Should We Still Abstract Core Measures?

With all the changes related to the COVID-19 pandemic, hospitals are still trying to stabilize operations. It seems like each week CMS is putting out new press releases about changes to regulations.

As it relates to hospital abstracted core measures, CMS has decided that these measures are optional for hospitals to submit to the Hospital Inpatient Quality Reporting (IQR) program for Q1 and Q2 of 2020.

Read more: Changes in Quality Reporting in Response to COVID-19

Soooo, does that mean we should just stop abstracting altogether?

Well if you’re looking for a simple yes or no answer, I’m afraid you’ve come to the wrong place. However, you can consult the Magic 8 Ball below if that helps you.

Although it’s true we can’t give you a yes or no answer without knowing your exact situation, we are offering below a few thoughts for you to consider.

Two questions to ask yourself

1. Should we still continue to abstract our core measures? 

2. Should we still submit our core measures to CMS?

CMS said you don’t have to submit your core measures, but even if you choose not to submit, that doesn’t necessarily mean you should stop abstracting.

In general, Medisolv recommends that, regardless of whether or not you choose to submit your core measures to CMS, you continue abstracting. However, we recognize that not all hospitals are the same and events like huge layoffs could dramatically affect the wisdom of this advice. Every situation is unique. This is our general recommendation and here is why.

Should we continue abstracting?

Continuing to abstract gives you more freedom of choice when it comes to submission time. As you near the deadline for submission later this year, you can look through your performance results and decide then whether you’d like to submit. It’s also probably best internally to keep abstracting so you don’t have a data dark period.

Let’s remember the reason these core measures were required for submission in the first place. There were underlying problems in our hospitals which were uncovered by analyzing performance rates for conditions like sepsis. You do not want to let your performance flounder because you were in the dark about how your hospital was performing during the COVID-19 crisis.

In fact, by continuing to abstract you may see that COVID-19 is affecting your rates. Medisolv analyzed over 220,000 inpatient encounters for hospitals nationwide during the month of April. We found that COVID-19 patients are making their way into abstracted measure populations.

For instance, of the 220,935 April encounters, 12,026 patients fell into the Severe Sepsis/Septic Shock measure patient population. Of that population, 37% (4,429) were COVID-19 patients.

We draw no conclusions here other than the fact that you need to be aware that your sepsis population volumes may be increasing. If you continue to abstract your cases you'll have data to illustrate that jump. 

Here is an example of one of our client’s sepsis patient volumes month over month. The orange line is the two-month moving average.

This hospital discovered a significant increase in March and April for their sepsis population volumes. In April alone this hospital's sepsis volumes went up by 50%. This hospital also happened to have been largely affected by the COVID-19 crisis at that time. In April, 75% of their sepsis volumes had a positive COVID-19 diagnosis. 75%! By continuing to abstract their sepsis measure they identified a disturbing trend that a Quality leader would want to draw attention to and attempt to rectify.

In fact, this would be a good way to ensure you can speak to dips in performance if and when COVID-19 affects your performance rates this year. Let’s say the executives want you to speak to why your sepsis volumes took a huge jump this year. By having the data available, you will be in a better position to speak to the challenges you faced this year.

Note* The Medisolv team is currently working on a COVID-19 impact report for clients to pair with your abstracted measures data.

Yes, but should we submit our data?

Medisolv is working on putting together some comprehensive decisioning guidance to help you come to a reasoned decision. Ultimately though, the decision to submit is one you and your leadership are going to have to make based on the specific data points applicable to your hospital. But you don’t have to make that decision right now. By continuing to abstract your core measures you’ll have the data you need on-hand to make that decision when the time comes.

CMS has not released additional information or guidance related to data transmitted for submissions and its usage for Hospital Compare. We are hopeful CMS will provide more clarity to the usage of data if submitted in the coming months. When they do, we will be sure to keep everyone updated.

Make sure to check out our on-demand webinar below 👇 to get information on commonly asked questions about changes to quality reporting due to COVID-19.