or
Depression Screening
The percentage of patients 12-17 years of
age who were screened for mental health
and/or depression
Patients may be screened using any of the following tools: Patient Health Questionnaire – 9 item version (PHQ-9); PHQ-9M Modified for Teens and
Adolescents; Kutcher Depression Scale (KADS); Beck Depression Inventory II (BDI-II); Beck Depression Inventory Fast Screen (BDI-FS); Child Depression
Inventory (CDI); Child Depression Inventory II (CDI-2); Patient Health Questionnaire – 2 item version (PHQ-2); Pediatric Symptom Checklist – 17 item version
(PSC-17) - parent version; Pediatric Symptom Checklist – 35 item (PSC-35) - parent version; Pediatric Symptom Checklist – 35 item Youth Self-Report (PSC YSR); Global Appraisal of Individual Needs screens for mental health and substance abuse (GAIN-SS).
Measure steward: MN Community Measurement
53
Adolescent Mental Health and/or
Depression Screening, Statewide Rate
7 out of every 10
adolescent patients were screened for mental health or
depression
The 2015 statewide screening rate was 70%.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2015 service dates.
54
Adolescent Mental Health and/or
Depression Screening, Stratified by
Insurance Type
Patients with commercial insurance had the highest screening rates. Rates for all insurance types
increased between 2014 and 2015.
100%
90%
2014
Percent of patients
80%
2015
70%
60%
50%
40%
30%
20%
10%
0%
Commercial
Medicare
MHCP
Self-Pay/Uninsured
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Service year: January 1 through December 31.
The first year of reporting for this measure was 2014.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
55
Summary of graph
Adolescent Mental Health and/or
Depression Screening, Clinic Performance
In 2015, compared to 2014, the share of clinics that screened more than 50% of their patients for
mental health or depression increased by 32 percentage points.
50%
45%
Percent of clinics
40%
35%
2014
30%
2015
25%
20%
15%
10%
5%
0%
0-10%
11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%
Percent of patients who received screening
There were 557 reporting clinics in 2014 and 571 in 2015.
The first year of reporting for this measure was 2014.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
56
Adolescent Mental Health and/or
Depression Screening Patients
Nearly 32,000 more patients were screened in 2015 as compared to 2014. In 2014, the statewide
screening rate was 45% and in 2015 it was 70%.
120,000
Number of patients
100,000
80,000
48,143
80,047
60,000
# of patients who
were screened
# of patients who
were not
screened
40,000
58,882
20,000
0
33,583
2014
There were 558 reporting clinics in 2014 and 571 in 2015.
The first year of reporting for this measure was 2014.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
2015
57
Spinal Surgery: Lumbar Fusion
Functional Status and Pain
The average change (preoperative to 1 year post-operative) in
functional status or pain, respectively, for patients 18 years of age or
older who had lumbar spine fusion surgery.
Functional status is measured using the Oswestry Disability Index
(ODI), which asks patients about 10 topics, including:
•
Pain
•
Ability to lift, walk, sit and stand
•
Quality of life issues
Pain is measured using the Visual Analog Scale (VAS) for leg and back
pain. VAS asks patients to rate their pain on a 1-10 scale.
Patients complete tests 3 months before surgery and at 1 year (+/- 3
months) after surgery to measure change. A positive average change
indicates that patients had improved functional status or less pain
after surgery.
Measure steward: MN Community Measurement
National Quality Forum #2643
58
Spinal Surgery: Lumbar Fusion
Average Functional Status Improvement
Average change in functional status after lumbar fusion surgery varied across medical groups.
The largest average improvement in functional status was 36.8, and the smallest average
improvement was 2. The statewide average improvement in functional status was 18. This
indicates that on average, patients had improved functional status after surgery.
Average functional status improvement
40
35
30
25
20
Statewide average improvement in functional status is 18
15
10
5
0
0
50
100
150
200
250
300
350
400
Number of patients with pre- and post-surgery ODI tests per medical group
In report year 2016, 16 medical groups that provided lumbar fusion surgeries in 2014 reported some data to MDH; and of these, 12 medical groups
provided patients with pre-and post-surgery ODI tests.
