Prediabetes Quality Measures

Transcription

1 American Medical Association (AMA) Prediabetes Quality Measures Developed by AMA s Prediabetes Quality Measures Technical Expert Panel PUBLIC COMMENT OBSOLETE AFTER MAY 31, 2018 Copyright 2018 American Medical Association. All Rights Reserved.

2 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Table of Contents Disclaimer Notice... 2 AMA Prediabetes Technical Expert Panel Members... 3 Purpose of the Measurement Set... 4 Measure #1: Screening for Abnormal Blood Glucose in Overweight/Obese Patients... 5 Measure #2: Screening for Abnormal Blood Glucose in High Risk Patients... 6 Measure #3: Intervention for Prediabetes... 8 Measure #4: Retesting of Abnormal Blood Glucose in Patients with Prediabetes Evidence Classification/Rating Schemes Copyright 2018 American Medical Association. All Rights Reserved. 1

3 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Disclaimer Notice The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association (AMA). The AMA shall not be responsible for any use of the Measures. The AMA encourages use of the Measures by other health care professionals, where appropriate. THE MEASURES AND SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND American Medical Association. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. CPT contained in the Measures specifications is copyright American Medical Association. copyright Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT ) copyright The International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2017 World Health Organization. All Rights Reserved. The date of the copyright notice shall be the date of first publication of the Measure by the AMA or the date of subsequent updating and publication of the Measure. Copyright 2018 American Medical Association. All Rights Reserved. 2

4 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE AMA Prediabetes Technical Expert Panel Members Ronald Ackermann, MD, MPH (Co-Chair) William Golden, MD, MACP (Co-Chair) Stephen Benoit, MD, MPH Ameldia R. Brown, MDiv, BSN, RN Brian S. Cohen, PhD Laura Clapper, MD, MPPA, CPE, FAAPL Mary Carol Greenlee, MD, FACP, FACE Elizabeth Joy, MD, MPH Mary E. Krebs, MD Leslie Kolb, RN, BSN, MBA Tannaz Moin, MD, MBA, MSHS Jennifer Torres Most, PhD, MscPH, MSSW Maria Prince, MD, MPH James L. Rosenzweig, MD Anita Stewart, MD, MPH, JD AMA Staff Kate Kirley, MD, MS Karen Kmetik, PhD Koryn Rubin Beth Tapper, MA Greg Wozniak, PhD PCPI Foundation Staff Beth Bostrom, MPH Kerri Fei, MSN, RN Diedra Gray, MPH Courtney Hurt, MSW, LCSW Sam Tierney, MPH Patrick Yep, MS, MPH Ann Albright, PhD, RD CDC Subject Matter Expert Copyright 2018 American Medical Association. All Rights Reserved. 3

5 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Purpose of the Measurement Set The AMA convened a cross-specialty, multidisciplinary technical expert panel (TEP) to identify and define new measures for prediabetes. The focus of these measures is to support the prevention of type 2 diabetes in our nation. Specific areas of focus include increasing screening and testing for prediabetes, referring/providing those at risk an intervention, and follow-up testing. The recommendations of this Technical Expert Panel have resulted in the first measurement set in the U.S. for use at the individual physician/group practice level intended to help prevent type 2 diabetes. Currently, eightyfour million Americans have prediabetes and 9 out 10 of these individuals are unaware that they have this condition. CDC-recognized lifestyle change programs are included in the health benefit plans of many private health insurers and the Medicare Diabetes Prevention Program will extend the program to Medicare beneficiaries in April Copyright 2018 American Medical Association. All Rights Reserved. 4

