Quality

Introduction

A primary goal of the Society of Interventional Radiology is ensuring high-quality outcomes and patient safety in vascular and interventional radiology.

Proposals for IR Performance and Quality Improvement Data Collection

SIR and SIR Foundation are committed to quality improvement and mechanisms to assess performance in interventional radiology. Please use this opportunity to provide feedback regarding specific data elements, performance measures or broader lines of investigation that support the development of meaningful multi-institutional clinical trials and registries. Suggestions are welcome from individuals with an interest in IR. These suggestions may be used to improve clinical trial, registry and research consensus panel planning as well as standardized reporting. Provide feedback.

SIR has representation in the AMA PCPI. SIR representatives participate on Joint Commission advisory panels. SIR monitors NQF, AHRQ, and other quality-focused organizations and agencies.

Quality news

2015 Annual QRURs Webcast — September 29

Save the Date: Thursday, Sept. 29 from 1:30 to 3 p.m. ET
Save the date. Registration will open soon on the MLN Connects Event Registration website.
In mid-September 2016, CMS will make 2015 Annual Quality and Resource Use Reports (QRURs) available to all group practices and solo practitioners nationwide. This event provides an overview of the report and explains how to interpret and use the information.
2015 Annual QRURs show how groups and solo practitioners performed in 2015 on the quality and cost measures used to calculate the 2017 Value-Based Payment Modifier (Value Modifier) and how the Value Modifier will be applied to physician payments. Learn more on the 2015 QRUR and 2017 Value Modifier webpage. Visit How to Obtain a QRUR to access your report prior to the event.

Quality measures update

SIR Performance and Quality Improvement Committee within the Quality and Outcomes Division has worked closely with the service lines to propose and refine performance measures for inclusion in the Physician Quality Reporting System (PQRS). The SIR Foundation made performance measurement a central focus of the foundation’s efforts with goals to propose PQRS measures relevant to IR, develop IR registries, and streamline the process of data collection such that it occurs as part of routine clinical care by launching a structured reporting initiative.

SIR submitted a total of 13 measures for the 2016 PQRS program in June 2014. Following the Centers for Medicare and Medicaid services (CMS) review, six of these measures were passed on to the National Quality Foundation (NQF) convened Measures Applications Partnership (MAP) for their recommendations and public comment. Based on the MAP review, five measures were passed along to the Physicians Quality Measures Management (PQMM) group. The SIR worked closely with PQMM to specify the measures, including the measure definitions, exclusions, and exemptions. Following CMS’ final review this fall, all five of these measures were published in the Federal Register on Nov. 16, 2015. A summary of the measures is provided below. SIR has also submitted a total of 22 additional measures for consideration in the 2017 PQRS program.

NQF/PQRS Number	NQS Domain	Measure title	Description
409	Effective Clinical Care	Clinical Outcome Post Endovascular Stroke Treatment	Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention
413	Effective Clinical Care	Door to Puncture Time for Endovascular Stoke Treatment	Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours
420	Effective Clinical Care	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey	Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease-specific patient reported outcome survey instrument after treatment
421	Effective Clinical Care	Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal	Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal, or the inability to contact the patient with at least two attempts
437	Patient Safety	Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure	In patients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo an unplanned major amputation or surgical bypass within 48 hours of the index procedure

Resources

Patient–Reported Outcome Measurement Information System (PROMIS®)

The Patient–Reported Outcome Measurement Information System (PROMIS®), funded by the National Institutes of Health, aims to provide clinicians and researchers access to efficient, precise, valid and responsive adult– and child–reported measures of health and well–being. PROMIS measures can be used as primary or secondary endpoints in clinical studies of the effectiveness of treatment, and PROMIS tools can be used across a wide variety of chronic diseases and conditions and in the general population.

Assessment Center data collection tool available

The Assessment Center^SM is a free, online data collection tool that enables researchers to create study-specific websites for capturing participant data securely online. Studies can include measures within the Assessment Center library as well as custom instruments entered by the researcher. The instrument library includes self- and proxy-report short forms, computerized adaptive tests (CATs), and batteries or profiles from Patient-Reporting Outcomes Measurement Information System (PROMIS), Quality of Life in Neurological Diseases (Neuro-QoL), NIH Toolbox, and Health LiTT.

Accreditation

SIR is a sponsoring organization of the Intersocietal Accreditation Commission (IAC). IAC offers the following accreditation programs of interest to interventional radiology.

Vascular Testing
Carotid Stenting
Vein Center

The American College of Radiology (ACR) offers a variety of accreditation programs for radiology.

American Board of Medical Specialties (ABMS)

ABMS announces two new important online features to its online Evidence Library: a living document that is a growing list of peer review publications on the value of certification and MOC: Myths and Facts.

Appropriateness Criteria

The American College of Radiology has a number of interventional radiology topics.

SIR has collaborated with the American College of Cardiology Foundation on the development of appropriateness criteria.

Measurement

CMS Physician Quality Reporting System (PQRS)

Physician Quality Improvement/MOC/Maintenance of Privileges

SIR SAMs

Practice Guidelines

See a full listing of these guidelines.

Registries and Data Collection

SIR is a partner with the ACC Foundation--Carotid Artery Revascularization and Endarterectomy Registry (CARE Registry^®).

Society for Vascular Surgery Vascular Quality Initiative^® (VQI) provides an opportunity for individual providers, hospitals and regional quality improvement groups to collect and analyze clinical data in an effort to improve patient care.

SIR initiates and participates in claims analysis projects on interventional radiology areas of specific interest.

Consortium for Performance Improvement (PCPI)

Physician Consortium for Performance Improvement® (PCPI®) Opens Comment Period on Draft Measures for Non-cardiac Diagnostic Imaging: Submit Comments Until Oct. 1

The American Medical Association (AMA) convened the Physician Consortium for Performance Improvement® (PCPI®) more than a decade ago with its goal of enhancing quality and patient safety, and fostering accountability. The AMA-convened PCPI continues to lead efforts in developing, testing and implementing evidence-based performance measures for use at the point of care.
The PCPI is a national, physician-led initiative dedicated to improving patient health and safety by:

Identifying and developing evidence-based clinical performance measures and measurement resources that enhance the quality of patient care and foster accountability
Promoting the implementation of effective and relevant clinical performance improvement activities
Advancing the science of clinical performance measurement and improvement

The PCPI develops, tests, implements and disseminates evidence-based measures that reflect the best practices and best interest of medicine.

The PCPI is nationally recognized for measure development, specification and testing of measures, and enabling use of measures in electronic health records (EHRs). The PCPI’s measure development resources include a measure testing protocol, a position statement on the evidence base required for measure development, a composite framework, specification and categorization of measure exceptions and an outcomes measure framework.

Reporting

Structured Reports

To promote standardized IR data collection, the SIR has begun developing a range of structured report templates including IVC filter insertion/removal, renal ablation, venous access/ports, uterine artery embolization and spinal interventions. More templates will be added on on an ongoing basis.
SIR collaborated with RSNA on the development of interventional radiology reports.
Standardization of terminology
SIR has developed guidelines for standardization of terminology and reporting criteria in:

Transcatheter therapy for hepatic malignancy
Image-guided tumor ablation

SIR has participated in Radlex: The IR Radlex Project: An Interventional Radiology Lexicon--A Project of the Radiological Society of North America and the Society of Interventional Radiology.

Tools

HI-IQ^® enables IR departments to streamline patient scheduling and tracking and proactively manage both the QA process and inventory.

Safety

Choosing Wisely

Image Gently: SIR is an alliance organization with Image Gently.

Radiation safety statements