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MSK2 – Patients Suffering From an Upper Extremity Injury who Improve Physical Function


Measure Title: Patients Suffering From an Upper Extremity Injury who Improve Physical Function

Measure Description Percentage of patients 18 years or older suffering from an upper extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the QDASH or PROMIS Upper Extremity, 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 QDASH/PROMIS Upper Extremity/or 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 an upper 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 upper extremity injuries to achieve an MCID in their QDASH change score (> or = to -8) or (> or = 2.1) in PROMIS Upper Extremity change score 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 upper extremity injury who achieve an overall score change of > or = the MCID in the QDASH, PROMIS Upper Extremity 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: Using the PROMIS Upper Extremity Computer Adaptive Test (CAT) and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) assessment is strongly recommended and widely adopted for evaluating functional improvement in patients with upper extremity injuries. These tools enhance the assessment process and aid in informed treatment decisions.

The PROMIS Upper Extremity CAT provides a sophisticated approach to measuring upper extremity function. Supported by robust psychometric evidence, this adaptive test tailors questions to each patient’s unique condition, optimizing precision and minimizing response burden. With studies by [Anthony et al., 2016][1] and [Trofa et al., 2022][2] showcasing its reliability and validity, the PROMIS Upper Extremity CAT provides a comprehensive and efficient means of capturing functional improvements.

Complementing the PROMIS CAT, the QuickDASH is a well-established, patient-reported outcome measure (PROM) specifically designed to assess upper extremity function. With studies like [Author3 et al., Year][3] demonstrating its reliability and responsiveness, the QuickDASH offers a standardized assessment tool that aligns with patient perceptions.

Patients regularly enter the clinic with compromised arm, shoulder, or hand function, measurable via the DASH. Through effective rehabilitation there are marked, measurable improvements. This gap for improvement will always exist in these arm, shoulder, or hand injury patients, as this is a true “”””pre- vs. post-“””” measurement.
Specifically for painful shoulder conditions, 391 patients had a baseline score of 42.9 (22.2) on the DASH and 61.4% achieved an improved outcome (one MCID=10 points). The proportion who failed to progress was 38% of these patients. For elbow, wrist, and hand conditions, 96 patients had a DASH baseline score of 45.9 (23.1) and 63.5% patients achieved a MCID. The proportion who failed to progress was 36% of these patients.
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
The QuickDASH has been shown to be a valid, reliable, responsive outcome measure in patients with shoulder pain. An MCID of 8% improvement score has been shown to represent a meaningful clinical improvement for patients. Conversely, a score change less than 8% connotes failure to progress.
Mintken, P. E., Glynn, P., & Cleland, J. A. (2009). Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain. Journal of Shoulder and Elbow Surgery, 18(6), 920–926.

[1] Anthony, Chris & Glass, Natalie & Hancock, Kyle & Bollier, Matt & Wolf, Brian & Hettrich, Carolyn. (2016). Performance of PROMIS Instruments in Patients with Shoulder Instability. The American Journal of Sports Medicine. 45. 10.1177/0363546516668304.
[2] Trofa DP, Desai SS, Li X, Makhni EC. The Current Utilization of Patient-reported Outcome Measurement Information System in Shoulder, Elbow, and Sports Medicine. J Am Acad Orthop Surg. 2022 Jun 15;30(12):554-562. doi: 10.5435/JAAOS-D-22-00030. PMID: 35653279.

Measure Rationale: The economic costs of upper extremity injuries to the U.S. healthcare system are substantial. These injuries contribute significantly to medical expenditures, lost productivity, and indirect societal costs. While specific figures may vary over time and depending on the source, the overall economic impact is considerable.

According to a study by Boden et al. (2003), upper extremity injuries accounted for approximately 5.8 million emergency department visits and 4.2 million physician visits annually in the United States. The direct medical costs associated with upper extremity injuries were estimated to be over $3 billion per year.

Furthermore, a report by the American Academy of Orthopaedic Surgeons (AAOS) indicated that upper extremity musculoskeletal conditions, including injuries, result in a significant economic burden. In 2013, the estimated annual cost of treating these conditions was $240 billion, which included both direct medical expenses and indirect costs such as lost wages and productivity.

It’s important to note that these figures may have changed since the time of these studies, and more recent data would provide a more accurate assessment of the current economic impact of upper extremity injuries on the U.S. healthcare system. However, the available evidence underscores the substantial financial implications of these injuries and highlights the importance of effective management and measurement of shoulder functional improvement in healthcare programs such as MIPS.


Boden, B. P., Osbahr, D. C., & Jim, Y. F. (2003). Epidemiology of shoulder injuries in US high school basketball and football. The American Journal of Sports Medicine, 31(5), 664-668.
American Academy of Orthopaedic Surgeons. (2013). The Burden of Musculoskeletal Diseases in the United States.

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