6 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Measure #1: Screening for Abnormal Blood Glucose in Overweight/Obese Patients Measure Description Percentage of patients aged 40 to 70 years who are overweight or obese who are seen for at least two visits or at least one preventive visit during the 12-month measurement period who were screened or have documented previous results for abnormal blood glucose at least once in the last 3 years Numerator Statement Patients who were screened* for abnormal blood glucose at least once in the last 3 years *Screening for abnormal blood glucose may include using a fasting plasma glucose, 2-h plasma glucose during a 75g oral glucose tolerance test, or A1C. Statement All patients aged 43 to 70 years who are overweight or obese* seen for at least two office visits or one preventive visit during the 12-month measurement period *Overweight or obese adults are defined as those with a BMI 25 kg/m 2 Exclusions/ Exceptions Guideline Recommendations Exclusions: Exclude patients who are pregnant. Exclude patients who have any existing diagnosis of diabetes (Type 1, Type 2, latent autoimmune diabetes of adults [LADA], monogenic diabetes [MODY]). Exclude patients in palliative care/hospice The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: Rationale Measure Designation Measure Purpose Measure Type Level of Measurement Improvement Notation National Quality Strategy Priority/CMS Measure Domain The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years of age who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity 1. (USPSTF, 2015) (B recommendation) Overall, screening patients for prediabetes does not occur as often as it should. In a nationally representative sample of patients from the National Health and Nutrition Examination Survey (NHANES) from , only 45% of those who met screening criteria were actually screened. 2 Additionally, survey data show that while primary care physicians are aware of the guidelines that support screening for prediabetes, there is a disconnect between this knowledge and actual practice 3,4 Quality Improvement Accountability Process Individual Practitioner Group Practice Higher score indicates better quality Communication and Care Coordination Community/Population Health Effective Clinical Care Efficiency and Cost Reduction Patient Safety Person and Caregiver-Centered Experience Copyright 2018 American Medical Association. All Rights Reserved. 5

7 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Measure #2: Screening for Abnormal Blood Glucose in High Risk Patients Measure Description Percentage of patients aged 18 years and older who have risk factors* for diabetes who were seen for at least two office visits or one preventive visit in the 12-month measurement period who were screened or have documented previous results for abnormal blood glucose at least once in the last 3 years Numerator Statement Patients who were screened* for abnormal blood glucose at least once in the last 3 years *Screening for abnormal blood glucose may include using a fasting plasma glucose, 2-h plasma glucose during a 75g oral glucose tolerance test, or A1C. Statement All patients aged 21 years and older who have risk factors* for diabetes seen for at least 2 office visits or one preventive visit during the 12-month measurement period *Risk factors for diabetes include: Adults who are overweight or obese (BMI 25 kg/m2 or 23 kg/m2 in Asian Americans) who have one or more of the following: First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) History of CVD Blood pressure 140/90 mmhg or on therapy for hypertension HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or triglyceride level >250 mg/dl (2.82 mmol/l) or on therapy for hypercholesterolemia Women with polycystic ovary syndrome Physical inactivity Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nirgricans) History of gestational diabetes mellitus Exclusions/ Exceptions Guideline Recommendations Exclusions: Exclude patients who are pregnant. Exclude patients who have any existing diagnosis 2 diabetes (Type 1, Type 2, latent autoimmune diabetes of adults [LADA], monogenic diabetes [MODY]). Exclude patients in palliative care/hospice The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: Testing for prediabetes and risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI >=25kg.m2 or >=23kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes 5 (ADA, 2018) (B). To test for prediabetes, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test, and A1C are equally appropriate 5 (ADA, 2018) (B). Testing for prediabetes should be considered in children and adolescents who are overweight or obese and who have two or more risk factors for diabetes 5 (ADA, 2018) (E). If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable 5 (ADA, 2018) (C). Copyright 2018 American Medical Association. All Rights Reserved. 6

8 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Rationale Measure Designation Measure Purpose Measure Type Level of Measurement Improvement Notation National Quality Strategy Priority/CMS Measure Domain Overall, screening patients for prediabetes does not occur as often as it should. In a nationally representative sample of patients from the National Health and Nutrition Examination Survey (NHANES) from , only 45% of those who met screening criteria were actually screened. 2 Additionally, survey data show that while primary care physicians are aware of the guidelines that support screening for prediabetes, there is a disconnect between this knowledge and actual practice. 4. Error! Bookmark not defined. Quality Improvement Accountability Process Individual Practitioner Group Practice Higher score indicates better quality Communication and Care Coordination Community/Population Health Effective Clinical Care Efficiency and Cost Reduction Patient Safety Person and Caregiver-Centered Experience Copyright 2018 American Medical Association. All Rights Reserved. 7

