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MSK4 –  Patients Suffering From a Lower Extremity Injury who Improve Physical Function


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

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 LEFS or PROMIS Physical Function, 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 LEFS/PROMIS Physical Function/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 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 LEFS change score (> or = to 9) or (> or = 2.1) in PROMIS Physical Function 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 a lower extremity injury who achieve an overall score change of > or = the MCID in the LEFS, PROMIS Physical Function 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; Post-Acute Care; Outpatient Services

Clinical Recommendation Statement: Patients regularly enter the clinic with compromised hip, leg, or ankle (lower extremity except knee) function, measurable via the LEFS. Through effective rehabilitation there are marked, measurable improvements. This gap for improvement will always exist in these hip, leg, or ankle injury patients, as this is a true “”””pre- vs. post-“””” measurement, reflected in the proportion of patients achieving an MCID. Specifically, LEFS scores (n=129) the baseline mean was 34.1 and 53.6% patients (ave. age=74.7) achieved an improved outcome of one MCID level (9 points). Failure to progress would be the inverse proportion of 46.4%. For foot and ankle conditions, patients (n=45), average age 73.6 years, had a LEFS baseline score of 41.6 (20.0) and 60% achieved a successful outcome (one MCID), a proportion failing to progress of 40% (Fritz, et al., 2011).
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.

The use of PROMIS Physical Function Computer Adaptive Test (CAT) for measuring lower extremity functional improvement in physical therapy patients is strongly recommended. Supported by robust evidence, including studies by [Neville et al., 2023][1] and [Rothrock et al., 2019][2], the PROMIS Physical Function CAT offers an efficient and precise way to assess lower extremity function. Its adaptive testing tailors questions to patient responses, enhancing accuracy while minimizing patient burden. Validity and reliability, with decreased floor and ceiling effects make it an invaluable tool for evaluating lower extremity function. Integrating the PROMIS CAT into clinical practice empowers therapists to make informed decisions and optimize patient care by tracking progress and tailoring interventions effectively.

[1] Christopher Neville, Judith Baumhauer & Jeff Houck (2023) Are Patient Reported Outcome Measurement Information System scales responsive in patients attending physical therapy with foot and ankle diagnoses?, Physiotherapy Theory and Practice, 39:7, 1493-1503, DOI: 10.1080/09593985.2022.2037116
[2] Rothrock NE, Kaat AJ, Vrahas MS, O?Toole RV, Buono SK, Morrison S, Gershon RC. Validation of PROMIS Physical Function Instruments in Patients With an Orthopaedic Trauma to a Lower Extremity. J Orthop Trauma. 2019 Aug;33(8):377-383. doi: 10.1097/BOT.0000000000001493. PMID: 31085947.

Measure Rationale: According to the World Health Organization (2022), MSKD effects 1.71 billion people worldwide, is the leading cause of disability globally, and is the primary reason for rehabilitation treatment. The total economic burden of MSKD is around $980.1B, which represents 5.7% of the gross domestic product and 30% of the national health expenditures (Wright, et al., 2014). There is a significant impact on mobility with functional limitations that can result in decreased overall health and welfare, engagement in society, or one’s ability to work. Although there is strong evidence of the burden of MSKD dysfunction and pain, it is likely it is underestimated in both prevalence and severity (Blyth, et al., 2019). According to Pain Management Best Practices from Health and Human Services (2019), physical therapists (PTs) and occupational therapists (OTs) play a pivotal role in the multidisciplinary team’s management of both acute and chronic pain by contributing to maintaining function in an effort to reduce opioid prescriptions. PTs and OTs are also positioned to improve long-term outcomes by providing high-quality and timely care while reducing downstream costs. Improving quality of care begins with tracking outcomes and use of the Lower Extremity Function Scale (LEFS – legacy13) patient reported outcome measure (PROM) has proven to be a reliable cost effective measurement tool in multiple studies. Fritz, et al. (2011) performed an original study on the outcomes of physical therapy in Medicare patients utilizing the legacy measures including the LEFS. 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 LEFS as one of the measurement tools. A meta-analysis of 27 studies by Mehta, et al. (2016) demonstrated that the LEFS scores demonstrated excellent test-retest reliability, no floor / ceiling effects, and concluded that their research supports the reliability, validity, and responsiveness of the LEFS scores for assessing functional impairment in a wide array of patient groups with lower extremity musculoskeletal conditions. In addition, the LEFS average completion time is 2 minutes and can be easily scored in 20 seconds without use of a computer or calculator. (Binkley, et al, 1999).The LEFS is a widely used tool among healthcare professionals in the United States as well as worldwide; in fact, a PubMed search includes validation of the LEFS in Malaysia, China, Turkey, Finland, and Arabic and Dutch- speaking countries to name a few. 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.

The use of the PROMIS Physical Function Computer Adaptive Test (CAT) is strongly recommended for physical therapists, orthopedic therapists, and musculoskeletal doctors for assessing back function in clinical practice. Supported by robust psychometric evidence, including studies by Brodke et al. (2016) and Cheung et al. (2019), the PROMIS Physical Function CAT demonstrates excellent reliability, validity, and efficiency. Its adaptive testing algorithm tailors questions to individual responses, enhancing measurement precision and minimizing patient burden. This tool’s clinical applicability is underscored by its ability to capture subtle changes, as highlighted by Horn et al. (2020), making it an indispensable resource for tracking progress and facilitating informed treatment decisions, ultimately improving patient outcomes.

Blyth, F. M., Briggs, A. M., Schneider, C. H., Hoy, D. G., & March, L. M. (2019). The Global burden of musculoskeletal pain-where to from here?. American Journal of Public Health, 109(1), 35–40. 10.2105/AJPH.2018.304747
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
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
Health and Human Services (2019). Pain management best practices. files/pain-mgmt-best-practices-draft-final-report-05062019.pdf
Hochberg, M., & Watkins-Castillo, S. (n.d.). Joint pain and joint replacement. Bone and Joint Initiative USA.
Mehta,S.P., Fulton, A., Quach, C., Thistle, M., Toledo, C., Evans, N. (2016). Measurement properties of the lower extremity functional scale: a systematic review. Journal of Orthopedic & Sports Physical Therapy, 46(3), 200-216.
Wright, N. C., Looker, A. C., Saag, K. G., Curtis, J. R., Delzell, E. S., Randall, S., & Dawson-Hughes, B. (2014). The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine: Recent US prevalence of osteoporosis and low bone mass. Journal of Bone and Mineral Research, 29(11), 2520–2526. 10.1002/jbmr.2269
Zhang, C., Liu, Y., Yuan, S., Yang, T., Gao, Y. Zhu, C., Ding, Z. (2020) Cross-cultural adaptation and validation of the simplified chinese version of the lower extremity functional scale. BioMed Research International, 7 pages. 10.1155/2020/1421429
Cheung EC, Moore LK, Flores SE, Lansdown DA, Feeley BT, Zhang AL. (2019) Correlation of PROMIS with Orthopaedic Patient-Reported Outcome Measures. JBJS Rev. 2019 Aug;7(8):e9. doi: 10.2106
Horn ME, Reinke EK, Couce LJ, Reeve BB, Ledbetter L, George SZ. Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review. J Orthop Surg Res. 2020 Nov 23;15(1):553. doi: 10.1186

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