WORKING P A P E R WR-515/2

Transcription

1 WORKING P A P E R Appedix to Applicatio of ACOVE-3 Quality Idicators to Patiets with Advaced Demetia ad Poor Progosis (Appedices 1 & 2 ad Figures 1 & 2) NEIL S. WENGER DAVID SOLOMON AND THE ACOVE-3 CLINICAL COMMITTEE: ALPESH AMIN, RICHARD K. BESDINE, DAN G. BLAZER, HARVEY COHEN, TERRY FULMER, PATRICIA A. GANZ, MARK GRUNWALD, WILLIAM J. HALL, PAUL R. KATZ, DALANE W. KITZMAN, ROSANNE M. LEIPZIG, AND RONNIE A. ROSENTHAL This Workig Paper is the techical appedix to a article published i a scietific joural. It has bee subject to the joural's usual peer review process. is a registered trademark. WR-515/2 August 2007

2 Applicatio of ACOVE-3 Quality Idicators To Patiets with Advaced Demetia ad Poor Progosis Appedix 1 Appedix 2 Figure 1 Figure 2

3 Appedix 1: ACOVE-3 QI Dimesios ad Proposed Exclusio for Poor Progosis ad Advaced Demetia Descriptio of QI BPH 1. IF a male VE complais of ew or worseig uriary frequecy, urgecy, uriary icotiece,* octuria, decreased force of stream, feelig of icomplete bladder emptyig, or post void dribblig (er Uriary Tract Symptoms or LUTS), THEN a history should documet the followig: Medicatios associated with symptoms Neurologic coditios that ca affect the urologic system Prior urologic, eurosurgical, orthopedic, or geeral surgery procedures Whether symptoms are bothersome Prior treatmet 2. IF a male VE complais of ew LUTS*, THEN a rectal exam (icludig prostate size, degree of tederess, ad odularity) ad abdomial exam should be performed. *For icotiece, see UI #5 3. IF a male VE complais of ew or worseig LUTS, THEN a urialysis (microscopic exam or dipstick) should be performed AND a urie culture, if the urialysis demostrates pyuria or hematuria. 4. IF a male VE presetig with ew/worseig uriary icotiece, or complaits of icomplete emptyig or LUTS ad has eurologic disease (e.g. spial cord ijury, multiple sclerosis) or has had a procedure that ca affect iervatio of the bladder or urethral sphicter mechaism (e.g. spial surgery), THEN he should have a postvoid residual measuremet Log for

4 5. IF a male VE presetig with ew or worseig LUTS has a history of lower tract urologic surgery or urethral trauma (icludig traumatic catheterizatios), THEN he should be referred to a urologist withi 2 moths 6. IF a male VE has ew microhematuria (>3 RBCs/hpf) ad a egative urie culture (or has 1 positive ad 1 egative urialysis), THEN a repeat urialysis should be performed withi 1 moth. 7. IF a male VE has uexplaied gross hematuria or microhematuria (>3 RBCs/hpf o 2 of 3 urialyses) ad a egative urie culture, THEN he should have the followig withi 3 moths: Serum creatiie Upper urologic tract imagig Referral to a urologist or ephrologist. 8. IF a male VE receives a screeig prostate specific atige (PSA) test, THEN the chart should documet a discussio of the pros ad cos of the test. 9. IF a male VE with presumed BPH has bladder stoes, uriary retetio (>1 episode), uriary tract ifectio or real failure with hydroephrosis, THEN the patiet should be referred to a urologist. 10. IF a male VE with BPH has a AUA SI score 7, the symptoms are ot bothersome, ad the patiet is ot kow to have bilateral hydroephrosis, bladder stoes, hematuria attributable to the prostate or uriary tract ifectio, THEN he should ot be prescribed medicatios or surgery for BPH. 11. IF a male VE with BPH has moderate to severe symptoms (or a AUA SI score >7) that are bothersome, THEN the medical record should documet that treatmet optios were discussed (e.g., medical, surgical, watchful waitig). Log for X X E (except uriary retetio) E (except uriary retetio)

