Longitudinal Reliability of Rheumatology Patient Safety Measures and Implications for CMS Case Minimums

IF 3 Q2 HEALTH CARE SCIENCES & SERVICES

Joint Commission journal on quality and patient safety Pub Date : 2026-04-01 Epub Date: 2026-01-31 DOI:10.1016/j.jcjq.2026.01.008

Eric T. Roberts PhD, MPH (is Epidemiologist and Research Specialist, Department of Medicine, University of California, San Francisco (UCSF)), Gabriela Schmajuk MD, MSc (is Professor, Department of Medicine, UCSF, and Chief of Rheumatology, San Francisco Veterans Affairs Medical Center), Jessica Fitzpatrick PhD, MPH (is Research Data Analyst, UCSF), Jing Li MPH (is Senior Research Data Analyst, UCSF), Jinoos Yazdany MD, MPH (is Professor, Department of Medicine, UCSF, and Chief, Division of Rheumatology, Zuckerberg San Francisco General Hospital. Please address correspondence to Eric T. Roberts)

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引用次数: 0

Abstract

Background

Metrics with acceptable reliability are necessary to ensure that quality measures reward performance. Low metric reliability may result from a lack of differences between reporting entities or low numbers of eligible patients. The Merit-based Incentive Payment System (MIPS) incentivizes high-performing practices to report, which may lower practice-to-practice variation and lower reliability. This study evaluated the impact of voluntary participation in MIPS and measure denominator counts on practice-specific reliability estimates.

Methods

Data came from the Rheumatology Informatics System for Effectiveness (RISE) registry, which passively collects electronic health record (EHR) data. Practice-specific metric reliability was calculated on two safety measures—QPP176 (tuberculosis screening) and ACR10 (hepatitis B screening)—in two cohorts: the full sample of practices with data in RISE and the subset of practices that reported performance data on these measures to MIPS. The authors report longitudinal summary statistics on metric reliability, performance, and the number of eligible patients. The study team also examined estimates longitudinally stratified by patients counts.

Results

Both the RISE and MIPS samples had acceptable median reliability (> 0.85) but a wide range (0.04–1.0) despite differences in performance. Analyses showed that for both measures for all years, the practice-specific metric reliability remains ≥ 0.80 when the number of eligible patients was at least 20 and ≥ 0.70 when the number of eligible patients was at least 10.

Conclusion

Self-selection into the MIPS program did not reduce the reliability of the examined patient safety measures. In addition, we found acceptable metric reliability at denominator counts lower than currently required by CMS suggesting case minimums for certain measures could be lowered to further encourage quality improvement in a wider subset of practices.

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风湿病患者安全措施的纵向可靠性及其对CMS病例最小值的影响。

背景：具有可接受可靠性的度量是必要的，以确保质量度量奖励绩效。指标可靠性低可能是由于报告实体之间缺乏差异或符合条件的患者数量少。基于绩效的激励支付系统（MIPS）鼓励高绩效的实践报告，这可能降低实践之间的差异和可靠性。本研究评估了自愿参与MIPS的影响，并测量了具体实践可靠性估计的分母计数。方法：数据来自风湿病有效性信息系统（RISE）注册表，该注册表被动收集电子健康记录（EHR）数据。在两个队列中，对两项安全措施——qpp176（结核病筛查）和ACR10（乙型肝炎筛查）——计算了实践特定度量的可靠性：具有RISE数据的实践的全部样本和向MIPS报告这些措施的绩效数据的实践子集。作者报告了度量可靠性、性能和合格患者数量的纵向汇总统计。研究小组还检查了按患者数量纵向分层的估计。结果：RISE和MIPS样本均具有可接受的中位信度（> 0.85），但尽管在性能上存在差异，但范围很广（0.04-1.0）。分析表明，对于所有年份的两种测量，当符合条件的患者人数至少为20人时，实践特异性度量信度保持≥0.80，当符合条件的患者人数至少为10人时，度量信度保持≥0.70。结论：自我选择进入MIPS计划并没有降低被检查患者安全措施的可靠性。此外，我们发现在分母计数时可接受的度量可靠性低于CMS目前的要求，这表明可以降低某些措施的最小病例数，以进一步鼓励在更广泛的实践子集中进行质量改进。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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