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  • Measure Summary
  • NQMC:010613
  • Oct 2015

Frequency of selected procedures: summary of utilization of fourteen frequently performed procedures.

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.
National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

This is the current release of the measure.

This measure updates previous versions:

  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

Measure Hierarchy

HEDIS 2016: Health Plan Collection > Utilization and Risk Adjusted Utilization > Utilization

Age Group

UMLS Concepts (what is this?)

Primary Measure Domain

Related Health Care Delivery Measures: Use of Services

Secondary Measure Domain

Does not apply to this measure

Description

This measure summarizes the utilization of the following frequently performed procedures that often show wide regional variation and have generated concern regarding potentially inappropriate utilization:

  • Tonsillectomy
  • Bariatric weight loss surgery
  • Hysterectomy
  • Cholecystectomy
  • Back surgery
  • Percutaneous coronary intervention (PCI)
  • Cardiac catheterization
  • Coronary artery bypass graft (CABG)
  • Prostatectomy
  • Total hip replacement
  • Total knee replacement
  • Carotid endarterectomy
  • Mastectomy
  • Lumpectomy

Rationale

This measure lists several frequently performed procedures (mostly surgical) that contribute substantially to overall cost. Wide variations among geographic regions in medical procedure rates appear to have little correlation with health outcomes. The reasons for this are unclear. Some variation is because of unnecessary procedures; conversely, some procedures may not be performed often enough. These rates are likely to be strongly influenced by how the organization manages care.

Variation in procedure rates presents a starting point in examining the kind of care that is being rendered to members. Coding practices, epidemiology, demographics and practice patterns may be responsible for variation. Examining these measures may help eliminate unwarranted variation in the delivery of medical care.

Evidence for Rationale

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Primary Health Components

Tonsillectomy; bariatric weight loss surgery; hysterectomy; cholecystectomy; back surgery; percutaneous coronary intervention (PCI); cardiac catheterization; coronary artery bypass graft (CABG); prostatectomy; total hip replacement; total knee replacement; carotid endarterectomy; mastectomy; lumpectomy

Denominator Description

For commercial, Medicaid, and Medicare product lines, all member months for the measurement year, stratified by age and sex (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of the following selected procedures:

  • Tonsillectomy
  • Bariatric weight loss surgery
  • Hysterectomy
  • Cholecystectomy
  • Back surgery
  • Percutaneous coronary intervention (PCI)
  • Cardiac catheterization
  • Coronary artery bypass graft (CABG)
  • Prostatectomy
  • Total hip replacement
  • Total knee replacement
  • Carotid endarterectomy
  • Mastectomy
  • Lumpectomy

See the related "Numerator Inclusions/Exclusions" field.

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

All HEDIS measures undergo systematic assessment of face validity with review by measurement advisory panels, expert panels, a formal public comment process and approval by the National Committee for Quality Assurance's (NCQA's) Committee on Performance Measurement and Board of Directors. Where applicable, measures also are assessed for construct validity using the Pearson correlation test. All measures undergo formal reliability testing of the performance measure score using beta-binomial statistical analysis.

Evidence for Extent of Measure Testing

Rehm B. (Assistant Vice President, Performance Measurement, National Committee for Quality Assurance, Washington, DC). Personal communication. 2015 Mar 16.  1 p.

State of Use

Current routine use

Current Use

Accreditation

External oversight/Medicaid

External oversight/Medicare

External oversight/State government program

Monitoring and planning

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Hospital Inpatient

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

All ages

Target Population Gender

Either male or female

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

The measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
For commercial, Medicaid, Medicare product lines, all member months for the measurement year, stratified by age and sex. Refer to Specific Instructions for Utilization Tables in the original measure documentation for more information.

Exclusions
Unspecified

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
Number of the following selected procedures:

  • Tonsillectomy (Tonsillectomy Value Set). Report tonsillectomy (with or without adenoidectomy).
  • Bariatric weight loss surgery (Bariatric Weight Loss Surgery Value Set). Report the number of bariatric weight loss surgeries.
  • Hysterectomy. Report abdominal and vaginal hysterectomy separately.
    • Abdominal Hysterectomy Value Set
    • Vaginal Hysterectomy Value Set
  • Cholecystectomy. Report open and laparoscopic cholecystectomy separately.
    • Open Cholecystectomy Value Set
    • Laparoscopic Cholecystectomy Value Set
  • Back surgery (Back Surgery Value Set). Report all spinal fusion and disc surgery, including codes relating to laminectomy with and without disc removal.
  • Percutaneous coronary intervention (PCI) (PCI Value Set). Report all PCIs performed separately.
  • Cardiac catheterization (Cardiac Catheterization Value Set). Report all cardiac catheterizations performed separately.
  • Coronary artery bypass graft (CABG) (CABG Value Set). Report each CABG only once for each date of service per patient, regardless of the number of arteries involved or the number or types of grafts involved.
  • Prostatectomy (Prostatectomy Value Set). Report the number of prostatectomies.
  • Total hip replacement (Total Hip Replacement Value Set). Report the number of total hip replacements.
  • Total knee replacement (Total Knee Replacement Value Set). Report the number of total knee replacements.
  • Carotid endarterectomy (Carotid Endarterectomy Value Set). Report the number of carotid endarterectomies.
  • Mastectomy. Report the number of mastectomies. Report bilateral mastectomy procedures as two procedures, even if performed on the same date.
    • Identify unilateral mastectomies using any of the following:
      • Unilateral Mastectomy Value Set
      • Unilateral Mastectomy Left Value Set
      • Unilateral Mastectomy Right Value Set
    • Identify bilateral mastectomies using either of the following:
      • Bilateral mastectomy (Bilateral Mastectomy Value Set)
      • Unilateral mastectomy (Unilateral Mastectomy Value Set) with a bilateral modifier (Bilateral Modifier Value Set)
  • Lumpectomy (Lumpectomy Value Set). Report the number of lumpectomies. Report multiple lumpectomies on the same date of service as one lumpectomy procedure per patient.

