Proposed Measures for HEDIS : Schizophrenia

Transcription

1 Proposed Measures for HEDIS : Schizophrenia NCQA seeks comments on seven proposed schizophrenia and bipolar disorder measures for inclusion in the HEDIS 2013 measurement set: 1. Continuity of Antipsychotic Medications for Treatment of Schizophrenia. 2. Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications. 3. Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications. 4. Diabetes Monitoring for People With Diabetes and Schizophrenia. 5. Cardiovascular Health Monitoring for People With Cardiovascular Disease and Schizophrenia. 6. Cervical Cancer Screening for Women With Schizophrenia. 7. Follow-Up After Hospitalization for Schizophrenia. Note: Acronyms will be assigned upon inclusion in HEDIS set. The measures represent an important area of care for HEDIS. They address a vulnerable population of members: people with schizophrenia or bipolar disorder, who are disproportionately more likely to suffer chronic diseases and have a significantly shorter lifespan than the general population. The measures are similar in structure to current HEDIS measures. All seven measures are specified for administrative data collection, thereby reducing the reporting effort by health plans. In 2011, NCQA and Mathematica Policy Research conducted a field-test using the Medicaid Analytic Extract (MAX). The dataset included fee-for-service data that comprised beneficiaries from 22 states to evaluate the measure specifications. About 10 percent of the Medicaid population was identified as having schizophrenia. Expanding the measure denominator to include people with bipolar disorder identified an additional three percent of the Medicaid population. Average performance levels suggest substantial room for improvement for nearly all measures, and the variance between these measures and related HEDIS measures currently in use indicates a large disparity in care between the general population and people with schizophrenia or bipolar disorder. The proposed measures have the potential to identify members at greater risk for morbidity and mortality from adverse outcomes resulting from a lack of adherence to antipsychotic medications, preventive care and treatment. Establishment of standardized metrics provides a significant opportunity for improvement and acknowledges health plans providing the highest quality of care to their members. Comment requests NCQA specified the measures with a minimum age of 25 years as a result of improved diagnostic fidelity in older patients. Do you recommend keeping that minimum age or dropping it to 18? Supporting documents Measure specifications: Numerator and denominator algorithms, including calculation steps. Measure work-up: Analysis of measure relevance, feasibility and usability. NCQA thanks its advisory panels for their input on this work, particularly the Behavioral Health Advisory Panel. 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

2 Cardiovascular Health Monitoring for People With Cardiovascular Disease and Schizophrenia SUMMARY OF CHANGES TO HEDIS 2013 First-year measure. Description The percentage of members years of age with a diagnosis of schizophrenia and a diagnosis of cardiovascular disease, who received a cardiovascular health monitoring test during the measurement year. Eligible Population Product lines Ages Continuous enrollment Allowable gap Anchor date Benefits Event/ diagnosis Step 1 Medicaid years as of December 31 of the measurement year. The measurement year. No more than one gap in enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled). December 31 of the measurement year. Medical. Follow the steps below to identify the eligible population for the measure. Identify members as having schizophrenia using at least one of the following criteria during the measurement year. Table XXX-A: Codes to Identify Visit Type At least one acute inpatient or ED visit (Table XXX-A), with schizophrenia (Table XXX-B) as the principal diagnosis. At least two outpatient or nonacute inpatient visits (Table XXX-A), with schizophrenia (Table XXX-B) as the principal diagnosis. Description CPT UB Revenue Outpatient 92002, 92004, 92012, 92014, , , , , , , , , , 99411, 99412, 99420, 99429, 99455, Nonacute inpatient , 99315, 99316, 99318, , Acute inpatient , , 99238, 99239, , ED x, x, , , 057x-059x,, 082x- 085x, 088x, 0982, , 0128, 0138, 0148, 0158, 019x, 0524, 0525, 055x, 066x 010x, , 0119, , 0129, , 0139, , 0149, , 0159, 016x, 020x,021x, 072x, 080x, 0987

3 Table XXX-B: Codes to Identify Schizophrenia Diagnosis ICD-9-CM Diagnosis 295 Step 2 Members are identified as having cardiovascular disease in two ways: by event or by diagnosis. The organization must use both methods to identify the eligible population, but a member need only be identified by one to be included in the measure. Event. Identify members from step 1 who were also discharged alive for AMI, CABG or PCI in the year prior to the measurement year. Refer to Table CMC-A for codes to identify AMI, PCI and CABG. Include only AMI and CABG from inpatient claims/encounters. Include all cases of PCI, regardless of setting (e.g., inpatient, outpatient). Diagnosis. Identify members from step 1 as also having IVD who met at least one of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years. At least one outpatient visit (Table XXX-A) with a diagnosis of IVD (Table CMC-B), or At least one acute inpatient claim/encounter (Table XXX-A) with a diagnosis of IVD (Table CMC-B). Administrative Specification Denominator Numerator LDL-C Test The eligible population. An LDL-C test performed during the measurement year as identified by claim/encounter or laboratory data. Use any code in Table CMC-D. An LDL-C test performed during the measurement year, as identified by claim/encounter or automated laboratory data. Use any code in Table CMC-D. The organization may use a calculated or direct LDL for an LDL-C test. Table XXX-1: Data Elements for Cardiovascular Health Monitoring for People With Cardiovascular Disease and Schizophrenia Measurement year Data collection methodology (Administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Administrative