9 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Measure Description Numerator Statement Statement Measure #3: Intervention for Prediabetes Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention* Patients who were provided an intervention* *Intervention must include one of the following: referral to a CDC-recognized diabetes prevention program; referral to medical nutrition therapy with a registered dietician; prescription of metformin. All patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period **Abnormal lab result in the range of prediabetes includes a fasting plasma glucose level between 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l) a 2-hour glucose during a 75g oral glucose tolerance test between 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l) and A1C between % (39-47 mmol/mol). Exclusions/ Exceptions Exclusions: Exclude patients who are pregnant. Exclude patients who have any existing diagnosis of diabetes (Type 1, Type 2, latent autoimmune diabetes of adults [LADA], monogenic diabetes [MODY]). Exceptions: Documentation of medical reason(s) for not providing an intervention for prediabetes (eg, limited life expectancy, lack of program availability, other medical reason) Documentation of patient reason(s) for not providing an intervention (eg, patient refusal) Guideline Recommendations The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years of age who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity 1. (USPSTF, 2015) (B recommendation) Patients with prediabetes should be referred to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program to achieve and maintain 7% loss of initial body weight and increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/week 5. (ADA, 2018) (A). Metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially for those with BMI 35 kg/m 2, those aged <60 years, women with prior gestational diabetes mellitus 5. (ADA, 2018) (A). Rationale Patients who are diagnosed with prediabetes benefit from referral to intervention programs. Data from the 2012 National Ambulatory Medical Care Survey show that only 23% of visits that were associated with prediabetes showed that any type of referral or intervention was made 6. In a small study, survey data show that while providers report following patients with prediabetes closely, only 11% reported referring to a behavioral weight loss program 4. Data support that there is room for improvement in providing patients with prediabetes an intervention. Copyright 2018 American Medical Association. All Rights Reserved. 8

10 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Measure Designation Measure Purpose Quality Improvement Accountability Measure Type Level of Measurement Improvement Notation National Quality Strategy Priority/CMS Measure Domain Process Individual Practitioner Group Practice Higher score indicates better quality Communication and Care Coordination Community/Population Health Effective Clinical Care Efficiency and Cost Reduction Patient Safety Person and Caregiver-Centered Experience Copyright 2018 American Medical Association. All Rights Reserved. 9

11 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Measure #4: Retesting of Abnormal Blood Glucose in Patients with Prediabetes Measure Description Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of prediabetes in the previous year who have a blood glucose test performed in the oneyear measurement period Numerator Statement Statement Patients who had a blood glucose test performed *Retesting for abnormal blood glucose may include using a fasting plasma glucose, 2-h plasma glucose during a 75g oral glucose tolerance test, or A1C. All patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of prediabetes in the year prior to the one-year measurement period **Abnormal lab result in the range of prediabetes includes a fasting plasma glucose level between 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l) a 2-hour glucose during a 75g oral glucose tolerance test between 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l) and A1C between % (39-47 mmol/mol). Exclusions/ Exceptions Guideline Recommendations Exceptions. Documentation of patient reasons for exception (eg, patient moved, changed insurance coverage) The following evidence statements are quoted verbatim from the referenced clinical guidelines and other sources, where applicable: Rationale Measure Designation Measure Purpose Measure Type Level of Measurement Improvement Notation National Quality Strategy Priority/CMS Measure Domain At least annual monitoring for the development of diabetes in those with prediabetes is suggested 5 (ADA, 2018) (E) At least annual glucose testing in patients who were previously found to have lab results in the range of prediabetes is an important aspect of care so that patients can be monitored for improvement or potential transition to Type 2 diabetes 5. While there are no current studies that show patients with prediabetes do not have follow-up testing completed, the TEP felt that this is a key area in which to have a measure. Quality Improvement Accountability Process Individual Practitioner Group Practice Higher score indicates better quality Communication and Care Coordination Community/Population Health Effective Clinical Care Efficiency and Cost Reduction Patient Safety Person and Caregiver-Centered Experience Copyright 2018 American Medical Association. All Rights Reserved. 10

12 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE Evidence Classification/Rating Schemes United States Preventive Services Task Force (USPSTF) Recommendation Grade Definitions 7 Grade A B C D I Definition The USPSTF recommends the service. There is high certainty that the net benefit is substantial. The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Level of Certainty* Regarding Net Benefit 7 *The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service. Level of Certainty High Medium Low Description The available evidence usually includes consistent results from well-designed, wellconducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: The number, size, or quality of individual studies. Inconsistency of findings across individual studies. Limited generalizability of findings to routine primary care practice. Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies. Important flaws in study design or methods. Inconsistency of findings across individual studies. Gaps in the chain of evidence. Findings not generalizable to routine primary care practice. Lack of information on important health outcomes. More information may allow estimation of effects on health outcomes. Copyright 2018 American Medical Association. All Rights Reserved. 11

