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Measure Use, Continuing Evaluation & Maintenance

Measure Maintenance Reviews

Annual Update

The annual update process includes updates to the measure's code sets. As development and reporting standards evolve, consider any updates to code languages. Also consider any comments and suggestions received after implementation to determine whether there is a need for revision beyond updating the codes.

For measures proposed for revision, suspension, removal, or retirement, the measure developer evaluates the impact of the decision on the program using the measure.

Comprehensive Reevaluation

Measure developers should conduct a formal review of the measure every 3 years. The CMS consensus-based entity (CBE) requires comprehensive reevaluation for endorsed measures. In many ways, the comprehensive reevaluation process parallels the measure development process. 

The comprehensive reevaluation process ensures that measures continue to be of the highest caliber possible. By periodically reviewing the measures against standard measure evaluation criteria, the measure developer helps maintain the best measures over time.

The comprehensive reevaluation process assumes the measure developer has been monitoring the scientific literature and clinical environment related to the measure, including relevant clinical guidelines.

When updating measure documentation, the measure developer must ensure the documentation of any updates to the evidence, clinical guidelines, impact of the measure, experience of measure use in programs, gaps in care, and measure performance and disseminated to measured entities and other stakeholders in a timely manner. The CMS CBE may require additional measure testing for maintenance review. At the time of initial submission, the measure developer must be aware of any testing requirements needed at maintenance. As the science of measurement advances, evaluation and endorsement processes also evolve. Therefore, the measure developer must also stay abreast with changes in measure testing standards for the purposes of measure maintenance. Refer to Measure Testing for additional details. 

The measure developer should include specific elements in the updated business case:

  • Comparison of the actual performance of the measure with the projected rates
  • Statement of the impact of the measure on the quality topic focus
  • Updated projections for the next evaluation period

The updated documentation must adequately address any areas of potential concern that the measure developer anticipates arising during public comment or CMS CBE review.

Early Maintenance Review

An early maintenance review, previously known as ad hoc review, is a focused examination of the measure’s methodology or data collection process based on new information from clinical evidence or feedback from the field. If there is new evidence that a measure may have significant, adverse effects on patients, the measure developer must undertake an early maintenance review. Measure developers should conduct the early maintenance review only when new evidence indicates a major overhaul of the methodology.

Last Updated: May 2022