Two eligible medical groups—Twin Cities Orthopedics and St. Cloud Orthopedics—did not report procedures or results to MDH; therefore, measure
results may not be representative of the full lumbar fusion patient population.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 dates of procedure.
Summary of graph
59
Spinal Surgery: Lumbar Fusion
Average Functional Status Improvement
Stratified by Insurance Type
Patients with commercial insurance and Medicare had the most improvement in functional status
after surgery in 2014.
Average functional status improvement
35
30
25
2013
2014
20
15
10
5
0
Commercial
Medicare
MHCP
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Dates of procedure: January 1 through December 31, 2013 and 2014; 2013 was the first year of data collection for this measure.
Self-pay/Uninsured patient average change is not reported because there were fewer than 10 Self-Pay/Uninsured patients with pre- and post-tests.
60
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
Spinal Surgery: Lumbar Fusion
Functional Status Patients
Forty-two percent of patients who had lumbar fusion surgery in 2014 received pre- and post-surgery
ODI tests. This is a decrease from the 2013 rate of 45%. The majority of patients are not receiving
functional status tests at the appropriate times before and after surgery.
2,500
Number of patients
2,000
875
1,500
761
# of patients who
did not receive
pre- and postsurgery ODI
1,000
500
0
940
2013
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
# of patients who
received pre- and
post-surgery ODI
1,220
2014
61
Spinal Surgery: Lumbar Fusion
Average Decrease in Back and Leg Pain
Stratified by Insurance Type
Commercial and Medicare patients had larger decreases in back and leg pain than MHCP
patients. Average decreases represent the reduction in patient leg and back pain ratings (0-10),
before and after lumbar fusion surgery.
5
Average decrease in pain
4
Statewide average decreases in back pain and leg pain are both 3.2
3
2
1
0
Commercial
Medicare
MHCP
Average decrease in back pain
Average decrease in leg pain
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Dates of procedure: January 1 through December 31, 2014.
Self-pay/Uninsured patient average change is not reported because there were fewer than 10 Self-Pay/Uninsured patients with pre- and post-tests.
62
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 dates of procedure.
Summary of graph
Spinal Surgery: Lumbar Discectomy
Laminotomy
Functional Status and Pain
The average change (preoperative to 1 year post-operative) in functional
status or pain, respectively, for patients 18 years of age or older who
had a lumbar discectomy laminotomy procedure.
Functional status is measured using the Oswestry Disability Index (ODI),
which asks patients about 10 topics, including:
•
Pain
•
Ability to lift, walk, sit and stand
•
Quality of life issues
Pain is measured using the Visual Analog Scale (VAS) for leg and back
pain. VAS asks patients to rate their pain on a 1-10 scale.
Patients complete tests 3 months before surgery and at 1 year (+/- 3
months) after surgery to measure change. A positive average change
indicates that patients had improved functional status or less pain after
surgery.
Measure steward: MN Community Measurement
63
Spinal Surgery: Lumbar Discectomy Laminotomy
Average Functional Status Improvement
Average change in functional status after lumbar discectomy laminotomy surgery varied across
medical groups. The largest average improvement in functional status was 36.5, and the smallest
average improvement was 12.8. The statewide average improvement in functional status was
25.3.
Average functional status improvement
40
35
30
Statewide average improvement in functional status is 25.3
25
20
15
10
5
0
0
20
40
60
80
100
120
140
160
180
Number of patients with pre- and post-surgery ODI tests per medical group
200
In report year 2016, 18 medical groups that provided lumbar discectomy laminotomy surgeries in 2014 reported data to MDH; and of these, 12 medical
groups provided patients with pre- and post-surgery ODI tests.
Two eligible medical groups—Twin Cities Orthopedics and St. Cloud Orthopedics—did not report procedures or results to MDH; therefore, measure results
may not be representative of the full lumbar discectomy/laminotomy patient population.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 dates of procedure.