13 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE American Diabetes Association (ADA) Evidence Grading System 5 Copyright 2018 American Medical Association. All Rights Reserved. 12

14 CONFIDENTIAL DRAFT F COMMENT ONLY-DO NOT DISTRIBUTE References 1 Siu L on behalf of the U. S. Preventive Services Taskforce. Screening for abnormal blood glucose and type 2 diabetes mellitus: U. S. Preventive Services Task Force recommendation. Ann Intern Med. 2015;163: Kiefer M, et al. National patterns in diabetes screening: Data from the National Health and Nutrition Examination Survey (NHANES) J Gen Intern Med. 2014;30(5): Mehta S, Mocarski M, Wisniewski T, Gillepsie K, Narayan Venkat KM, Lang K. Primary care physician s utilization of type 2 diabetes screening guidelines and referrals to behavioral interventions: a survey-linked retrospective study. BMJ Open Diab Res Care. 2017;5:e Doi: /bmjdrc Tseng E, Greer R C, O Rourke, P, Yeh, H-C, McGuire, M M, Clark, J M, & Maruthur, N M. Survey of primary care providers knowledge of screening for, diagnosing and managing prediabetes. Journal of General Internal Medicine, 32(11), American Diabetes Association. Standards in medical care in diabetes Diabetes Care. 2018:41 (Suppl.1);S1-S Mainous A G, Tanner R J, & Baker R. Prediabetes and Treatment in Primary Care. The Journal of the American Board of Family Medicine (2), Grade Definitions. U.S. Preventive Services Task Force. November Copyright 2018 American Medical Association. All Rights Reserved. 13

15 American Medical Association Prediabetes Quality Measures Measure Component Initial Population QDM Datatype Value Set Name Standard Terminology OID or Reference Code Attributes/Relationships Comments/Rationale n/a Measurement Period n/a n/a by Measure Implementer Patient Characteristic Age CPT SNOMED-CT CPT SNOMED-CT CPT SNOMED-CT HCPCS CPT CPT CPT Physical Exam, Performed Body mass index (BMI) [Ratio] Equals Initial Population Office Visit Outpatient Consultation Nursing Facility Visit Annual Wellness Visit Preventive Care Services - Established Office Visit, 18 and Up Preventive Care Services-Initial Office Visit, 18 and Up Preventive Care Services - Other Measure Title: Screening for Abnormal Blood Glucose in Overweight/Obese Patients age at start of ["Measurement Period"] >= 43 years age at start of ["Measurement Period"] <=70 years ["Office Based Visits"] Count >= 2 during ["Measurement Period"] ["Preventive Visit"] Count >=1 during ["Measurement Period"] during ["Office Based Visits"] BMIexam.result: >=25 kg/m2 during ["Preventive Visit"] BMIexam.result: >=25 kg/m2 To ensure the measure is only looking for a blood test after an individual turns 40, the youngest age in this population is 43. To satisfy the measure requirements, there must be at least two encounters of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count of two or more visits has been met, one of those encounters may be used to meet additional measure criteria. Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter. To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count of one or more visits has been met, one of those encounters may be used to meet additional measure criteria. Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter. Pregnancy Diabetes Diabetes mellitus due to underlying condition without complications ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-10-CM E08.9 Diabetes value set includes diagnosis codes for Type 1 and Type 2 Diabetes, latent autoimmune diabetes of adults (LADA), and monogeneic diabetes (MODY). Based upon TEP feedback, code will be included to account for other unspecified diabetes diagnoses such as: cystic fibrosis diabetes, pancreatogenic diabetes (pancreatitis, pancreatectomy). Exclusions Encounter Inpatient SNOMED-CT ends during ["Measurement Period"] Attribute: Discharge Disposition Discharge to home for hospice care (procedure) SNOMED-CT n/a Attribute: Discharge Disposition Discharge to healthcare facility for hospice care (procedure) SNOMED-CT n/a Intervention, Order Hospice care ambulatory SNOMED-CT during ["Measurement Period"] Intervention, Performed Hospice care ambulatory SNOMED-CT overlaps ["Measurement Period"] Intervention, Order Palliative Care SNOMED-CT starts during ["Measurement Period"] SNOMED-CT Intervention, Performed Palliative Care SNOMED-CT overlaps ["Measurement Period"] SNOMED-CT This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype. This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype. Numerator HbA1c Laboratory Test Grouping Value Set Fasting Plasma Glucose Test ["HbA1c Laboratory Test Grouping Value Set"] Performed 3 years or less before end of "Measurement Period" AND result is "not null" ["Fasting Plasma Glucose Test"] Performed 3 years or less before end of "Measurement Period" AND result is "not null" 2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test ["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Performed 3 years or less before end of "Measurement Period" AND result is "not null" Exceptions None *This document uses Quality Data Model (QDM) version American Medical Association. All Rights Reserved.

