Intermountain ROMS® is a CMS-approved Qualified Clinical Data Registry (QCDR).

As part of the Centers for Medicare and Medicaid Services’ (CMS) Merit-based Incentive Payment System (MIPS), therapists can report outcomes and quality measures on their payments to receive reimbursement from CMS. As a QCDR, ROMS can collect and submit this important information on your behalf, enabling a more streamlined process for reimbursement. When therapists use ROMS to report quality payment, they can receive up to a 7 percent Medicare bonus payment.

Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

Measure ID: IROMS11

Measure Description: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury patients treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.

Denominator Description: The total number of all patients with knee injury evaluated and treated by a PT or OT, or PT or OT Group, during the observation window.

Numerator Description:The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their KOS change score (MCID >10) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions:PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Patient Reported Outcome (PRO)

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients not achieving an MCID in KOS change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in KOS change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in KOS change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in revalidation patients with knee injury pain.

Measure ID: IROMS12

Measure Description: The proportion of patients failing to achieve MCID of two (2) points or more improvement in the NPRS change score for patients with knee injuries treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level."

Denominator Description: The total number of all patients with knee injury evaluated and treated by a PT or OT, or PT or OT Group, during the observation window.

Numerator Description: The total number of patients with knee injuries to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions: "Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding."

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Outcome

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in NDI change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in NDI change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in NDI change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

Measure ID: IROMS13

Measure Description: The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description: The total number of patients with hip, leg, or ankle injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

Numerator Description: The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their LEFS change score (MCID ≥ 9) from their initial visit to their final visit in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions: Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding."

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Outcome

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in LEFS change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported.                                     

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in LEFS change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in LEFS change score will be reported. 
6)  A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury.

Measure ID: IROMS14

Measure Description: The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description:The total number of patients with hip, leg, or ankle injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

Numerator Description: The total number of patients with hip, leg, or ankle injuries hip, leg, or ankle (lower extremity except knee), to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions: Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Outcome

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in NDI change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in NDI change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in NDI change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).

Measure ID: IROMS15

Measure Description:The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported.

Additionally, a risk-adjusted NDI change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description: The total number of neck pain/injury patients evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

Numerator Description: The total number of patients with neck pain/injury to not achieve an MCID in their NDI change score (MCID >10) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions:Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Patient Reported Outcome (PRO)

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in NDI change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in NDI change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in NDI change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.

Measure ID: IROMS16

Measure Description:The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description: The total number of patients with neck pain/injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

Numerator Description: The total number of patients with neck pain/injury to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions:Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Patient Reported Outcome (PRO)

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in NDI change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in NDI change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in NDI change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.

Measure ID: IROMS17

Measure Description:The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description: The total number of patients with low back pain evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

Numerator Description: The total number of patients with low back pain to not achieve an MCID in their MDQ change score (MCID >6) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions:Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Patient Reported Outcome (PRO)

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients not achieving an MCID in MDQ change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in MDQ change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in MDQ change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in revalidation patients with low back pain.

Measure ID: IROMS18

Measure Description:The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description: The total number of patients with low back pain evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

Numerator Description: The total number of patients with low back pain to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions:Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Outcome

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in NDI change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in NDI change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in NDI change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

Measure ID: IROMS19

Measure Description:The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported.

Additionally, a risk-adjusted DASH change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description: The total number of surgical patients with arm, shoulder, or hand injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

Numerator Description: The total number of patients with arm, shoulder, or hand injuries to not achieve an MCID in their DASH change score (MCID >10 for DASH, MCID>8 for QDASH) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions:Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Patient Reported Outcome (PRO)

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in DASH change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in DASH change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in DASH change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.

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Measure Title: Failure to Progress (FTP): Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.

Measure ID: IROMS20

Measure Description:The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description: The total number of patients with arm, shoulder, or hand injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

Numerator Description: The total number of patients with arm, shoulder, and hand injuries to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

Denominator Exclusions:Exclude patients who did not complete 2 or more surveys.

Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

Denominator Exceptions: PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

Numerator Exclusions: None

Is the QCDR measure a high priority measure? Yes

Measure Type: Outcome

NQS Domain: Effective Clinical Care

What one meaningful measure area applies to this measure? Patient Reported Functional Outcomes

Risk-Adjusted: Yes

Number of performance rates to be calculated: 

Six measures will be reported, two overall performance measures and four stratified performance measures are to be included: 

1) Overall proportion of patients achieving an MCID in NDI change score will be reported. 
2) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For operative (surgical) patients:
3) The proportion of patients not achieving an MCID in NDI change score will be reported. 
4) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported. 

For non-operative (non-surgical) patients:
5) The proportion of patients not achieving an MCID in NDI change score will be reported. 
6) A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported.

Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted: 2nd Performance Rate (Risk Adjusted Overall)

Inverse Measure: Yes.

Proportional Measure: Yes.

Continuous Variable Measure: No.

Ratio Measure: No.