5 12. IF a male VE has surgery for BPH, THEN a urialysis or a urie culture should have bee doe withi 6 weeks prior to surgery AND treated, if ecessary. Breast Cacer 1. IF a female VE is less tha age 70, THEN she should be offered mammographic screeig for breast cacer every 2 years. 2. IF a female VE is diagosed with breast cacer, THEN physical ad psychosocial performace status should be evaluated. 3. IF a female VE is diagosed with breast cacer, THEN comorbid illesses should be evaluated. 4. IF a female VE has a ew diagosis of breast cacer, THEN there should be documetatio of a discussio regardig: Surgical optios ad goals of therapy Post-treatmet quality of life Fuctioal outcomes Risk ad beefits of adjuvat therapy 5. IF a female VE is diagosed with locally ivasive breast cacer, THEN tumor size, grade, ad margis should be recorded after surgery. 6. IF a female VE is diagosed with locally ivasive breast cacer, THEN the estroge ad progesteroe receptor status of the tumor should be documeted. 7. IF a female VE is diagosed with locally ivasive breast cacer ad chemotherapy is plaed, THEN at the time of diagosis HER- 2/eu receptor status should be evaluated. Log for

6 8. IF a female VE is diagosed with locally ivasive breast cacer, chemotherapy is plaed, ad she has a score of 2+ for HER- 2/eu over-expressio by immuohistochemistry testig, THEN HER- 2/eu receptor status should be cofirmed by fluorescece i-situ hybridizatio (FISH). 9. IF a female VE with locally ivasive breast cacer has ay of the followig: (a) symptoms of boe pai, (b) elevated serum alkalie phosphatase, (c) tumor size >5cm, or (d) positive lymph odes, THEN radiographic boe imagig should be performed durig the stagig work-up. 10. IF a female VE is diagosed with early stage locally ivasive breast cacer (Stage I- III) ad chemotherapy is plaed, THEN the patiet should udergo axillary stagig with either a setiel lymph ode biopsy or a complete axillary lymph ode dissectio at the time of surgery. 11. IF a female VE is diagosed with oly lobular carcioma i-situ, THEN further surgical resectio should ot be performed. 12. IF a female VE is diagosed with ductal carcioma i-situ or early stage ivasive breast cacer, THEN breast-coservig surgery should be offered. 13. IF a female VE with locally ivasive breast cacer is treated with a mastectomy, THEN she should be offered breast recostructio. 14. IF a female VE is diagosed with early stage ivasive breast cacer ad udergoes a lumpectomy, THEN breast radiatio therapy should be discussed. Log for X X E (except boe pai) E (except boe pai)

7 15. IF a female VE is diagosed with ivasive breast cacer with a tumor >5cm OR 4 positive lymph odes ad udergoes mastectomy, THEN postoperative radiatio therapy should be discussed withi 2 moths after surgery or after chemotherapy. 16. IF a female VE is diagosed with estroge receptor-positive locally ivasive breast cacer of >1 cm size, THEN adjuvat hormoal therapy should be offered. 17. IF a female VE with a life expectacy >5 years is diagosed with locally ivasive breast cacer with 4 positive lymph odes, THEN adjuvat chemotherapy should be offered. 18. IF a female VE with ormal cardiac fuctio ad a life expectacy >5 years is diagosed with locally ivasive breast cacer with positive lymph odes ad HER-2/eu receptor over-expressio, THEN adjuvat chemotherapy with trastuzumab should be offered. 19. IF a female VE is diagosed with ometastatic breast cacer ad receives primary treatmet, THEN the patiet should ot receive follow-up surveillace with imagig (e.g., CT sca) or laboratory studies (e.g., CA 15-3, CA 27.29, CEA). 20. IF a female VE is diagosed with advaced breast cacer with symptomatic or lytic boe metastasis, THEN bisphosphoate treatmet should be offered. 21. IF a female VE is diagosed with advaced estroge receptor-positive breast cacer with boe metastasis ad without extesive visceral ivolvemet, THEN edocrie therapy should be offered. Log for

