Specifications Manual for Joint Commission National Quality Measures (v2021A1)
Posted: 9/25/2020

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Release Notes:
Measure Information Form
Version 2021A1

Measure Information Form

Measure Set: Palliative Care (PAL)

Set Measure ID: PAL-03

Performance Measure Name: Dyspnea Screening

Description: Proportion of palliative care patients who were screened for dyspnea during the palliative care initial encounter.

Rationale: As described from the University of Chapel Hill PEACE Measure Set project, dyspnea is prevalent and undertreated for many populations of seriously ill patients, including those patients nearing the end of life. Screening for dyspnea is necessary to determine its presence and severity, and forms the basis for treatment decision-making. Unlike pain, structured clinical assessment of the symptom is less well-defined, yet similar to pain, effective treatment is available to alleviate symptom distress. Prevalence of dyspnea in advanced cancer ranges from 50-70%. Among COPD patients with advanced illness enrolled in the SUPPORT Study, dyspnea which was moderate to severe at least half of the time was present for at least 65% of patients throughout the 6 months preceding death. Effective treatment for dyspnea is available, but not consistently administered. Evidence-based treatments include pharmacologic interventions such as opioids and inhaled bronchodilators, and non-pharmacologic interventions including oxygen for hypoxic patients, pulmonary rehabilitation and exercise in COPD, and drainage of pleural effusion. (PEACE, 2015)

National Consensus Project for Quality Palliative Care (2013) guidelines recommend that the interdisciplinary team assesses and manages pain in a safe and timely manner to a level acceptable to the patient or surrogate and that symptom assessment, treatment, side effect and treatment outcome information should be recorded in the medical record

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who are screened for the presence or absence of Dyspnea and its severity during the initial encounter for palliative care.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Patients receiving specialty palliative care in an acute hospital setting for one (1) or more days
Included Populations:

Excluded Populations:
  • Palliative care program length of stay less than one (1) day

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10CM/PCS diagnosis and procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10CM/PCS codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Original Performance Measure Source / Developer:
American Academy of Hospice and Palliative Care (AAHPM) and Hospice and Palliative Nurses Association (HPNA) Measuring What Matters Project Top Ten Measures That Matter List
CMS Hospice Item Set
PEACE Hospice and Palliative Care Quality Measures Set

Measure Algorithm:

Measure Information Form PAL-03
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Specifications Manual for Joint Commission National Quality Measures (v2021A1)
Discharges 01-01-21 (1Q21) through 06-30-21 (2Q21)


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