4 Cardiovascular Health Monitoring for People With Cardiovascular Disease and Schizophrenia (Measure Workup) Description The percentage of individuals years of age with a diagnosis of schizophrenia and a diagnosis of cardiovascular disease, who received a cardiovascular health monitoring test (LDL-C) during the measurement year. Importance Health Importance Monitoring complications of antipsychotic medications is important because the use of these medications in people with schizophrenia results in higher incidences of metabolic diseases (e.g., diabetes) and cardiovascular concerns (e.g., hyperlipidemia). Metabolic syndrome risk is 42.6 percent for males and 48.5 percent for females, compared with rates in the general population (24 percent for males, 23 percent for females) (Cohn et al., 2004). These effects occur for first generation antipsychotic medications and for some second-generation antipsychotic medications. Patients with schizophrenia are likely to have higher levels of blood cholesterol and receive less treatment for it. Patients with schizophrenia and elevated blood cholesterol levels are prescribed statins at approximately a quarter of the rate of the general population. Furthermore, some atypical antipsychotic drugs increase total and low-density lipoprotein (LDL) cholesterol and triglycerides, and decrease high-density lipoprotein (HDL) cholesterol, which increases the risk of coronary heart disease (Henneksen et al, 2005). Among patients with co-occurring schizophrenia and metabolic disorders, rates of nontreatment for diabetes, hyperlipidemia and hypertension ranged from 30.2 percent for diabetes, to 62.4 percent for hypertension and 88.0 percent for dyslipidemia (CATIE trial: Nasrallah, et al., 2006). Atypical antipsychotic medications elevate the risk of metabolic conditions, relative to typical antipsychotic medications (Nasrallah, 2008). Individuals with schizophrenia are more likely than the general population to have lifestyle risk factors for cardiovascular disease and mortality (Brown, 1997; Phelan, et al., 2001; McCreadie, 2003; Osborn, et al., 2006; de Leon & Diaz, 2005; Hennekens, et al., 2005). Evidence suggests a higher prevalence of cardiovascular disease, most particularly in younger people with schizophrenia (Bresee et al., 2010). Although some evidence suggests high nontreatment rates for hyperlipidemia in patients with schizophrenia (Nasrallah, et al., 2006), patients who have schizophrenia and elevated blood cholesterol levels are 25 percent less likely to be prescribed statins, compared with the general population (Redelmeier, et al., 1998). Cardiovascular health monitoring for individuals with schizophrenia may lead to proper treatment and control of blood lipid levels. Financial Importance In 2003, the overall cost burden of cardiovascular disease (CVD) was estimated at $351 billion. Of this, $209 billion made up the amount allocated for health care expenditures (direct cost) and $142 billion was the result of lost worker productivity (indirect cost) (CDC, 2005). According to the American Heart Association (AHA), the estimate for total cost burden of CVD in 2005 stood at $393.5 billion a significant increase in just two years (AHA, 2005).

5 Opportunity for Improvement This process measure captures one or more LDL-C tests to monitor cardiovascular conditions in individuals with schizophrenia. Evidence Citations American Heart Association (AHA) Heart Disease and Stroke Statistics-2005 Update. Dallas, Texas: American Heart Association. Angst, F., H.H. Stassen, P.J. Clayton, et al Mortality of patients with mood disorders: follow-up over years. J Affect Disord. 68: Bresee, L.C., S.R. Majumdar, S.B. Patten, J.A. Johnson Prevalence of cardiovascular risk factors and disease in people with schizophrenia: a population-based study. Schizophr Res. 117: Brown, S Excess mortality of schizophrenia: a meta-analysis. Br J Psychiatry. 171: Buchanan, R.W., J. Kreyenbuhl, D.L. Kelly, J.M. Noel, D.L. Boggs, B.A. Fischer, S. Himelhoch, B. Fang, Peterson, E., Aquino, P.R., Keller, W The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull. 36: Centers for Disease Control and Prevention (CDC) Trends in cholesterol screening and awareness of high blood cholesterol United States, MMWR. 2005a;54: Cohn, T., D. Prud'homme, D. Streiner, H. Kameh, G. Remington Characterizing coronary heart disease risk in chronic schizophrenia: high prevalence of the metabolic syndrome. Can J Psychiatry. 49(11): De Leon, J. and F.J. Diaz A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res. 76: Henderson, D.C Atypical antipsychotic-induced diabetes mellitus: how strong is the evidence? CNS Drugs, 16(2): Paper presented at the Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes Diabetes Care. 27:596. Hennekens, C.H., A.R. Hennekens, D. Hollar, D.E. Casey Schizophrenia and increased risks of cardiovascular disease. Am Heart J. 150: Marder, S.R., S.M. Essock, A.L. Miller, R.W. Buchanan, D.E. Casey, J.M. Davis, et al Physical health monitoring of patients with schizophrenia. Am J Psychiatry. 161(8): McCreadie, R. The Scottish Schizophrenia lifestyle group Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. British J of Psychiatry. 183: Melkersson, K.I., A.L. Hulting, K.E. Brismar Elevated levels of insulin, leptin and blood lipids in olanzapinetreated patients with schizophrenia or related psychoses. J Clin Psychiatry. 61: Meyer, J.M Novel antipsychotics and severe hyperlipidemia. J Clin Psychopharmacol. 21, Nasrallah, H.A Atypical antipsychotic-induced metabolic side effects: insights from receptor-binding profiles. Mol Psychiatry. 13(1): Nasrallah H.A., J.A. Meyer, D.C. Goff, J.P. McEvoy, S.M. Davis, S. Stroup, J.A. Lieberman Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: Data from the CATIE schizophrenia trial sample at baseline. Schizophr Res. 86: Newcomer, J.W Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs. 19,1 93. Newcomer, J.W., D.W. Haupt The metabolic effects of antipsychotic medications. Can J Psychiatry. 51: Osborn, D.J., M.B. King, I. Nazareth Risk for coronary heart disease in people with severe mental illness: cross-sectional comparative study in primary care. Br J Psychiatry. 188: Osby, U., L. Brandt, N. Correia et al Excess mortality in bipolar and unipolar disorder in Sweden. Archives of General Psychiatry. 58: Phelan, M., L. Stradins, S. Morrison Physical health of people with severe mental illness. BMJ. 322: Redelmeier, D.A., H.T. Siew, G.L. Booth The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med. 160: Sikich, L., J.A. Frazier, J. McClellan et al Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizo-affective disorder: findings from the treatment of earlyonset schizophrenia spectrum disorders (TEOSS) study. Am J Psychiatry. 165:

