PPS-Exempt Hospitals Quality Reporting (PCHQR) Program Measure Specifications

Measure Specifications
PPS-Exempt Hospitals Quality Reporting (PCHQR) Program
Section 3005 of the Patient Protection and Affordable Care Act (ACA) requires the Centers for Medicaid
& Medicare Services (CMS) to establish a “Cancer Hospital Quality Reporting Program (CHQRP)”, also
known as “PCHQR”, and to begin public reporting by 2014. CMS seeks to promote higher quality and
more efficient health care for Medicare beneficiaries. This effort is supported by the implementation of
an increasing number of widely-agreed upon quality measures and payment incentives for Inpatient
Prospective Payment System hospitals to submit data on quality measures. Facilitated by the National
Quality Forum (NQF), the Commission on Cancer (CoC), the American Society of Clinical Oncology
(ASCO), and the National Comprehensive Cancer Network (NCCN) agreed to synchronize their
developed measures to ensure that a unified set were put forth to the public. Extensive assessment and
validation of the measures was performed using cancer registry data reported to the National Cancer
Database (NCDB) in collaboration with senior scientists at the NQF and National Cancer Institute (NCI).
The Centers for Medicare & Medicaid Services (CMS) has contracted with the American College of
Surgeons to plan and implement the reporting of cancer care measures to CMS on behalf of the 11 PPSexempt cancer hospitals (PCH) through its Rapid Quality Reporting System (RQRS). CMS has identified
the following three NQF–endorsed quality of cancer care measures that will be reported on the Hospital
Compare website.
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(NQF #0559) Combination chemotherapy is considered or administered within 4 months (120 days)
of diagnosis for women under 70 with AJCC T1cN0M0, or Stage II or III hormone receptor negative
breast cancer.
(NQF #0220) Tamoxifen or third generation aromatase inhibitor is considered or administered within
1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor
positive breast cancer.
(NQF # 0223) Adjuvant chemotherapy is considered or administered within 4 months (120 days) of
diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer.
Information related to the reporting project: it’s participating hospitals; the development of measures used
in the PCHQR project; the technical specifications of these three measures; and the manner in which caselevel data are collected, abstracted, reported and verified, are all available at the following URLs:
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Project details and information on participating cancer hospitals:
http://www.facs.org/cancer/ncdb/pchrqp.html
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Details on the measure development and specification process:
http://www.facs.org/cancer/qualitymeasures.html
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Measure specification and rate calculation algorithms
http://www.facs.org/cancer/ncdb/measure-specifications.pdf
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Information on RQRS, enrolling to participate in the reporting system, how to submit data, and how
to navigate and interpret the information displayed in RQRS:
http://www.facs.org/cancer/ncdb/rqrs.html
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All data is coded and transmitted according to NAACCR guidelines:
http://www.naaccr.org/StandardsandRegistryOperations/VolumeII.aspx
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Data elements and coding and abstracting rules are documented in the Facilities Oncology Registry
Data Standards Manual (FORDS):
http://www.facs.org/cancer/coc/fordsmanual.html
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Coding accuracy and inter-item consistency testing is performed using EDITS software, available
through the Centers for Disease Control and Prevention:
http://www.cdc.gov/cancer/npcr/tools/edits/
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Direct questions for the American College of Surgeons regarding the reporting project or the RQRS
can be directed to:
[email protected]
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