8 22. IF a female VE has symptomatic multifocal metastatic hormoe-refractory breast cacer OR symptomatic hormoe receptor-egative breast cacer with extesive visceral metastasis, THEN treatmet with systemic chemotherapy should be offered. 23. IF a female VE with ormal cardiac fuctio with HER-2/eu-positive metastatic breast cacer is treated with systemic chemotherapy, THEN trastuzumab should be offered. COPD 1. IF a VE presets with ocardiac exertioal dyspea, chroic cough ( 6 moths), wheeze or 2 episodes/year of brochitis, THEN s/he should have spirometry. 2. IF a VE with COPD lives with others who smoke, THEN the patiet ad/or smoker should be couseled to elimiate smokig i the home. 3. IF a VE with COPD is ew to a primary care practice, THEN smokig status should be documeted, ad if the patiet ever smoked, smokig status should be assessed aually. 4. IF a VE with COPD is a curret smoker, THEN couselig to quit smokig should be documeted aually. 5. IF a VE with COPD does ot use supplemetal oxyge ad has a postbrochodilator FEV 1 <50% predicted (or ukow), THEN oxygeatio (pulse oximetry or arterial blood gas) should be assessed aually. 6. IF a VE has COPD (GOLD stage >I), THEN s/he should be prescribed a rapidactig brochodilator. 7. IF a VE with COPD is give a ew ihaler device, spacer, or ebulizer, THEN traiig to use the device should be documeted. Log for X

9 8. IF a VE with moderate-very severe COPD (GOLD stage II-IV) has symptoms ot cotrolled by PRN brochodilator use or had 2 exacerbatios i the past year, THEN a log-actig brochodilator should be prescribed. 9. IF a VE with severe-very severe COPD (GOLD stage III-IV) has 2 exacerbatios requirig atibiotics or oral corticosteroids i the past year, THEN (i additio to a logactig brochodilator) ihaled steroids (if ot o oral steroids) should be prescribed. 10. IF a VE with COPD has a po 2 < 55 mmhg or a O 2 Sat<88% (ot durig a exacerbatio), THEN log-term oxyge therapy should be offered. 11. IF a VE with COPD is prescribed logterm oxyge therapy, THEN ecouragemet to use it >18 hours/day (icludig portable oxyge) should be documeted. Colorectal Cacer Care 1. IF a VE is less the age 70, THEN there should be documetatio that the optio of colorectal cacer screeig was discussed. 2. IF a VE is diagosed with colorectal cacer, THEN physical ad psychosocial performace status should be evaluated. 3. IF a VE is diagosed with colorectal cacer, THEN comorbid illesses should be evaluated. 4. IF a VE has a ew diagosis of colorectal cacer ad is a cadidate for therapy, THEN s/he should have a pre-treatmet CEA level. 5. IF a VE with a ew diagosis of colo or rectal cacer is a cadidate for elective resectio of the primary tumor ad has a elevated (or ukow) CEA, THEN pretreatmet imagig with a CT sca (or similar imagig) of the abdome ad pelvis should be doe. Log for

10 6. IF a VE has a ew diagosis of rectal cacer with a ormal CEA ad is a cadidate for elective resectio of the primary tumor, THEN pelvic imagig should be performed by ultrasoud (EUS or TRUS), MRI or CT. 7. IF a VE has a ew diagosis of colorectal cacer ad is a cadidate for potetial cure, THEN s/he should have a total coloic exam prior to surgery. 8. IF a VE uderwet colorectal cacer resectio for cure ad total coloic examiatio was ot performed preoperatively (e.g. due to a obstructig lesio), THEN total coloic examiatio should be performed withi 6 moths after surgery. 9. IF a VE has a ew diagosis of colorectal cacer, THEN there should be documetatio of a discussio regardig: Surgical optios ad goals of surgery Post treatmet quality of life Fuctioal outcomes Risks ad beefits of adjuvat therapy (if colo cacer) or eoadjuvat therapy (if rectal cacer) 10. IF a VE udergoes surgery for colorectal cacer, THEN a qualified physicia (e.g. surgeo, ocologist, radiatio ocologist) should discuss with the patiet/caregiver fial pathology (e.g., stage, status of lymph odes, margis), ad idicatios for further treatmet (e.g., chemotherapy, radiatio therapy). 11. IF a VE has a ew diagosis of colorectal cacer ad is ot a cadidate for surgical therapy, THEN this should be oted as well as a alterative treatmet pla. 12. IF a VE is diagosed with icurable, metastatic colorectal cacer, THEN progosis ad ed-of-life discussios should be documeted. Log for

