MSK9 – Patients Suffering From a Lower Extremity Injury who Improve Pain

Measure Title: Patients Suffering From a Lower Extremity Injury who Improve Pain

Measure Description Percentage of patients 18 years or older suffering from a lower extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year.

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.

This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.

Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or start of care with a lower extremity injury evaluated and treated by a Physical Therapist (PT), Occupational Therapist (OT), or Musculoskeletal(MSK) Provider or group.

Numerator: The total number of patients with lower extremity injuries to achieve an MCID in their Numeric Pain Rating Scale change score (MCID > or = to 2) or like mapped measure, from their initial visits to their final visits in PT/OT practice or PT/OT group during the performance year.

Denominator Exclusions: Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15

Denominator Exceptions: Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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 or follow a standard care pathway. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions: None

Published Specialty: Physical Therapy/Occupational Therapy

High Priority Measure: Yes

Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)

Include Telehealth: Yes

Inverse Measure: No

Proportional Measure: Yes

Continuous Variable Measure: No

Ratio Measure: No

Score Range: N/A

Number of Performance Rates: 1

Performance Rate Description: This measure will include the combined rate of;
Rate 1) Total number of patients aged 18 years or older with an lower extremity injury who achieve an overall score change of > or = the MCID in the NPRS, or like mapped measure.

Risk Adjusted Status: Yes

MIPS Reporting Options: Traditional MIPS

Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care

Clinical Recommendation Statement: “”Patients regularly enter the clinic with compromised hip, leg, or ankle hip, leg, or ankle (lower extremity except knee) pain associated with the injury. That pain is measurable via the NPRS. Through effective rehabilitation there are marked, measurable improvements. This gap for improvement will always exist in these patients, as this is a true “”””pre- vs. post-“””” measurement. Rehabilitation patients ubiquitously experience pain scores greater than zero upon entry into the clinic. With improvements in outcomes, they also experience lessening of pain (improvement of NPRS).

There is little research that describes outcomes of usual physical therapy care for older adults with musculoskeletal conditions. Specifically for pain outcomes using the NPRS for patients with lower extremity clinical conditions: patients (ave age=74.7, SD 6.3) with hip dysfunction (n=140) had baseline NPRS=4.8 (2.6) and an average change of 2.2 (95% CI: 1.9, 2.6). Fritz JM, Hunter SJ, Tracy DM, Brennan GP. Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. PTJ. 2011; 91: 330-345.””

Measure Rationale: “”The World Health Organization (WHO) (2022) describes musculoskeletal conditions / disease as those that are experiencing recurrent pain that limits both mobility and dexterity, ultimately reducing the person’s ability to work and function in society. In 2016 alone, the United States spent $380 billion on healthcare related to musculoskeletal pain and other musculoskeletal disorders, which accounted for some of the highest spending of all conditions reviewed (Dieleman, et al., 2020). Physical Therapists (PTs) and Occupational Therapists (OTs) are positioned to improve long-term outcomes by providing high-quality and timely care while reducing downstream costs. According to Pain Management Best Practices from Health and Human Services (2019), PTs and OTs play a pivotal role in management of both acute and chronic pain contributing to maintaining function in an effort to reduce opioid prescriptions. Measuring pain along with appropriate patient functional outcomes helps to capture how pain and function impact the patients’ lives, assists with development and management of treatment interventions, and recent research indicates it can stand as a predictor of future healthcare utilization (Lentz, et al., 2018) When evaluating the scope of the burden of MSKD, pain as well as other physical and emotional functional impairments should be assessed regardless of context (Blyth et al. 2019). The use of the Numeric Pain Rating Scale (NPRS) is a common and well known tool to assess the pain component of musculoskeletal disease. . Fritz, et al. (2011) performed an original study on the outcomes of physical therapy in Medicare patients utilizing the legacy measures, including the use of the NPRS. Results of the 3-year study, including over 14,000 episodes in an outpatient setting, established that use of legacy PROMs facilitated the identification of factors related to improvement and utilization. A further study by Brennan, et al (2017) reviewed over 165,000 Medicare patient PROs and found that the legacy have been validated as a standard approach to identifying accurate functional limitations and detecting improvements while using the NPRS to assess pain intensity.The numeric pain rating scale has been found to be sensitive for pain assessment of non chronic and chronic osteoarthritic conditions, demonstrates high responsiveness, and shows high reliability – particularly in elderly and less educated patients (Alghadir, AH 2018). In addition to its reliability, research conducted by Hawker, GA (2011) demonstrated that the NPRS takes less than 1 minute to complete, is easy to administer and score, and can be given verbally and in writing making it accessible for more people to readily use. Further research by the British Pain Society (2019) confirmed that the NPRS is an easy to use measure that takes less than 1-3 minutes to complete, it is easy to score, and requires minimal language translations. Additionally, research by Hjermstad, MJ et al (2011) demonstrated that in 15/19 studies comparing various pain outcome tools, the NPRS had better reporting compliance, and was the recommended tool based on higher compliance rates, better responsiveness and ease of use, and good applicability. Given the economic and psycho-social burden of knee pain and disability, use of valid, reliable, and feasible outcome tools are paramount not only for the direct management of individual patient care, but also for the ability to collectively compare health outcomes among providers to determine effective treatment and help drive value.

Alghadir, A. H., Anwer, S., Iqbal, A., & Iqbal, Z. A. (2018). Test-retest reliability, validity, and minimum detectable change of visual analog, numerical rating, and verbal rating scales for measurement of osteoarthritic knee pain. Journal of pain research, 11, 851–856. https://doi.org/10.2147/JPR.S158847

Brennan, G. P., Hunter, S. J., Snow, G., & Minick, K. I. (2017). Responsiveness to change of functional limitation reporting: Cross-sectional study using the intermountain roms scale in outpatient rehabilitation. Physical Therapy, 97(12), 1182–1189. 10.1093/ptj/pzx093
Dieleman, J. L., Cao, J., Chapin, A., Chen, C., Li, Z., Liu, A., Horst, C., Kaldjian, A., Matyasz, T., Scott, K. W., Bui, A. L., Campbell, M., Duber, H. C., Dunn, A. C., Flaxman, A. D., Fitzmaurice, C., Naghavi, M., Sadat, N., Shieh, P., … Murray, C. J. L. (2020). US health care spending by payer and health condition, 1996-2016. JAMA, 323(9), 863. 10.1001/jama.2020.0734
Fritz, J. M., Hunter, S. J., Tracy, D. M., & Brennan, G. P. (2011). Utilization and clinical outcomes of outpatient physical therapy for Medicare beneficiaries with musculoskeletal conditions. Physical Therapy, 91(3), 330–345. 10.2522/ptj.20090290
Lentz, T. A., Beneciuk, J. M., & George, S. Z. (2018). Prediction of healthcare utilization following an episode of physical therapy for musculoskeletal pain. BMC Health Services Research, 18(1). 10.1186/s12913-018-3470-6
World Health Organization (2022). Musculoskeletal health. https://www.who.int/news-room/fact -sheets/detail/musculoskeletal-conditions””