64
Summary of graph
Spinal Surgery: Lumbar Discectomy Laminotomy
Average Functional Status Improvement
Stratified by Insurance Type
Patients with commercial insurance had the most improvement in functional status after surgery
in both 2013 and 2014.
Average functional status improvement
30
2013
2014
25
20
15
10
5
0
Commercial
Medicare
MHCP
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Dates of procedure: January 1 through December 31, 2013 and 2014; 2013 was the first year of data collection for this measure.
Self-pay/Uninsured patient average change is not reported because there were fewer than 10 Self-Pay/Uninsured patients with pre- and post-tests.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
65
Summary of graph
Spinal Surgery: Lumbar Discectomy Laminotomy
Functional Status Patients
Thirty-seven percent of patients who had lumbar discectomy laminotomy surgery in 2014 received
pre- and post-surgery ODI tests. The 2013 rate was 36%. The majority of patients are not receiving
functional status tests at the appropriate times before and after surgery.
2,000
1,800
Number of patients
1,600
1,400
1,200
669
569
# of patients who
did not receive
pre- and postsurgery ODI
1,000
800
600
400
# of patients who
received pre- and
post-surgery ODI
1,001
1,122
200
0
2013
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
2014
66
Spinal Surgery: Lumbar Discectomy Laminotomy
Average Decrease in Back and Leg Pain
Stratified by Insurance Type
Lumbar discectomy laminotomy patients had larger decreases in leg pain than in back pain after
surgery. Commercial patients had the largest average decrease in leg pain. Average decreases
represent the reduction in patient leg and back pain ratings (0-10), before and after lumbar fusion
surgery.
Average decrease in pain
5
Statewide average decrease in leg pain is 4.3
4
Statewide average decrease in back pain is 3.2
3
2
1
0
Commercial
Medicare
Average decrease in back pain
MHCP
Average decrease in leg pain
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Dates of procedure: January 1 through December 31, 2014.
Self-pay/Uninsured patient average change is not reported because there were fewer than 10 Self-Pay/Uninsured patients with pre- and post-tests.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 dates of procedure.
67
Summary of graph
Total Knee Replacement
Functional Status
The average change (preoperative to 1 year post-operative) in
functional status for patients 18 years of age or older who had
primary total knee replacement surgery.
Functional status is measured using the Oxford Knee Score
(OKS), which asks patients about 12 topics, including:
• Pain
• Ability to kneel, walk, and sit
• Ability to complete everyday tasks
Patients complete tests 3 months before surgery and at 1 year
(+/- 3 months) after surgery to measure change. A positive
average OKS change indicates that patients had improved
functional status after surgery.
Measure steward: MN Community Measurement
National Quality Forum #2653
68
Total Knee Replacement
Average Functional Status Improvement
Average functional status improvement
Average change in functional status after total knee replacement varied across medical groups.
The largest average improvement in functional status was 21.4, and the smallest average
improvement was 5. The statewide average improvement in functional status was 16.4. This
indicates that on average, patients had improved functional status after surgery.
25
20
Statewide average improvement in functional status is 16.4
15
10
5
0
0
100
200
300
400
Number of patients with pre- and post-surgery OKS tests
500
600
In report year 2016, 34 medical groups that provided primary total knee replacement surgeries in 2014 reported data to MDH; and of these, 25 medical
groups provided patients with pre- and post-surgery OKS tests.
Two eligible medical groups—Twin Cities Orthopedics and St. Cloud Orthopedics—did not report procedures or results to MDH; therefore, measure
results may not be representative of the full primary total knee replacement patient population.
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 dates of procedure.
69
Summary of graph
Total Knee Replacement
Average Functional Status Improvement
Stratified by Insurance Type
Patients with commercial insurance had the most improvement in functional status after surgery
in 2014, followed closely by Medicare and MHCP patients.
