Taking ‘Our Own Medicine’ Through the Nutritional Screening Quality Measure & Quality Payment Program

The late basketball coach John Wooden offered some wise words for living that also apply to wound care practice: “It’s what you learn after you know it all that counts.” The field of wound healing has a way of keeping a clinician humble. Just about the time you think you know something about wound care, you find out that you really don’t. While I didn’t think I knew everything about nutrition in relation to patients living with wounds, I thought I knew enough, until I began developing the nutritional screening quality measure. It turns out I had a lot to learn. This article will discuss the implications of this measure and quality measures overall for the current state of our industry. In 2014, after seven futile years of trying to get quality measures relevant to wound care patients into the Physician Quality Reporting System (PQRS), the Centers for Medicare & Medicaid Services (CMS) opened the back door for wound care quality measures via qualified clinical data registries (QCDRs). That year, CMS allowed these newly recognized QCDRs to develop specialty-specific quality measures. The U.S. Wound Registry (USWR) ran through this door by developing a suite of 14 quality measures that first year, in conjunction with the Alliance of Wound Care Stakeholders, which CMS agreed represented the de facto “specialty society” for the field of wound care. The USWR later brought the total to 21 quality measures. (The measures are available online by the USWR at www.uswoundregistry.com/specifications.aspx). The big barrier encountered by the USWR was funding. A few companies gave small grants, but wound care manufacturers in general did not seem to comprehend the titanic shift that was taking place in healthcare reimbursement, the vital role that quality measures were going to play in this new reimbursement structure, how quality measures could improve quality of care, and the potential value (to the companies themselves!) of the data collected through the quality measure process. Pleas for financial support fell on deaf ears until the USWR connected with Nestlé. The Nestlé team was already well versed on the topic of healthcare reform and understood what a nutrition quality measure could do to improve the awareness of nutritional issues among patients living with chronic wounds. Nestlé officials provided a grant for the USWR’s development of a nutritional screening quality measure. The measure was programmed as an electronic clinical quality measure that remains posted “open source” on the USWR website so that anyone can download it and install it into a certified electronic health record (follow this link: www.uswoundregistry.com/specifications/uswr%2020.pdf). 

Nutritional Screening Quality Measure

Since most of us are still wrapping our heads around the sausage-making that constitutes the quality measure process, think of the measure as the “test” that determines whether a clinical practice guideline has been implemented. No test can really determine whether one comprehends a subject, and no quality measure can really measure quality of care. However, one cannot improve a process that cannot be measured, so we have to find a way to measure something. Quality measures are never perfect. There is always some detail of their design that one could argue needs improvement. The nutritional screening measure is designed as “the percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé Mini Nutritional Assessment [MNA]), and for whom an appropriate nutritional intervention was ordered based on the results of the tool.” That’s pretty simple. The way to pass the measure is to screen each patient living with a wound or an ulcer with a validated screening tool (any validated tool is OK) and then to implement a nutritional intervention based on the tool. Using the MNA short-form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring, or rescreening recommendations. These include: nutrition interventions (eg, diet enhancement, oral supplementation of 400 kcal/d2 close weight monitoring, and a more in-depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (oral nutritional supplementation of 400-600 kcal/day and diet enhancement), close weight monitoring, and a more in-depth nutritional assessment. No specific products are recommended as part of the measure. Although ample data exist to validate the role of nutrition in preventing or healing wounds, the importance of nutrition in the care of patients living with chronic wounds is poorly recognized by healthcare providers in the United States, leading to a “gap in practice” for the recognition of nutritional deficits as well as appropriate clinical interventions to correct them. The goal of this measure is to increase provider awareness of nutritional status among patients living with wounds and ulcers and to correct nutritional deficits if they exist via a simple screening tool. It’s difficult for anyone to argue against improved nutrition, and it’s tough to find a downside to this activity. Of the 14 measures the USWR launched that first year, which included diabetic foot ulcer (DFU) offloading, venous ulcer compression, the appropriate use of cellular products, vascular assessment, and several other measures that involved devices and products used by wound care clinicians every day, only the nutritional assessment measure was actually funded — and it was really thanks to Nestlé that the USWR got off the ground. Every other specialty registry is supported by its respective specialty society, but since wound care doesn’t have a recognized medical specialty, there’s no society to support its registry. Unfortunately, not having a recognized medical specialty doesn’t change the fact that wound care practitioners need quality measures to survive healthcare reform — it just means that there’s no money to support the development of the measures providers need to use.

