Hospital Outpatient Quality Data Reporting Program

What Is the HOP QDRP?

HOP QDRP stands for the Hospital Outpatient Quality Data Reporting Program. This program is a pay for quality data reporting program implemented by the CMS for outpatient hospital services. It was instituted by the Tax Relief and Health Care Act of 2006¹ and requires hospitals to submit data on measures regarding the quality of care provided in the outpatient setting. Measures of quality include those of process, structure, outcome, and efficiency.

What Is the Purpose of This Program?

The outpatient measures are used to evaluate the consistency with which a health care provider administers the best known available outpatient care for a particular condition. Specifically for radiologists, the goal is to promote high-quality efficient care, reduce unnecessary exposure to contrast materials and/or radiation, and promote adherence to evidence-based medicine practice guidelines.

In addition to providing hospitals with a financial incentive to report their quality of care measure data, the program provides CMS with data to help Medicare beneficiaries make more informed decisions about their health care. Hospital quality of care information gathered through this program is available on the Hospital Compare Web site (www.hospitalcompare.hhs.gov).

How Will HOP QDRP Affect Radiology Practice?

Outpatient imaging is a ubiquitous component of health care delivery, with important implications in the diagnosis, management, and treatment of disease. Few national standards exist to address the variations in the delivery of these services, define its quality, or allow its measurement. Thus, the establishment of OIE measures can help define measurable indicators such as appropriate utilization, excellence in technical performance, timeliness in study reporting, and clinical effectiveness to improve the quality of radiology practice at the national level.

How is “Efficiency” Defined?

“Efficiency” can be defined as the absence of waste. The Institute of Medicine has defined “efficiency” as avoiding the use of resources that do not provide any benefit to patients and classifies the use of such resources as “waste.”² The Research and Development Corporation has defined “clinical waste” as the provision of clinical services for which the cost of the service outweighs the benefit.³

How Does HOP QDRP Differ from Other Incentive Programs?

In this program, hospitals that do not successfully meet the administrative data-collection, submission, validation, and publication requirements will receive a 2% reduction in their annual payment update under the HOPPS. This is different from such programs as the PQRS, which is a voluntary program that offers an incentive payment if the requirements are successfully met. The HOP QDRP is calculated on a per-hospital basis, whereas the PQRS is calculated on a per-physician or group practice basis.

What Criteria Are Used in the Development of HOP QDRP Measures?

To be implemented, measures must meet 4 criteria:

• 1) Importance and relevance with respect to prevalence, cost burden, and vulnerable populations

• 2) Scientific soundness—consistent evidence-based clinical guidelines

• 3) Usability—clear guidelines that highlight room for improvement

• 4) Feasibility—minimal data-collection requirements

What Measures are Currently Used by CMS in This Program?

CMS is currently using 14 measures in the HOP QDRP. Seven of the measures (OP-8, 9, 10, 11 and OP-13, 14, 15) are OIE measures and are of interest to radiologists. These measures are described in detail below:

• OP-8: MR Imaging Lumbar Spine for Low Back Pain. This measure calculates the percentage of patients who had an MRI of the lumbar spine with a diagnosis of low back pain without Medicare claims-based evidence of antecedent conservative therapy.

• OP-9: Mammography Follow-up Rates. This measure calculates the percentage of patients with mammography screening studies done in the outpatient hospital setting that are followed within 45 days by diagnostic mammography or sonography of the breast in an outpatient or office setting.

• OP-10: Abdomen CT—Use of Contrast Material. This measure calculates the ratio of CT abdomen studies that are performed both with and without contrast of all CT abdomen studies performed (those with contrast, those without contrast, and those with both).

• OP-11: Thorax CT—Use of Contrast Material. This measure calculates the ratio of CT thorax studies that are performed with and without contrast of all CT thorax studies performed (those with contrast, those without contrast, and those with both).

The following are new measures adopted in 2011:

• OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery. This measure calculates the ratio of stress echocardiography, SPECT myocardial perfusion imaging, and stress MR imaging studies performed within 30 days of ambulatory low-risk noncardiac surgery of the total number of outpatient studies performed. High values may indicate high use of stress tests before low-risk noncardiac procedures and raise the question of inefficient examination protocols.

• OP-14: Simultaneous Use of Brain CT and Sinus CT. This measure calculates the percentage of brain CT studies that are simultaneously accompanied by a sinus CT study. High values may indicate high use of simultaneous brain and sinus CT examinations and raise the question of inefficient examination protocols and exposure to additional unnecessary radiation.

• OP-15: Use of Brain CT in the Emergency Department (ED) for Atraumatic Headache. This measure calculates the percentage of emergency department visits with a coincident brain CT study of all emergency department visits with a primary diagnosis of headache. High values may indicate high use of brain CT in the emergency department for atraumatic headache and raise the question of inefficient examination protocols.

How Are These Measures Categorized?

These OIE measures are classified within 6 domains:

• 1) Duplication—studies that are duplicated within a short time of each other without any identified clinical indication

• 2) Overlap—different imaging modalities for the same area of the body within a short time of each other that serve the same clinical purpose

• 3) Screening—imaging studies without identified clinical indications based on symptoms or existing diagnoses

• 4) Negative Studies—clinically noncontributory studies

• 5) With and Without Contrast—imaging studies repeated in a short time frame on same body area differing only in whether contrast is used

• 6) Adjacent Body Areas—imaging studies repeated in a short time frame on adjacent body areas

What Are the Current Exclusion Criteria?

Exclusion criteria are used to restrict the scope of the OIE measures to clinical circumstances that are guided by evidence-based guidelines and research evidence. The exclusions applied to each measure serve the following purposes:

• 1) Standardize measures across providers

• 2) Eliminate cases for which there is expected to be little variation

• 3) Eliminate cases for which there is little agreement on the correct clinical course

Please refer to the CMS Web site (www.cms.gov) for further details regarding exclusion criteria for each measure.

What Are Minimum Case-Count Requirements?

For public reporting purposes, there must be an adequate number of cases in the denominator of the measure. If a hospital outpatient department performs a small number of imaging studies meeting the specifications of the measure, the observed value may be an unreliable indicator of the true performance of a hospital. Thus, the CMS established minimum case counts for each measure. If a hospital does not meet the minimum case count for public reporting, Hospital Compare will not report the data for the imaging measures. The minimum case-count requirements are different for each measure and apply specifically to each observed percentage value. A more thorough description of minimum case counts can be found by using the following Web site: https://www.cms.gov/HospitalQualityInits/Downloads/HospitalOutpatientImagingEfficiencyMinimumCaseCounts.pdf.

Where Can I Find More Information about These Programs?

More information about the HOP QDRP and the HOPPS can be found at the CMS Web site (www.cms.gov).