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In Practice: More Quality Measures for Neurology Under Development


As the need to improve the quality of health care in America becomes ever more clear, the AAN is working to advance quality measurement for neurological conditions and neurology services.

The AAN has led or helped develop measurement sets for stroke and stroke rehabilitation, obstructive sleep apnea, epilepsy, Parkinson disease, dementia, distal symmetric polyneuropathy (DSP), and amyotrophic lateral sclerosis (ALS). An update to the stroke and stroke rehabilitation measurement is currently being finalized.


: “Quality measures give the practitioner a way of evaluating their practice in a systematic way and allow them to identify problem areas and improve their performance.”

Developing quality measures is a rigorous, time-consuming and expensive process, but the work is preparing neurologists for the future of medical practice.

“Measures are going to be coming, whether we develop them or not,” said Rebecca J. Swain-Eng, the AAN senior manager for measurement and implementation. “So we want to make sure that neurologists can help make measures that will improve patient care the most.”

“I think all neurologists would say that they are interested in improving the quality of what they do, and they are interested in analyzing their practice so that they understand the areas where they can improve and can implement improvement strategies,” said Christopher T. Bever, MD, professor of neurology at the University of Maryland Medical School and associate chief of staff for research and development at the VA Medical Center in Baltimore. Dr. Bever, who is chair of the AAN Quality Measurement and Reporting (QMR) Subcommittee, said: “Quality measures give the practitioner a way of evaluating their practice in a systematic way and allow them to identify problem areas and improve their performance.”

In neurology, quality measures for stroke care have been available for many years and have been used by the Joint Commission and the Centers for Medicare & Medicaid Services (CMS) in their evaluations of hospitals since 2009. Beyond that, however, quality measurement is not standard practice for most neurologists.

“Stroke measures for the hospital setting have existed for over a decade, but non-stroke neurologists are probably unfamiliar with quality measurements,” said Eric M. Cheng, MD, a health services researcher and assistant professor of neurology at the David Geffen School of Medicine at the University of California, Los Angeles. Dr. Cheng, vice chair of the AAN QMR subcommittee, added: ”However, quality measures will be increasingly implemented in the outpatient setting for all subspecialties, so this is something that they will need to understand.”

A few specialties — cardiology and endocrinology — have led the way in the development and widespread use of quality measures. And neurology is catching up.

“They are farther along than we are, but neurology is right behind the leading medical specialty societies in moving forward with measures and educating our membership about the implementation of quality improvement processes in practice,” Dr. Bever said.


The AAN published articles on the Parkinson disease and epilepsy measurement sets in 2009 and 2010, respectively. Last fall the AAN board of directors approved the dementia measurement set that was developed in collaboration with the American Geriatrics Society, the American Psychiatric Association, the American Medical Directors Association, and the AMA-convened Physician Consortium for Performance Improvement (PCPI).

“The measures for DSP and ALS care are still under development. We expect that the AAN will release them sometime in 2012,” Swain-Eng said.

Meanwhile, the AAN will be developing new measures for multiple sclerosis, muscular dystrophies, and headache measures in 2012 and 2013.

“We will work with the AMA-convened PCPI and plan to partner with the American Academy of Family Physicians on the development of headache measures because headache is such a cross-disciplinary project,” Swain-Eng said.

Among other uses, the neurology care measures may make the federal government's Physician Quality Reporting System (PQRS) more attractive for neurologists. Since the program — originally called the Physician Quality Reporting Initiative — launched in 2007, many neurologists have lamented that there were too few relevant measures to make participation worthwhile.

In the 2012 PQRS program, three of the Academy's epilepsy measures and six Parkinson disease measures are included, along with seven stroke and stroke rehabilitation measures, nine dementia measures, and four obstructive sleep apnea measures developed by other organizations with input from the AAN.

All the Parkinson disease and epilepsy measures developed by the Academy were submitted to PQRS, but the CMS does not notify submitters why some measures are chosen and others are ignored. Starting this year, Swain-Eng said, the process by which measures are considered is changing.

“The Academy is trying to have more of a voice on which measures are included in the program and trying to get more neurology specific measures in there,” she said. “The AAN will continue to submit new measures to CMS for consideration for use in the PQRS program.”

Whenever possible, the CMS prefers to use measures that have been endorsed by the National Quality Forum, a nonprofit agency that is the official “endorser” of health care performance measures. The NQF has not issued a call for neurology-related measures for many years.

“However, we have heard that the National Quality Forum later this year will be doing a call for neurology care measures, so we plan to submit our measures for endorsement at that time,” Swain-Eng said.


The Academy's focus on quality measures is to support quality improvement, rather than pay-for-performance programs, Swain-Eng said.

But measures will increasingly be used by payers to differentiate physicians on the quality of care they deliver and to calculate pay in value-based payment systems. Although the PQRS program is voluntary, physicians who do not participate will start seeing their Medicare pay decrease in 2015. (See “PQRS Participation Affects Medicare Pay.”)

“If you are going to be compensated on these metrics, it is essential for you to know what the metrics are,” Dr. Cheng said.

Neurologists and other specialists frequently lament that measurement programs such as PQRS do not have measures that are relevant to their practice. That does not mean they will be exempt from the measurement movement, so understanding the big picture is essential knowledge for physicians.

“Everyone is going to have measures apply to them, whether they think the measures are relevant or not,” he said. “They're going to be scored in some way, so it's better to know what the

rules are.”


  • Visit to learn more about quality measurement and reporting programs such as PQRS.
  • Attend educational sessions at the annual meeting.
  • Use the Physician Consortium for Performance Improvement website to learn about measure development for all medical specialties.
  • For more Neurology Today reports about the AAN measures: “AAN Develops Quality Measures for Epilepsy,” Jan. 20, 2011:; “AAN Develops Quality Measures for Neurology for Parkinson Disease,” Dec. 2, 2010: