The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale

Abstract

Meaningful quality measurement and public reporting have the potential to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. Recent developments in national quality reporting programs, such as the Centers for Medicare & Medicaid Services Qualified Clinical Data Registry (QCDR) reporting option, have enhanced the ability of specialty groups to develop relevant quality measures of the care they deliver. QCDRs will complete the collection and submission of Physician Quality Reporting System (PQRS) quality measures data on behalf of individual eligible professionals. The National Neurosurgery Quality and Outcomes Database (N(2)QOD) offers 21 non-PQRS measures, initially focused on spine procedures, which are the first specialty-specific measures for neurosurgery. Securing QCDR status for N(2)QOD is a tremendously important accomplishment for our specialty. This program will ensure that data collected through our registries and used for PQRS is meaningful for neurosurgeons, related spine care practitioners, their patients, and other stakeholders. The 2015 N(2)QOD QCDR is further evidence of neurosurgery's commitment to substantively advancing the health care quality paradigm. The following manuscript outlines the measures now approved for use in the 2015 N(2)QOD QCDR. Measure specifications (measure type and descriptions, related measures, if any, as well as relevant National Quality Strategy domain[s]) along with rationale are provided for each measure.

Keywords: ACS NSQIP = American College of Surgeons National Surgical Quality Improvement Program; BMI = body mass index; CMS = Centers for Medicare & Medicaid Services; CVA = cerebrovascular accident; DVT = deep venous thrombosis; EP = eligible professional; MI = myocardial infarction; N2QOD; N2QOD = National Neurosurgery Quality and Outcomes Database; NPA = NeuroPoint Alliance; NQS = National Quality Strategy; PE = pulmonary embolism; PQRS = Physician Quality Reporting System; Physician Quality Reporting System; QCDR = Qualified Clinical Data Registry; SSI = surgical-site infection; UTI = urinary tract infection; qualified clinical data registry; registry.