16 American Medical Association Prediabetes Quality Measures Measure Title: Screening for Abnormal Blood Glucose in High Risk Patients Measure Component QDM Datatype Value Set Name Standard Terminology OID or Reference Code Constraints Comments/Rationale n/a Measurement Period n/a n/a by Measure Implementer Initial Population Patient Characteristic Age Office Visit CPT SNOMED-CT Outpatient Consultation CPT SNOMED-CT Nursing Facility Visit CPT SNOMED-CT Annual Wellness Visit HCPCS Preventive Care Services - Established Office Visit, and Up CPT Preventive Care Services-Initial Office Visit, 18 and Up CPT Preventive Care Services - Other CPT Physical Exam, Performed Body mass index (BMI) [Ratio] Patient Characteristic Race Asian CDCREC age at start of ["Measurement Period"] >= 18 years ["Office Based Visits"] Count >= 2 during ["Measurement Period"] ["Preventive Visit"] Count >=1 during ["Measurement Period"] during ["Office Based Visits"] BMIexam.result: >=25 kg/m2 during ["Preventive Visit"] BMIexam.result: >=25 kg/m2 during ["Office Based Visits"] BMIexam.result: >=23 kg/m2 where ["Patient Characteristic Race": "Asian"] during ["Preventive Visit"] BMIexam.result: >=23 kg/m2 where ["Patient Characteristic Race": "Asian"] To satisfy the measure requirements, there must be at least two encounters of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count of two or more visits has been met, one of those encounters may be used to meet additional measure criteria. Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter. To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count has been met, one of those encounters may be used to meet additional measure criteria. Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter. Family History Family history: Diabetes mellitus in first degree relative (situation) SNOMED-CT starts before end of ["Measurement Period"] Family History Family history of diabetes mellitus ICD-10-CM Z83.3 starts before end of ["Measurement Period"] Patient Characteristic Race Black or African American CDCREC during ["Measurement Period"] Patient Characteristic Race African American CDCREC during ["Measurement Period"] Patient Characteristic Ethnicity Hispanic or Latino CDCREC during ["Measurement Period"] Patient Characteristic Race American Indian or Alaska Native CDCREC during ["Measurement Period"] Patient Characteristic Race Asian CDCREC during ["Measurement Period"] Patient Characteristic Race Native Hawaiian or Other Pacific Islander CDCREC during ["Measurement Period"] overlaps ["Office Based Visits"] LDLTest.result > 250 'mg/dl' LDL-C Test overlaps ["Preventive Visit"] LDLTest.result > 250 'mg/dl' overlaps ["Office Based Visits"] HDLTest.result <35 'mg/dl' HDL-C Laboratory Test overlaps ["Preventive Visit"] HDLTest.result < 35 'mg/dl' Medication, Active Hypercholesterolemia Pharmacotherapy RX NM overlaps after["preventive Visit"] Polycystic Ovary Syndrome ICD-10-CM SNOMED-CT This concept is not included as a supplemental data element which are regularly captured in electronic measures. There is potential that this code is not utilized. What classes of medication should be included in value set? Should statin therapies be included? If so, what intensity of statin therapies should be included? *This document uses Quality Data Model (QDM) version American Medical Association. All Rights Reserved.