Average functional status improvement
35
30
2013
25
2014
20
15
10
5
0
Commercial
Medicare
MHCP
Self-Pay/Uninsured
MHCP is Minnesota Health Care Programs, which includes: Medical Assistance, MinnesotaCare, Minnesota Family Planning Program, home and communitybased waiver programs, and Medicare Savings Programs.
Dates of procedure: January 1 through December 31, 2013 and 2014.
70
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
Total Knee Replacement
Functional Status Patients
Twenty-nine percent of patients who had primary total knee replacement surgery in 2014 received
pre- and post-surgery OKS tests. This is a slight increase from the 2013 rate of 27%. The majority of
patients are not receiving functional status tests at the appropriate times before and after surgery.
10,000
9,000
Number of patients
8,000
7,000
6,000
2,498
1,957
# of patients who did
not receive pre- and
post-surgery OKS
5,000
4,000
3,000
# of patients who
recieved pre- and
post-surgery OKS
5,437
6,126
2,000
1,000
0
2013
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
2014
71
Clinic Patient Experience of Care


Clinics administer the Clinician & Group
Consumer Assessment of Healthcare Providers
and Systems (CG-CAHPS) every two years to
measure patients’ perceptions of their clinic
experience.
The CG-CAHPS 12-month Survey covers the
following domains:

Access to care

Provider communication

Office staff

Provider rating
Note: Clinics used the CG-CAHPS 6-Month Survey in 2016; this data will be available in 2017.
Measure steward: Agency for Healthcare Research and Quality (AHRQ).
National Quality Forum #0005
72
Clinic Patient Experience of Care
Domain
Description
Access to care
The survey asked patients how often they received:
1) appointments for care as soon as needed and
2) timely answers to questions when they called the office
Provider
communication
The survey asked patients if their doctors explained things
clearly, listened carefully, showed respect, provided easy to
understand instructions, knew their medical history, and
spent enough time with the patient.
Office staff
The survey asked patients if office staff were helpful and
treated them with courtesy and respect.
Provider rating
The survey asked patients to rate their doctors on a scale of 0
to 10, with 0 being the worst and 10 being the best.
73
Clinic Patient Experience of Care
Percent of Patients Who Chose the Most Positive Response to
Access to Care Questions, by Number of Clinics
For the majority of clinics, 51% to 70% of patients selected the highest possible positive response
when asked about getting timely appointments, care, and information.
350
300
268
Number of clinics
250
200
179
184
150
100
77
51
50
0
3
6
24-30%
31-37%
25
19
38-43%
44-50%
51-57%
58-63%
64-70%
Percent of most positive patient responses
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 service dates.
Summary of graph
71-77%
78-83%
7
84-90%
74
Clinic Patient Experience of Care
Percent of Patients Who Chose the Most Positive Response to
Provider Communication Questions, by Number of Clinics
For the majority of clinics, 76% to 92% of patients selected the highest possible positive response
when asked how well providers communicate with patients.
350
300
251
Number of clinics
250
266
200
150
114
109
100
37
50
0
3
4
8
54-58%
59-62%
63-66%
14
13
67-70%
71-75%
76-79%
80-83%
Percent of most positive patient responses
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 service dates.
Summary of graph
84-87%
88-92%
93-96%
75
Clinic Patient Experience of Care
Percent of Patients Who Chose the Most Positive Response to
Office Staff Questions, by Number of Clinics
For the majority of clinics, 75% to 92% of patients selected the highest possible positive response
when asked about how often office staff were helpful, courteous, and respectful.
350
338
300
Number of clinics
250
220
200
147
150
100
74
50
0
1
1
2
45-51%
52-57%
58-63%
17
17
64-69%
70-74%
75-80%
81-86%
Percent of most positive patient responses
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 service dates.
Summary of graph
87-92%
93-98%
2
99-100%
76
Clinic Patient Experience of Care
Percent of Patients Who Chose the Most Positive Response to
Provider Rating Question, by Number of Clinics
For the majority of clinics, 73% to 87% of patients selected the highest possible positive response
when asked to rate their doctor.
350
300
261
Number of clinics
250
218
200
150
131
100
83
63
50
0
5
9
13
46-51%
52-56%
57-62%
21
63-67%
68-72%
73-77%
78-82%
Percent of most positive patient responses
Source: MDH Health Economics Program analysis of Quality Reporting System data from 2014 service dates.
Summary of graph
15
83-87%
88-92%
93-97%
77
Hospital Quality Measures
78
Hospital Value-Based Purchasing
Total Performance Score
The Hospital Value-Based Purchasing (VBP) Program is a Centers for
Medicare & Medicaid Services incentive program designed to tie
payment to the quality of care provided by a hospital.
The VBP Total Performance Score is calculated based on each
prospective payment system hospital’s performance and improvement
on a number of measures in the following domains:
• Clinical care (process and outcome measures)
• Patient- and caregiver centered experience of care/care
coordination
• Patient safety
• Efficiency and cost reduction
79
Hospital Value-Based Purchasing
Total Performance Score
Total Performance Scores ranged from 22 to 82 for 44 Minnesota hospitals; 100 is the best
possible score.
95
85
82 - Highest Score
Total Performance Score
75
65
55
45
46 - Average Score
35
25
22 - Lowest Score
15
Service year varies by component: October 1, 2013 – June 30, 2015 and January 1 through December 31, 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
80
Hospital Acquired Condition
Reduction Program Score
The Hospital Acquired Condition Reduction Program is a Centers for
Medicare & Medicaid Services incentive program designed to tie
payment to hospital acquired conditions: conditions that patients
acquire while receiving treatment.
The Hospital Acquired Condition Reduction Program Score is calculated
based on how often hospital-acquired infections and other conditions,
including ulcers and falls, occur at each prospective payment system
hospital.
81
Hospital Acquired Condition Reduction
Program Score
Hospital Acquired Condition Scores ranged from 9.95 to 1.45 for 50 Minnesota hospitals. Higher
scores indicate a higher rate of hospital acquired conditions.
10
Hospital Acquired Condition Score
9
9.95 – Highest Score
8
7
6
5
4.93 – Average Score
4
3
2
1
1.45 – Lowest Score
0
Service year varies by domain: July 1, 2013 through June 30, 2015 and January 1, 2014 through December 31, 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
82
Hospital Readmissions Reduction
Program
Excess Readmission Score
The Readmission Reduction Program Excess Readmission Score is based
on each prospective payment system hospital’s 30-day readmission rate
for the following conditions:
•
•
•
•
•
•
•
Acute myocardial infarction (AMI)
Heart failure
Pneumonia
Chronic obstructive pulmonary disease (COPD)
Total hip arthroplasty
Total knee arthroplasty
Coronary artery bypass graft
Hospitals with Readmission Reduction Composite rates above 1 had
more readmissions than expected; hospitals with rates below 1 had
fewer readmissions than expected
83
Hospital Readmissions Reduction Program
Excess Readmission Score
The highest Excess Readmission Score was 1.11, and the lowest was 0.89. Twenty-five
out of 44 Minnesota hospitals (57%) had rates of 1.0 or lower, indicating that they had
fewer readmissions than expected or the expected number of readmissions.
1.15
1.11
Excess Readmission Score
1.1
1.05
1
0.95
0.9
0.89
0.89
0.85
Service years: July 1, 2011 through June 30, 2014.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
84
Hospital Emergency Department
Transfer Communication Composite
The Emergency Department Transfer Communication (EDTC) measure
tracks how well hospitals communicate patient information when they
transfer a patient to another health care facility.
The EDTC composite measure represents the percentage of each
hospitals’ transferred patients whose required information was quickly
communicated to the receiving facility. This required information
includes:
• Patient identity
• Vital signs
• Information about medications, procedures and tests
85
Hospital Emergency Department Transfer
Communication Composite
Percentage of pateints that met all EDTC criteria
Sixty percent or more of patients met all EDTC measure criteria at 45 of 78 critical access
hospitals.