11 13. IF a VE with a ew diagosis of rectal cacer is to be treated surgically, THEN the surgeo should preoperatively (or preeoadjuvat therapy) assess the mass (e.g., digital rectal exam or flexible sigmoidoscopy). 14. IF a VE with a ew diagosis of colorectal cacer is to have elective abdomial perieal resectio or other procedure with plaed creatio of a ostomy, THEN the ostomy should be sited preoperatively ad documeted i the medical record (e.g. eterostomal therapy ote or operative ote). 15. IF a VE has stage III colo cacer, THEN adjuvat chemotherapy should be give withi 4 moths of surgery. 16. IF a VE is thought to have stage II or III mid-low rectal cacer ad is a cadidate for surgery, THEN preoperative eoadjuvat chemotherapy ad radiatio therapy should be give. 17. IF a VE had surgical resectio for stage II or III rectal cacer ad did ot receive eoadjuvat radiatio ad/or chemotherapy, THEN postoperative adjuvat chemotherapy ad/or radiatio therapy should be provided withi 4 moths of surgery. 18. IF a VE with > stage I colorectal cacer uderwet resectio for cure, THEN a history ad physical examiatio should be performed every 6 moths for the first 2 years after surgery ad aually durig years 3 to IF a VE with > stage I colorectal cacer uderwet resectio for cure, THEN a CEA level should be performed every 3 moths for the first 2 years after surgery ad aually durig years 3 to IF a VE uderwet colorectal cacer resectio for cure, THEN a colooscopy should be performed withi 3 years after surgery. Log for

12 21. IF a VE had prior colorectal cacer resectio for cure ad has a elevated CEA > 7.5 (cofirmed by retestig if <10), THEN further workup should be iitiated (e.g. colooscopy, radiological imagig). Cotiuity ad iatio of Care 1. ALL VEs should be able to idetify a physicia or a cliic to call for medical care or kow the telephoe umber/other mechaism to reach this source of care. 2. IF a VE outpatiet is prescribed a ew chroic disease medicatio, ad s/he has a follow-up visit with the prescribig physicia, THEN 1 of the followig should be oted at the follow-up visit: Medicatio is beig take Patiet was asked about the medicatio (e.g., side effects, adherece, availability) Medicatio was ot started because it was ot eeded or chaged. 3. IF a VE is uder the outpatiet care of 2 physicias, ad oe physicia prescribed a ew chroic disease medicatio or a chage i prescribed medicatio, THEN the oprescribig physicia should ackowledge the medicatio chage at the ext visit. 4. IF a outpatiet, VE was referred to a cosultat ad revisited the referrig physicia, THEN the referrig physicia s medical record should ackowledge the cosultat s recommedatios, iclude the cosultat s report, or idicate why the cosult did ot occur. Log for

13 5. IF a outpatiet VE was give a order for a diagostic test, THEN 1 of the followig should be documeted at the follow-up visit: Result of the test iitialed/ackowledged te that the test was ot eeded/reaso why it will ot be performed te that the test is pedig 6. IF a VE misses a required prevetive care evet that is recurret with a specific periodicity, THEN there should be medical record documetatio of a remider that the prevetive care is eeded withi oe full iterval sice the missed evet. 7. IF a VE is treated at a emergecy departmet or admitted to a hospital, THEN there should be documetatio (durig the ER visit or withi the first 2 days after admissio) of commuicatio with a cotiuity physicia, of a attempt to reach a cotiuity physicia, or that there is o cotiuity physicia. 8. IF a VE is discharged from a hospital to home ad survives 6 weeks after discharge, THEN a physicia visit or telephoe cotact should be documeted withi 6 weeks of discharge AND the medical record should documet ackowledgemet of the recet hospitalizatio. 9. IF a VE is discharged from a hospital to home ad received a ew chroic disease medicatio or a chage i medicatio prior to discharge, THEN the outpatiet medical record should documet the medicatio chage withi 6 weeks of discharge. 10. IF a VE is discharged from a hospital to home with a ew medicatio that requires a serum medicatio level to be checked, THEN the medical record should documet the medicatio level, that the medicatio was stopped, or that the level was ot eeded. Log for