17 American Medical Association Prediabetes Quality Measures Measure Title: Screening for Abnormal Blood Glucose in High Risk Patients Measure Component QDM Datatype Value Set Name Standard Terminology OID or Reference Code Constraints Comments/Rationale ICD-10-CM SNOMED-CT Assessment, Performed Minutes of moderate aerobic physical activity per week Assessment, Performed Minutes of vigorous aerobic physical activity per week Myocardial Infarction ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-9-PCS ICD-10-PCS SNOMED-CT ICD-9-PCS ICD-10-PCS SNOMED-CT ICD-9-PCS ICD-10-PCS SNOMED-CT during ["Office Based Visits"] Test.result < 150 minutes/week' during ["Preventive Visit"] Test.result < 150 minutes/week' during ["Office Based Visits"] Test.result < 75 minutes/week' during ["Preventive Visit"] Test.result < 75 minutes/week' Procedure, Performed PCI starts before end of ["Measurement Period"] Procedure, Performed CABG Surgeries starts before end of ["Measurement Period"] Procedure, Performed Carotid Intervention starts before end of ["Measurement Period"] Physical Exam, Performed Physical Exam, Performed Acanthosis Nigricans Gestational Diabetes Systolic Blood Pressure Diastolic Blood Pressure starts before end of ["Measurement Period"] starts before end of ["Measurement Period"] Cerebrovascular disease, Stroke, TIA starts before end of ["Measurement Period"] Atherosclerosis and Peripheral Arterial Disease starts before end of ["Measurement Period"] Ischemic heart disease or coronary occlusion, rupture, or thrombosis starts before end of ["Measurement Period"] Stable and Unstable Angina starts before end of ["Measurement Period"] during ["Office Based Visits"] SystolicBP.result >= 140 'mm[hg]' during ["Preventive Visit"] SystolicBP.result >= 140 'mm[hg]' during ["Office Based Visits"] DiastolicBP.result >= 90 'mm[hg]' during ["Preventive Visit"] DiastolicBP.result >= 90 'mm[hg]' Currently, no concepts exist to capture the intent of this data element. Recommend considering requesting new concept. Currently, no concepts exist to capture the intent of this data element. Recommend considering requesting new concept. For the purposes of this measure, a history of CVD is defined as the folllowing diagnoses and procedures: -Myocardial Infarction -Cerebrovascular disease, Stroke, TIA -Atherosclerosis and Peripheral Arterial Disease -Ischemic heart disease or coronary occlusion, rupture, or thrombosis -Stable and Unstable Angina -PCI -CABG Surgeries -Carotid Intervention Medication, Active Hypertension Therapy RX NM Value set to include high blood pressure medications from the following classes: Diuretics, Beta Blockers, ACE inhibitors, Angiotensin II receptor blockers, Calcium channel blockers, Alpha blockers, Alpha-2 Receptor Agonists, Combined alpha and beta-blockers, Central agonists, Peripheral adrenergic inhibitors, Blood vessel dilators (vasodilators) Source: Medications_UCM_303247_Article.jsp#.WtDY2IjwZPY *This document uses Quality Data Model (QDM) version American Medical Association. All Rights Reserved.

18 American Medical Association Prediabetes Quality Measures Measure Title: Screening for Abnormal Blood Glucose in High Risk Patients Measure Component Exclusions QDM Datatype Value Set Name Standard Terminology OID or Reference Code Constraints Comments/Rationale Pregnancy Diabetes Diabetes mellitus due to underlying condition without complications ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-10-CM E08.9 Encounter Inpatient SNOMED-CT ends during ["Measurement Period"] Attribute: Discharge Disposition Discharge to home for hospice care (procedure) SNOMED-CT n/a Attribute: Discharge Disposition Discharge to healthcare facility for hospice care (procedure) SNOMED-CT n/a Intervention, Order Hospice care ambulatory SNOMED-CT during ["Measurement Period"] Diabetes value set includes diagnosis codes for Type 1 and Type 2 Diabetes, latent autoimmune diabetes of adults (LADA), and monogeneic diabetes (MODY). Based upon TEP feedback, code will be included to account for other unspecified diabetes diagnoses such as: cystic fibrosis diabetes, pancreatogenic diabetes (pancreatitis, s/p pancreatectomy). This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype. This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype. Intervention, Performed Hospice care ambulatory SNOMED-CT overlaps ["Measurement Period"] Intervention, Order Palliative Care SNOMED-CT starts during ["Measurement Period"] SNOMED-CT Intervention, Performed Palliative Care SNOMED-CT overlaps ["Measurement Period"] SNOMED-CT Numerator HbA1c Laboratory Test Grouping Value Set Fasting Plasma Glucose Test ["HbA1c Laboratory Test Grouping Value Set"] Performed 3 years or less before end of ["Measurement Period"] AND result is "not null" ["Fasting Plasma Glucose Test"] Performed 3 years or less before end of ["Measurement Period"] AND result is "not null" 2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test ["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Performed 3 years or less before end of ["Measurement Period"] AND result is "not null" Exceptions None *This document uses Quality Data Model (QDM) version American Medical Association. All Rights Reserved.