6 Benefits Envisioned by the Measure This measure concept is supported by systematic literature reviews, including the Consensus Development Conference (2004). The Mount Sinai Conference (Marder et al., 2004) rated the [q]uality of evidence for an association between specific antipsychotics and risk for hyperlidemia: level 2 [cohort studies, outcomes research, etc.]. The National Institute for Health and Clinical Excellence (NICE) and the American Psychiatric Association (level II, moderate clinical confidence) also recommend such monitoring. Appropriate monitoring of individuals with schizophrenia and cardiovascular disease may lead to proper treatment and management, as necessary. Gap in Care NCQA worked with Mathematica Policy Research to field-test this measure using Medicaid Analytic Extract (MAX) claims data that comprised beneficiaries from 22 states who met the following criteria: Disability as the basis of eligibility. Continuously enrolled in Medicaid for 10 months. Field-test results show a performance gap. Among 22 states, the measure had a minimum value of 11.7%, mean=54.5%, 25th percentile=44.4%, median=59.6%, 75th percentile=67.3% and a maximum value of 85.7%. Health Care Disparities Performance rates* did not vary by gender or age. African Americans had lower monitoring rates for cardiovascular disease. Gender Age Race/Ethnicity Male: 56.4% Female: 55.5% 25 30: 55.6% 31 40: 56.8% 41 50: 55.7% 51 60: 56.5% 61 64: 53.8% Unknown: 0.0% African American: 49.3% Caucasian: 60.3% Hispanic: 69.0% Other: 66.9% Unknown: 56.0% Guidelines Existing guidelines do not focus on cardiovascular monitoring for people with schizophrenia and a cardiovascular diagnosis. USPSTF recommends routine screening for lipid disorders in adults at average and increased risk for coronary heart disease. NICE recommends that people with bipolar disorder have an annual physical health review, normally in primary care, to ensure that the following are assessed each year: lipid levels, including cholesterol in all patients over 40, even if there is no other indication of risk. When initiating long-term treatment of bipolar disorder with antipsychotics, lipids should be measured in all patients. This measure is supported by expert consensus and clinical experience.

7 Data Field-Test Data* Year 2007 Mean 54.5 Denominator Count 4,700 Min th Percentile th Percentile th Percentile 67.3 Max 85.7 * Using MAX claims data from 2007, we included beneficiaries from 22 states who met the following criteria: enrolled in feefor-service plans;** disability as the basis of eligibility; continuously enrolled in Medicaid for 10 months. From these beneficiaries, we drew two analytic samples. Beneficiaries who had a primary diagnosis of schizophrenia on either one inpatient claim or on two outpatient claims on different days were included in our sample. Overall, the sample had 98,412 beneficiaries. Data from the following states were included in both analytic samples: Alabama, Alaska, California, Connecticut, District of Columbia, Georgia, Idaho, Illinois, Indiana, Iowa, Louisiana, Maryland, Missouri, Mississippi, Nevada, New Hampshire, North Carolina, North Dakota, Oklahoma, South Dakota, West Virginia and Wyoming. Beneficiaries ranged in age from years. Just under half (49.2%) the schizophrenia population was female. About 7% of the sample was Hispanic; about 34% of the sample was African American. **Beneficiaries enrolled in managed care plans (e.g., BHO or HMO plans) that provided usable claims records were included. 1.4% of the schizophrenia sample were enrolled in a BHO and 11.5% were enrolled in an HMO.