14 11. IF a VE is discharged from a hospital to home or a ursig home ad the trasfer form or discharge summary idicates that a test result is pedig, THEN the outpatiet or ursig home medical record should iclude the test result withi 6 weeks of hospital discharge or idicate that the result was followed-up elsewhere or why the result caot be obtaied. 12. IF a VE is discharged from a hospital to home or a ursig home ad the hospital medical record specifies a follow-up appoitmet for a physicia visit or a treatmet (e.g., physical therapy or radiatio ocology), THEN the medical record should documet that the visit/treatmet took place, that it was postpoed, or ot eeded. 13. IF a VE is discharged from a hospital to home or ursig home, THEN there should be a discharge summary i the outpatiet or ursig home medical record. 14. IF a VE is discharged from a ursig home to home, THEN there should be a discharge summary i the outpatiet medical record. 15. IF a VE is ew to a primary care practice, THEN the medical record should cotai medical records from a prior care source, a request for such medical records, or a idicatio that such records are uavailable. 16. IF a VE is deaf or does ot speak Eglish, THEN a iterpreter or traslated materials should be utilized to facilitate commuicatio Demetia 1. IF a VE is ew to a primary care practice or ipatiet service, THEN there should be a documeted assessmet of cogitive ability ad fuctioal status. 2. ALL VEs should be evaluated aually for chages i memory ad fuctio. Log for X X X E I X X X (memory oly) E (memory oly) I

15 3. IF a VE screes positive for demetia, THEN the physicia should documet a objective cogitive evaluatio that tests 2 cogitive domais. 4. IF a VE screes positive for demetia, THEN the physicia should review the patiet s medicatios (icludig over-thecouter) for ay that may be associated with metal status chages. 5. IF a VE screes positive for demetia ad is takig medicatios that are commoly associated with metal status chages i the elderly, THEN the physicia should discotiue or justify cotiuig these medicatios. 6. IF a VE is ewly diagosed with demetia, THEN a cliicia should perform a eurologic examiatio that icludes evaluatio of gait, motor fuctio, ad reflexes. 7. IF a VE is ewly diagosed with demetia, THEN complete blood cout, thyroid testig, electrolytes, liver fuctio tests, glucose, blood uriary itroge, serum B 12 ad a syphilis test should be performed. 8. IF a VE is ewly diagosed with demetia AND has risk factors for HIV, THEN HIV testig should be offered. 9. IF a VE has ewly diagosed demetia, THEN s/he should be screeed for depressio durig the iitial evaluatio period. 10. IF a VE has bee diagosed with mild to moderate Alzheimer s disease, mild to moderate vascular demetia, or Lewy body demetia, THEN there should be a documeted discussio with the patiet ad/or caregiver about choliesterase ihibitor treatmet 11. IF a VE has mild to moderate vascular or mixed demetia, THEN s/he should receive stroke prophylaxis. Log for X X X E I X

16 12. IF a VE with demetia has a caregiver, THEN the patiet ad/or caregiver should be give iformatio o the followig: Demetia diagosis, progosis, ad associated behavioral symptoms Home occupatioal safety Commuity resources 13. IF a VE has demetia, THEN s/he should be screeed aually for behavioral symptoms of demetia. 14. IF a VE with demetia has behavioral symptoms, THEN specific target symptoms should be documeted ad behavioral itervetios istituted first or cocurretly with pharmacotherapy, OR if treatig first with a pharmacologic itervetio, the severe symptoms or safety cocers should be preset ad documeted. 15. IF a VE with demetia ad behavioral symptoms is ewly treated with a atipsychotic, THEN there should be a documeted risk-beefit discussio. 16. IF a VE has ewly diagosed demetia, THEN 1 of the followig should occur (cosistet with state law): Patiet advised ot to drive a motor vehicle Referral to the Departmet of Motor Vehicles to test drivig ability Referred to a driver s safety course that icludes assessmet of drivig ability 17. IF a VE with demetia is physically restraied i the hospital, THEN the target behavioral disturbace/safety issue justifyig the use of restraits must be documeted i the medical record ad commuicated to the patiet ad/or caregiver/guardia. Log for

17 Depressio 1. ALL VEs should have documetatio of a scree for depressio durig the iitial evaluatio ad aually. 2. IF a VE is admitted to a ursig home, THEN the patiet should have documetatio of a scree for depressio withi 2 weeks of admissio ad aually. 3. IF a vulerable elder presets with oe of the followig symptoms (ad the symptom has ot previously bee documeted as a chroic coditio): Sad mood, feelig dow Isomia or difficulties with sleep Apathy or loss of iterest i pleasurable activities Complaits of memory loss Uexplaied weight loss 5% i the past moth or 10% i the past year Uexplaied fatigue or low eergy 4. IF a VE receives a diagosis of a ew depressio episode, THEN the medical record should documet at least 3 of the 9 Diagostic ad Statistical Maual (DSM-IV) target symptoms for major depressio withi 2 weeks of diagosis. 5. IF a VE receives a diagosis of a ew depressio episode, THEN the medical record should documet o the day of diagosis the presece or absece of suicidal ideatio ad psychosis. 6. IF a VE has thoughts of suicide, THEN the medical record should documet, o the same date, that the patiet either has o immediate pla for suicide, or that the patiet was referred for evaluatio for psychiatric hospitalizatio. Log for X X X E I X X X E I X X X E I X X X E I X X E I

18 7. IF a VE has thoughts of suicide, THEN the medical record should documet, o the same date, that the patiet was asked about access to firearms. 8. IF a VE receives a diagosis of a ew depressio episode, THEN the medical record should documet evaluatio of the followig withi 1 moth or i the prior 3 moths: Hypothyroidism for wome Substace depedece or abuse 9. IF a VE is diagosed with depressio, THEN atidepressat treatmet, psychotherapy, or electrocovulsive therapy (ECT) should be offered withi 2 weeks after diagosis uless there is documetatio withi that period that the patiet has improved, or uless the patiet has substace abuse or depedece, i which case treatmet may wait util 8 weeks after the patiet is i a drug- or alcohol-free state. 10. IF a VE is started o atidepressat medicatio, THEN the followig medicatios should ot be used as 1 st - or 2 d -lie therapy: tertiary amie tricyclics (amitriptylie, imipramie, doxepi, clomipramie, trimipramie); mooamie oxidase ihibitors (uless atypical depressio is preset); bezodiazepies; or stimulats (except methylpheidate). 11. IF a VE has depressio with psychotic features, THEN s/he should be referred to a psychiatrist OR should receive treatmet with a combiatio of a atidepressat ad a atipsychotic, or with ECT. 12. IF a VE with a history of cardiac disease is started a a tricyclic medicatio, THEN a baselie electrocardiogram should be performed prior to iitiatio if ot doe i the prior 3 moths. Log for

19 13. IF a vulerable elder is takig a SSRI, THEN a MAOI should ot be used for at least 2 weeks after termiatio of the SSRI (ad for at least 5 weeks after termiatio of fluoxetie). 14. IF a VE is takig a MAOI, THEN he or she should ot receive medicatios that have the potetial for serious iteractios with MAOIs or for at least 2 weeks after termiatio of the MAOI. 15. IF a VE is ewly treated for depressio, THEN the followig should be documeted at the first follow-up visit to the same physicia or to a metal health provider withi 4 weeks of treatmet iitiatio: Degree of respose to at least 2 of the 9 DSM-IV target symptoms for major depressio Medicatio side effects, if he or she is takig atidepressat medicatios 16. IF a VE is ewly treated for depressio ad has suicidal ideatio at a outpatiet visit, THEN at the ext follow-up visit, which must occur withi 1 week, documetatio should reflect askig about suicide risk. 17. IF a vulerable elder has o meaigful symptom respose after 6 weeks of depressio treatmet, THEN oe of the followig treatmet optios should be iitiated by the 8th week of treatmet: medicatio dose should be optimized or chaged, or the patiet should be referred to a psychiatrist (if iitial treatmet was medicatio); or medicatio should be iitiated or referral to a psychiatrist should be offered (if iitial treatmet was psychotherapy aloe). Log for X X X E I X X X E I