91-100%
8
81-90%
12
71-80%
14
61-70%
11
51-60%
13
41-50%
5
31-40%
9
21-30%
4
11-20%
1
0-10%
1
Number of hospitals
Service year: October 1, 2014 through September 30, 2015.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
86
Hospital Patient Experience of Care
The Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) is a survey that measures patients’ perceptions of
their hospital experience.
The HCAHPS survey asks discharged patients 27 questions about
important aspects of their recent hospital stay, including:
• Communication with nurses and doctors
• Communication about medicines
• Overall rating of the hospital
87
Hospital Patient Experience of Care
Percent of Patients Who “Strongly Agreed” They Understood
Their Care When Leaving the Hospital
Minnesota’s rate was slightly higher than the national average in both 2013 and 2015.
100%
90%
Percent of patients
80%
70%
60%
54%
56%
51%
50%
52%
40%
30%
20%
10%
0%
2013
Minnesota
National
Service years: January 1 through December 31, 2013 and April 1, 2015 through March 31, 2016.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
2015
88
Hospital Patient Experience of Care
Percent of Patients Who Gave their Hospital a
Rating of 9 or 10
Minnesota’s rate was slightly higher than the national average in both 2013 and 2015.
100%
90%
Percent of patients
80%
74%
76%
71%
70%
72%
60%
50%
40%
30%
20%
10%
0%
2013
Minnesota
National
Service years: January 1 through December 31, 2013 and April 1, 2015 through March 31, 2016.
Source: MDH Health Economics Program analysis of Quality Reporting System data.
Summary of graph
2015
89
Appendix:
Quality Reporting System Measures
90
2016 Reporting Year
Clinic Quality Measures
Measure
Data Source: Medical Record
Optimal Diabetes Care
Optimal Vascular Care
Depression Remission at Six Months
Optimal Asthma Control – Adult and Child
Asthma Education and Self-Management - Adult and Child
Colorectal Cancer Screening
Cesarean Section Rate
Total Knee Replacement Outcome Measures
Spinal Surgery: Lumbar Spinal Fusion Outcome Measures
Spinal Surgery: Discectomy/Laminotomy Outcome Measures
Pediatric Preventive Care: Pediatric Overweight Counseling
Pediatric Preventive Care: Adolescent Mental Health and/or Depression Screening
Data Source: Health Care Claims
Healthcare Effectiveness Data and Information Set (HEDIS) measures
Data Source: Clinic Survey
Health Information Technology Survey
Data Source: Patient Survey
Patient Experience of Care Survey: Consumer Assessment of Healthcare Providers and Systems Clinician
& Group 3.0 Survey – Adult
Steward
MNCM
MNCM
MNCM
MNCM
MNCM
MNCM
MNCM
MNCM
MNCM
MNCM
MNCM
MNCM
NCQA
MNCM/MDH
AHRQ
NCQA is the National Committee on Quality Assurance, AHRQ is the Agency of Healthcare Research and Quality
Medical record data is obtained from electronic health records or paper records.
A Measure Steward is an organization that owns and is responsible for maintaining the measure. Measure stewards are often the same as measure developers, but not
always.
Source: Quality Reporting System, 2016.
91
2016 Reporting Year
Hospital Quality Measures
Measure
Steward
Hospital Type
CMS
CAH
CMS
CAH
The Joint
Commission
CAH
CMS
CAH
Data Source: Medical Record
Influenza Immunization: Influenza Immunization (IMM-2)
Emergency Department Measures
Median Time from ED Arrival to ED Departure for Admitted ED Patients – Overall
Rate (ED-1a)
Admit Decision Time to ED Departure Time for Admitted Patients - Overall Rate
(ED-2a)
Median Time from ED Arrival to ED Departure for Discharged ED Patients (OP-18)
ED Median Time to Pain Management for Long Bone Fracture (OP-21)
ED Patient Left without Being Seen (OP-22)
Elective Delivery (PC-01)
Outpatient Acute Myocardial Infarction and Chest Pain
Fibrinolytic Therapy Received within 30 Minutes (OP-2)
Median Time to Transfer to Another Facility for Acute Coronary Intervention –
Overall Rate (OP-3a)
Median Time to ECG (OP-5)
Median Time to Fibrinolysis (OP-1)
CMS is Centers for Medicare and Medicaid Services; CAH is Critical Access Hospitals
Medical record data is obtained from electronic health records or paper records.