19 American Medical Association Prediabetes Quality Measures Measure Title: Intervention for Prediabetes Measure Component QDM Datatype Value Set Name Standard Terminology OID or Reference Code Constraints Comments/Rationale n/a Measurement Period n/a n/a by Measure Implementer Patient Characteristic Age age at start of ["Measurement Period"] >= 18 years Initial Population Office Visit CPT To satisfy the measure requirements, there must be at least two encounters of any of these types documented during the SNOMED-CT measurement period to establish a patient-provider relationship. Once the count of two or more visits has been met, one of those encounters may be used to meet additional measure criteria. Outpatient Consultation CPT ["Office Based Visits Count"] >= 2 during ["Measurement Period"] SNOMED-CT Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the Nursing Facility Visit CPT encounter. SNOMED-CT Annual Wellness Visit HCPCS measurement period to establish a patient-provider relationship. Once the count has been met, one of those encounters To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the Preventive Care Services - Established Office Visit, may be used to meet additional measure criteria. and Up CPT ["Preventive Visit"] Count >=1 during ["Measurement Period"] Preventive Care Services-Initial Office Visit, 18 and Up Reference to an encounter in the constraints column for another data element will be specific to a single instance of an CPT encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the Preventive Care Services - Other HbA1c Laboratory Test Grouping Value Set Fasting Plasma Glucose Test ["HbA1c Laboratory Test Grouping Value Set"] Performed 12 months or less before end of ["Measurement Period"] ["Fasting Plasma Glucose Test"] Performed 12 months or less before end of ["Measurement Period"] CPT AND result >= 5.7% AND result =< 6.4% AND result >= 100 mg/dl (5.6 mmol/l) AND result =< 125 mg/dl (6.9 mmol/l) encounter. ["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] 2-H Plasma Glucose During a 75g Oral Glucose Performed 12 months or less before end of ["Measurement Period"] Tolerance Test AND result >= 140 mg/dl AND result =< 199 mg/dl Equals Initial Population Exclusions Pregnancy Diabetes Diabetes mellitus due to underlying condition without complications ICD-10-CM SNOMED-CT ICD-9-CM ICD-10-CM SNOMED-CT ICD-10-CM E08.9 or or or Encounter Inpatient SNOMED-CT ends during ["Measurement Period"] Attribute: Discharge Disposition Discharge to home for hospice care (procedure) SNOMED-CT n/a Attribute: Discharge Disposition Discharge to healthcare facility for hospice care (procedure) SNOMED-CT n/a Intervention, Order Hospice care ambulatory SNOMED-CT during ["Measurement Period"] Intervention, Performed Hospice care ambulatory SNOMED-CT overlaps ["Measurement Period"] Intervention, Order Palliative Care SNOMED-CT starts during ["Measurement Period"] SNOMED-CT Intervention, Performed Palliative Care SNOMED-CT overlaps ["Measurement Period"] SNOMED-CT Diabetes value set includes diagnosis codes for Type 1 and Type 2 Diabetes, latent autoimmune diabetes of adults (LADA), and monogeneic diabetes (MODY). Based upon TEP feedback, code will be included to account for other unspecified diabetes diagnoses such as: cystic fibrosis diabetes, pancreatogenic diabetes (pancreatitis, pancreatectomy). This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype. This attribute is applicable to the value set "Encounter Inpatient" using QDM datatype. *This document uses Quality Data Model (QDM) version American Medical Association. All Rights Reserved.