20 18. IF a vulerable elder with depressio respods oly partially after 12 weeks of treatmet, THEN oe of the followig treatmet optios should be istituted by the 16th week of treatmet: switch to a differet medicatio class or add a secod medicatio to the first (if iitial treatmet icludes medicatio); add psychotherapy (if the iitial treatmet was medicatio); try medicatio (if iitial treatmet was psychotherapy without medicatio); cosider ECT; or refer to a psychiatrist. 19. IF a VE with depressio has respoded to atidepressat medicatio, THEN s/he should be cotiued o the drug at the same dose for at least 6 moths, ad make at least 1 cliicia cotact (office visit or phoe) durig that time period. 20. IF a VE has experieced 3 or more episodes of depressio, THEN s/he should receive maiteace atidepressat medicatio with the same type ad dose of medicatio for at least 24 moths with at least 4 office or telephoe visits for depressio durig that period. Diabetes Mellitus 1. IF a VE has diabetes, THEN glycated hemoglobi should be measured aually. 2. IF a VE has a elevated HgbA1c, THEN a therapeutic itervetio should occur: HgbA1c %: Withi 3 moths HgbA1c >11%: Withi 1 moth 3. IF a diabetic VE does ot have established real disease ad is ot receivig a ACE ihibitor or ARB, THEN a test for proteiuria should be doe aually. 4. IF a diabetic VE has proteiuria, THEN a ACE ihibitor or ARB should be prescribed. 5. IF a VE has diabetes, THEN a foot exam should be performed aually. Log for X

21 6. IF a VE with diabetes has a retial examiatio, THEN the presece ad/or degree of diabetic retiopathy should be documeted. 7. IF a diabetic VE is ot blid, ad did ot have retiopathy o a previous examiatio, THEN s/he should have a retial eye examiatio performed by a specialist every 2 years. 8. IF a VE has diabetes, THEN blood pressure should be measured at each primary care ad edocriology visit. 9. IF a diabetic VE has a persistet (o 2 cosecutive visits) elevatio of systolic BP >130 mm Hg, THEN a itervetio (pharmacologic, lifestyle, compliace, etc.) should occur or there should be documetatio of a reversible cause/other justificatio for the elevatio. 10. IF a diabetic VE is ot o aticoagulat/atiplatelet therapy, THEN daily aspiri should be prescribed. 11. IF a diabetic VE has fastig LDL >130 mg/dl, THEN a pharmacologic or lifestyle itervetio should be offered withi 3 moths. Log for

22 Ed of life Care 1. IF a VE dies a expected death with metastatic cacer, oxyge depedet pulmoary disease, NYHA Class III-IV cogestive heart failure, ed-stage liver disease, ed-stage (stage IV) real disease, or demetia, THEN the chart should documet the followig withi the 6 moths prior to death: Pai ad other symptoms Spiritual ad existetial cocers Caregiver burdes/eed for practical assistace Advace care plaig 2. IF a VE dies a expected death with metastatic cacer, oxyge depedet pulmoary disease, NYHA Class III-IV cogestive heart failure, ed-stage liver disease, ed-stage (stage IV) real disease, or demetia, THEN the chart should documet 1 of the followig withi the 6 moths prior to death: Discussio of the medical coditio/goals for treatmet with a desigated surrogate Patiet s preferece for ot ivolvig a desigated surrogate i discussios te that a surrogate decisio maker is uavailable 3. ALL VEs should have i the outpatiet chart: Patiet s surrogate decisio maker Documetatio of a discussio to idetify/search for a surrogate decisio maker Log for

