Published 12/1/2018
Steve Olson, MD; Quinn Hall, MHA

AAOS Hip Fracture Time-to-surgery Performance Measure Passes First CMS Test

The measure could be eligible for MIPS reporting in 2020

Hip fractures in older patients have been an increasingly important health concern in the United States, as life expectancy in the country continues to rise. In April, AAOS published a performance measure (PM) to encourage hip fracture surgery within 48 hours of admission for patients 65 years of age or older. The PM stems from the AAOS evidence-based clinical practice guideline (CPG) on Management of Hip Fractures in the Elderly, which was published in 2014.

The time to the operating room (OR) metric is considered a process measure. Process measures demonstrate how orthopaedic specialists can provide care in ways that maintain or improve patients’ health. Multiple studies have shown that early surgery is associated with better outcomes in patients with geriatric hip fracture. The 2014 CPG recommended a time to OR of 48 hours. However, recent studies have suggested that 48 hours is readily achievable in high-functioning centers, whereas a measure of 24 hours represents an aspirational goal for all levels of centers providing geriatric hip fracture care.

The AAOS PM on the Management of Hip Fractures in the Elderly: Timing of Surgical Intervention addresses elderly patients with hip fractures resulting from low-energy trauma injuries, as this was the intended patient population for the hip fracture CPG. The PM reflects a percentage of the total number of elderly patients with a hip fracture eligible for inclusion in the measure who undergo surgery within 48 hours of admission. The PM explicitly excludes patients with nonoperative fractures, multiple injuries, periprosthetic fractures, or high-energy trauma, as well as those meeting local criteria for multiple trauma designation.

The need for PMs

When it comes to reimbursement, the healthcare environment is shifting from a fee-for-service model to demonstration of value and quality care. Orthopaedic specialists will be asked to document appropriate steps taken during the care of patients with standard clinical conditions such as hip fracture. Orthopaedic surgery needs measures that show how delivering appropriate care can influence patients’ health status. The AAOS Management of Hip Fractures in the Elderly PM Work Group believes that the PM evaluating timing of surgical intervention represents a realistic goal for qualifying patients in most health systems and that it will facilitate optimal delivery of musculoskeletal care for elderly patients with hip fractures. Quality metrics are benchmarks used by the Centers for Medicare & Medicaid Services (CMS) to measure a specific healthcare process or outcome against a high standard for all operating procedures.

However, the ability to meet an outcome measure can be impacted by multiple factors over which orthopaedic specialists may have little or no control. An example is a patient who presents on anticoagulation therapy. The CPG specifically identifies that there is no reason to delay operative care for patients taking clopidogrel (Plavix). However, orthopaedic surgeons often must delay surgical care for patients medically anticoagulated with vitamin K antagonists or nonvitamin K antagonists. Yet there is no consensus on the optimal delay in surgical care in such cases—with or without reversal of the anticoagulant. Therefore, anticoagulation with vitamin K antagonists or nonvitamin K antagonists is not included in exclusion criteria, as it will impact every center caring for hip fractures in the elderly.

CMS is interested in identifying evidence-based measures that it can use as quality metrics to determine positive or negative adjustments to orthopaedic specialists’ reimbursement. This will encourage orthopaedic surgeons to engage with their health systems to improve the flow of hip fracture patients to the OR. Because of factors outside of surgeons’ control, such as medical anticoagulation, no center will have 100 percent compliance. PMs such as timing of surgical intervention in the defined population allow centers to understand their own performance, compare it with others’ performance, and work to optimize care over time.

The AAOS Work Group for the Management of Hip Fractures in the Elderly PM identified four additional measures that had been developed previously. The measures have been approved by the National Quality Forum (NQF) and are nearly harmonized with the AAOS CPG. The measures include:

  • Osteoporosis Management in Women Who Had a Fracture–Physician Quality Reporting System (PQRS) #418/NQF #0053
    Percentage of women aged 50–85 years who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis within six months after the fracture.
  • Communication with the Physician or Other Clinician Managing Ongoing Care Post-fracture for Men and Women Aged 50 Years and Older–PQRS #24/NQF #0045
    Percentage of patients aged 50 years and older treated for a fracture with documentation of communication between the physician treating the fracture and the physician or other clinician managing the patient’s ongoing care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing.
  • Falls: Risk Assessment–PQRS #154/NQF #0101
    Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.
  • Falls: Plan of Care–PQRS #155/NQF #0101
    Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.

Together with the time-to-OR measure, these quality measures constitute a hip fracture measurement set that can be used in centers where clinical care pathways are in place to document the delivery of quality care for geriatric patients with hip fractures.

The AAOS PM on the Management of Hip Fractures in the Elderly: Timing of Surgical Intervention has been submitted for inclusion in the Merit-based Incentive Payment System (MIPS) and has been cleared by CMS for presentation to the Measure Applications Partnership (MAP) at its meeting this month. If approved by MAP, the measure will be published on the 2019 Measures Under Consideration (MUC) list. Following additional comment periods while on the MUC list, the measure is eligible to be included in MIPS for 2020 reporting. Orthopaedic specialists will be expected to report information to CMS based on four categories: advancing care information, quality, improvement activities, and cost. The combination of the four scores will result in a clinician’s final MIPS score.

In 2018, the quality component of MIPS will account for 50 percent of each practitioner’s score. To receive points toward this score, practicing physicians must submit at least six quality measures that have been accepted into the MIPS program. The AAOS PM on the Management of Hip Fractures in the Elderly: Timing of Surgical Intervention has been submitted under the measure domain called making care safer by reducing harm caused in the delivery of care.

The measurement of quality performance in the orthopaedic setting will establish the appropriate standards of care and enhance patient outcomes. The quality measure on the Management of Hip Fractures in the Elderly: Timing of Surgical Intervention will benefit orthopaedic specialists by providing leadership in the delivery of surgical care to elderly hip fracture patients within 48 hours of admission to ensure high-quality outcome measures. If accepted by CMS, this measure will join the 34 current measures in the CMS Orthopaedic Surgery Specialty Measure Set.

For more information, visit the AAOS Clinical Performance Measures website at www.aaos.org/Quality/Clinical_Performance_Measures.

Steve Olson, MD, is professor and chief of the orthopaedic trauma and hip preservation sections in the Department of Orthopaedic Surgery at Duke University School of Medicine. Dr. Olson chaired the AAOS Practice Management Committee for Management of Hip Fractures in the Elderly. He has served on the workgroup for Management of Hip Fractures in the Elderly CPG. In addition, Dr. Olson served as chief medical officer for Duke University Hospital from 2007 to 2010 and has served as president of the Orthopaedic Trauma Association. He received the Ann Donner Vaughn Kappa Delta Award for work in the mechanisms of development of post-traumatic arthritis.

Quinn Hall, MHA, is the quality dissemination associate in the Department of Clinical Quality and Value at AAOS.