A Measure Steward is an organization that owns and is responsible for maintaining the measure. Measure stewards are often the same as measure developers, but not always.
92
Source: Quality Reporting System, 2016.
Hospital Quality Measures
(Continued)
Measure
Steward
Hospital Type
Chronic Obstructive Pulmonary Disease 30-Day Readmission Rate (READM30-COPD)
CMS
CAH
Door to Diagnostic Evaluation by a Qualified Medical Professional (OP-20)
CMS
CAH
Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic
Stroke Patients who Received Head CT or MRI Scan Interpretation within
45 Minutes of Arrival (OP-23)
CMS
CAH
Catheter Associated Urinary Tract Infection (CAUTI)
CDC
Emergency Department Stroke Registry Indicators
Minnesota Stroke Registry
Program
PPS and CAH
American Heart Association/
American Stroke Association
PPS and CAH
Emergency Department Transfer Communication Composite
CMS
CAH
Hospital Value-Based Purchasing Total Performance Score
CMS
PPS
Hospital Readmissions Reduction Program Excess Readmission Score
CMS
PPS
Hospital Acquired Condition Reduction Program Score
CMS
PPS
Data Source: Medical Record
Door-to-Imaging Initiated Time
Time to Intravenous Thrombolytic Therapy
CAH
PPS stands for Prospective Payment System hospitals, CAH stands for Critical Access Hospital
Source: Quality Reporting System, 2016.
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Hospital Quality Measures
(Continued)
Steward
Hospital
Type
Heart Failure 30-Day Readmission Rate (READM-30-HF)
CMS
CAH
Pneumonia 30-Day Readmission Rate (READM-30-PN)
CMS
CAH
American Hospital
Association/MDH
PPS and CAH
CMS
PPS and CAH
CMS
CAH
Mortality for Selected Conditions (IQI 91)
AHRQ
PPS and CAH
Death Among Surgical Inpatients with Serious Treatable Complications (PSI 4)
AHRQ
PPS and CAH
Patient Safety and Adverse Events Composite (PSI 90)
AHRQ
PPS and CAH
Pediatric Patient Safety for Selected Indicators Composite (PDI 19)
AHRQ
PPS and CAH
CDC
CAH
Measure
Data Source: Health Care Claims
Data Source: Hospital Survey
Health Information Technology Survey
Data Source: Patient Survey
Patient Experience of Care: Hospital Consumer Assessment of Healthcare Providers
and Systems
Data Source: Provider Survey
Safe Surgery Checklist Use (OP-25)
Data Source: Inpatient Administrative Data
Data Source: Management & Personnel Data
Influenza Vaccination Coverage Among Healthcare Personnel (OP-27)
Source: Quality Reporting System, 2016.
94
Resources
95
Additional Information from the
Health Economics Program
Health Economics Program
www.health.state.mn.us/divs/hpsc/hep
Publications
www.health.state.mn.us/divs/hpsc/hep
Health Care Markets Chartbook
www.health.state.mn.us/divs/hpsc/hep/chartbook
Statewide Quality Reporting and Measurement System
www.health.state.mn.us/healthreform/measurement
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Quality Measurement Resources
MN Community Measurement and HealthScores
•
•
mncm.org
www.mnhealthscores.org
Stratis Health
•
www.stratishealth.org
Minnesota Hospital Association
•
•
www.mnhospitals.org
www.mnhospitalquality.org/#/consumer
Hospital Compare
•
www.medicare.gov/hospitalcompare
National Quality Forum
•
•
www.qualityforum.org
www.qualityforum.org/QPS/QPSTool.aspx
Agency for Healthcare Research and Quality
•
www.ahrq.gov
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