20 American Medical Association Prediabetes Quality Measures Measure Title: Intervention for Prediabetes Measure Component Numerator QDM Datatype Value Set Name Standard Terminology OID or Reference Code Constraints Comments/Rationale Intervention, Performed Referral to CDC-Recognized Diabetes Prevention Program SNOMED-CT Intervention, Performed Patient referral to dietitian (procedure) SNOMED-CT Medication, Order Metformin RX NM starts after end of: ["": "HbA1c Laboratory Test Grouping Value Set"] [": "Fasting Plasma Glucose Test"] ["": "2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] starts after end of: ["": "HbA1c Laboratory Test Grouping Value Set"] [": "Fasting Plasma Glucose Test"] ["": "2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] starts after end of: ["": "HbA1c Laboratory Test Grouping Value Set"] [": "Fasting Plasma Glucose Test"] ["": "2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Currently no concepts exist to capture the intent of this data element. Would recommend requesting new concept. Exceptions Intervention, Not Performed Referral to CDC-Recognized Diabetes Prevention Program SNOMED-CT Intervention, Not Performed Patient referral to dietitian (procedure) SNOMED-CT Medication, Not Ordered Attribute: Negation Rationale Attribute: Negation Rationale Metformin Medical Reason Patient Reason Limited Life Expectancy RXNM SNOMED-CT SNOMED-CT SNOMED-CT during ["Office Based Visits"] or during ["Preventive Visit"] during ["Office Based Visits"] or during ["Preventive Visit"] during ["Office Based Visits"] or during ["Preventive Visit"] n/a n/a or This attribute is applicable to the value sets "Referral to CDC-Recognized Diabetes Prevention Program" and "Patient referral to dietitian (procedure)" using QDM datatype Intervention, Not Performed. This attribute is also applicable to the value set "Metformin" using QDM datatype, Medication, Not Ordered. This attribute is applicable to the value sets "Referral to CDC-Recognized Diabetes Prevention Program" and "Patient referral to dietitian (procedure)" using QDM datatype Intervention, Not Performed. This attribute is also applicable to the value set "Metformin" using QDM datatype, Medication, Not Ordered. *This document uses Quality Data Model (QDM) version American Medical Association. All Rights Reserved.

21 American Medical Association Prediabetes Quality Measures Measure Title: Retesting of Abnormal Blood Glucose in Patients with Prediabetes Measure Component Initial Population Exclusions QDM Datatype Value Set Name Standard Terminology OID or Reference Code Constraints Comments/Rationale n/a Measurement Period n/a n/a by Measure Implementer Patient Characteristic Age age at start of ["Measurement Period"] >= 18 years Equals Initial Population None Office Visit Outpatient Consultation Nursing Facility Visit Annual Wellness Visit Preventive Care Services - Established Office Visit, 18 and Up Preventive Care Services-Initial Office Visit, 18 and Up Preventive Care Services - Other HbA1c Laboratory Test Grouping Value Set Fasting Plasma Glucose Test 2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test CPT SNOMED-CT CPT SNOMED-CT CPT SNOMED-CT HCPCS CPT CPT CPT ["Office Based Visits"] Count >= 2 during ["Measurement Period"] ["Preventive Visit"] Count >=1 during ["Measurement Period"] ["HbA1c Laboratory Test Grouping Value Set"] Performed 12 months or less before start of ["Measurement Period"] AND result >= 5.7% ["Fasting Plasma Glucose Test"] Performed 12 months or less before start of "Measurement Period" AND result >= 100 mg/dl (5.6 mmol/l) AND result =< 125 mg/dl (6.9 mmol/l) ["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] Performed 12 months or less before start of ["Measurement Period"] AND result >= 140 mg/dl AND result =< 199 mg/dl To satisfy the measure requirements, there must be at least two encounters of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count of two or more visits has been met, one of those encounters may be used to meet additional measure criteria. Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter. To satisfy the measure requirements, there must be at least one encounter of any of these types documented during the measurement period to establish a patient-provider relationship. Once the count has been met, one of those encounters may be used to meet additional measure criteria. Reference to an encounter in the constraints column for another data element will be specific to a single instance of an encounter, unless otherwise noted, so that the measure requirements will be assessed using the same instance of the encounter. Numerator HbA1c Laboratory Test Grouping Value Set Fasting Plasma Glucose Test 2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test ["HbA1c Laboratory Test Grouping Value Set"] during ["Measurement Period"] AND result is "not null" ["Fasting Plasma Glucose Test"] during ["Measurement Period"] AND result is "not null" ["2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test"] during ["Measurement Period"] AND result is "not null" Laboratory Test, Not Performed HbA1c Laboratory Test Grouping Value Set during ["Measurement Period"] Exceptions Laboratory Test, Not Performed Fasting Plasma Glucose Test during ["Measurement Period"] 2-H Plasma Glucose During a 75g Oral Glucose Laboratory Test, Not Performed during ["Measurement Period"] Tolerance Test Attribute: Negation Rationale Patient Reason n/a SNOMED-CT This attribute is applicable to the value sets "HbA1c Laboratory Test Grouping Value Set," "Fasting Plasma Glucose Test," and "2-H Plasma Glucose During a 75g Oral Glucose Tolerance Test" using QDM datatype Laboratory Test, Not Performed. *This document uses Quality Data Model (QDM) version American Medical Association. All Rights Reserved.