Improving Quality for Patients

Since this author was involved in developing a nutritional assessment quality measure, let’s begin this part of the discussion with my patients. I recently noticed there were many malnourished patients in my own practice. Was this something new? Why hadn’t I noticed before? One patient, a retired family practice physician who was losing so much protein from a fistula that he was starving to death, had not been considered for a malnutrition diagnosis as the reason for his rapidly declining status by any of the many specialists on his case. Additionally, I began noticing the appearance of sharp shoulder blades among some of the older women who were coming in with slow-to-heal skin tears. Through monitoring of dietary histories and asking patients what they ate for meals and who went grocery shopping for them, it became clear that many patients needed to be reminded that they should concentrate on eating better. One young man had been a promising college football player for a major university before a car accident paralyzed him. He was living with several terrible, nonhealing pressure sores and had seen two physicians previously. He began crying while discussing his food history, and it was clear that his family simply didn’t have the money needed for healthy food. That was the fundamental problem causing a wound to be refractory to healing in his case. Another patient, a frail, 81-year-old woman living with diabetes, rheumatoid arthritis, atrial fibrillation, spinal stenosis, and a history of falls, who was taking 26 medications, including prednisone and infliximab (both of which impair healing) as well as warfarin (which, of course, causes bleeding), developed cellulitis of her right lower leg — the skin of her leg split open from edema. On the first day of presentation (Figure 1), she was encouraged to improve her food intake and was prescribed Arginaid. The difference in granulation tissue 11 days later was striking (Figure 2). Within 18 more days the wound was epithelializing (Figure 3), and in about 7 weeks she was healed (Figure 4). It’s difficult to prove scientifically that taking this approach over several years will make a difference in patient outcomes. However, it’s certainly an approach that should be well received by patients and their families. 

Talk Less, Do More

There are many manufacturers and wound care professional association members who talk frequently at length about quality of care. The list of those who’ve been willing to commit ongoing resources to make that quality happen is much shorter. The USWR has 21 quality measures, but it remains to be seen for how long. CMS does not allow QCDRs to keep measures that are not used. It’s likely measures will be lost sometime this year due to lack of reporting. Those who participated in the USWR “Do the Right Thing” initiative and reported QCDR measures such as DFU offloading, venous ulcer compression, and vascular screening will be on the “honor role” of quality in wound care. These are the people who aren’t merely talking about quality — they actually practice it. They have committed time, resources, and money to support quality reporting in wound care. For the wound care professional associations, manufacturers, and wound care-related businesses that aren’t supporting quality initiatives, there’s no time for empty talk. The Merit-Based Incentive Payment System (MIPS), implemented as of Jan. 1, will result in financial penalties for eligible providers (EPs) who do not participate at all. EPs who participate fully will likely experience a bonus. This first year, EPs who submit even “test data” will manage to keep what they bill under Medicare Part B, but next year will be a different story. There are four components to the MIPS payment calculation, and three of the four components involve submitting quality data via a QCDR. Outpatient professional payment for wound care practitioners will be dependent on the availability of registries like the USWR as well as the quality measures and clinical practice improvement activities it offers. So far, Nestlé has been just about the only organization willing to do something about quality of care, rather than just talk about it. That needs to change fast or wound care practitioners will not survive the transition to MIPS. Wound care organizations must get their members behind quality reporting. Industry partners should fund it. EPs need to get ready to report relevant measures, and might want to start with nutritional screening. 

Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.