Note: Report counts for the procedures as specified regardless of the site of care (e.g., inpatient or ambulatory setting). Report the number of procedures rather than the number of members who had the procedures. Do not double-count the same procedure. Refer to the original measure documentation for additional details.

Exclusions

  • Tonsillectomy. Do not report adenoidectomy performed alone.
  • Hysterectomy. Do not double-count procedures; count multiple codes on the same date of service as one procedure.
  • PCI. Do not report PCI or cardiac catheterization performed in conjunction with (i.e., on the same date of service as) a CABG in the PCI rate or the cardiac catheterization rate; report only the CABG.
  • Cardiac catheterization.
    • Do not report a cardiac catheterization performed in conjunction with (i.e., on the same date of service as) a PCI in the cardiac catheterization rate; report only the PCI.
    • Do not report PCI or cardiac catheterization performed in conjunction with (i.e., on the same date of service as) a CABG in the PCI or the cardiac catheterization rate; report only the CABG.
  • CABG. Do not report PCI or cardiac catheterization performed in conjunction with (i.e., on the same date of service as) a CABG in the PCI or the cardiac catheterization rate; report only the CABG.

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Measure is disaggregated into categories based on different definitions of the denominator and/or numerator

Basis for Disaggregation

This measure is disaggregated according to the following selected procedures:

  • Tonsillectomy
  • Bariatric weight loss surgery
  • Hysterectomy
  • Cholecystectomy
  • Back surgery
  • Percutaneous coronary intervention (PCI)
  • Cardiac catheterization
  • Coronary artery bypass graft (CABG)
  • Prostatectomy
  • Total hip replacement
  • Total knee replacement
  • Carotid endarterectomy
  • Mastectomy
  • Lumpectomy

Scoring

Ratio

Interpretation of Score

Does not apply to this measure (i.e., there is no pre-defined preference for the measure score)

Allowance for Patient or Population Factors

Analysis by subgroup (stratification by individual factors, geographic factors, etc.)

Description of Allowance for Patient or Population Factors

This measure requires that separate rates be reported for commercial–by product or combined HMO/POS, total Medicaid, and Medicare product lines.

Measure results are stratified by age and sex.

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Frequency of selected procedures (FSP).

Measure Collection Name

HEDIS 2016: Health Plan Collection

Measure Set Name

Utilization and Risk Adjusted Utilization

Measure Subset Name

Utilization

Submitter

National Committee for Quality Assurance - Health Care Accreditation Organization

Developer

National Committee for Quality Assurance - Health Care Accreditation Organization

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

National Committee for Quality Assurance's (NCQA's) Measurement Advisory Panels (MAPs) are composed of clinical and research experts with an understanding of quality performance measurement in the particular clinical content areas.

Financial Disclosures/Other Potential Conflicts of Interest

In order to fulfill National Committee for Quality Assurance's (NCQA's) mission and vision of improving health care quality through measurement, transparency and accountability, all participants in NCQA's expert panels are required to disclose potential conflicts of interest prior to their participation. The goal of this Conflict Policy is to ensure that decisions which impact development of NCQA's products and services are made as objectively as possible, without improper bias or influence.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates previous versions:

  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

Source(s)

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Measure Availability

Source available for purchase from the National Committee for Quality Measurement (NCQA) Web site External Web Site Policy.

For more information, contact NCQA at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

Companion Documents

The following is available:

  • National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical update. Washington (DC): National Committee for Quality Assurance (NCQA); 2015 Oct 1. 12 p.

For more information, contact the National Committee for Quality Assurance (NCQA) at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on March 27, 2009. The information was verified by the measure developer on May 29, 2009.

This NQMC summary was updated by ECRI Institute on February 8, 2010 and on June 8, 2011.

This NQMC summary was retrofitted into the new template on July 1, 2011.

This NQMC summary was updated by ECRI Institute on October 5, 2012, August 5, 2013, March 3, 2014, April 10, 2015, and again on March 29, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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