23 4. IF a VE has a advace directive i the outpatiet, ipatiet, or ursig home medical record, or the patiet reports the existece of a advace directive i a iterview, ad the patiet receives care i a secod veue, THEN the advace directive should be preset i the medical record at the secod veue or documetatio should ackowledge its existece ad its cotets. 5. IF a VE is admitted to the hospital or ursig home, THEN withi 48 hours of admissio the medical record should cotai: Patiet s surrogate decisio maker, or Documetatio of a discussio to idetify/search for surrogate decisio maker. 6. IF a VE with severe demetia is admitted to the hospital ad survives 48 hours, THEN withi 48 hours of admissio, the medical record should documet that the patiet s prefereces for care have bee cosidered OR a attempt was made to idetify them. 7. IF a VE is admitted to the itesive care uit ad survives 48 hours, THEN withi 48 hours of itesive care uit admissio, the medical record should documet that the patiet s prefereces for care have bee cosidered OR a attempt was made to idetify them. 8. IF a hospitalized VE requires mechaical vetilatio (for > 48 hours), THEN withi 48 hours of the iitiatio of mechaical vetilatio, the medical record should documet the goals of care ad the patiet s preferece for mechaical vetilatio or why this iformatio is uavailable. Log for

24 9. IF a VE with decisio-makig capacity has orders i the hospital/ursig home to withhold or withdraw a life-sustaiig treatmet (e.g., DNR order), THEN the medical record should documet patiet participatio i the decisio OR why the patiet did ot participate. 10. IF a VE has documeted treatmet prefereces to withhold or withdraw lifesustaiig treatmet (e.g., DNR order, o tube feedig, o hospital trasfer), THEN these treatmet prefereces should be followed. 11. IF a VE with demetia has a gastrostomy or J-tube tube placed, THEN prior to placemet, the medical record should documet 1 of the followig: Patiet prefereces cocerig tube feedig If patiet is decisioally icapacitated ad a surrogate decisio maker is available, discussio of patiet prefereces or best iterests If patiet is decisioally icapacitated ad a surrogate decisio maker is NOT available, a formal decisio mechaism should be used. 12. IF a VE is diagosed with lug cacer or cacer metastatic to lug, NYHA Class III-IV cogestive heart failure, or oxyge depedet pulmoary disease, THEN a self-reported assessmet of dyspea should be documeted i the outpatiet chart. 13. IF a VE with metastatic cacer or oxyge depedet pulmoary disease has dyspea refractory to o-opiate medicatios, THEN opiate medicatios should be offered. Log for

25 14. IF a VE is i hospice or has a preferece for o hospitalizatio ad is livig with oxyge depedet pulmoary disease, lug cacer, or NYHA Class III-IV cogestive heart failure, THEN the medical record should documet a pla for maagemet of worseig or emerget dyspea. 15. IF a VE who had dyspea i the last 7 days of life died a expected death, THEN the chart should documet dyspea care ad follow-up. 16. IF a ocomatose VE is ot expected to survive ad a mechaical vetilator is withdraw or withheld, THEN the chart should documet whether the patiet has dyspea ad the patiet should receive (or have orders available for) a opiate/ bezodiazepie/barbiturate ifusio. 17. IF a VE with ed-stage metastatic cacer is treated with opiates for pai, THEN the medical record should documet a pla for maagemet of worseig or emerget pai. 18. IF a VE who was coscious durig the last 7 days of life died a expected death, THEN the medical record should cotai documetatio about presece/absece of pai durig the last 7 days of life. 19. IF a VE with ed-stage metastatic cacer has obstructive gastroitestial symptoms, THEN the medical record should documet a pla for maagemet of worseig or emerget ausea ad vomitig. 20. IF a VE is a caregiver for a spouse/sigificat other/depedet that is termially ill or has very limited fuctio, THEN the VE should be assessed for caregiver fiacial, physical, ad/or emotioal stress. Log for X X X E I

26 21. IF a VE's spouse/sigificat other dies, THEN the VE should be assessed for depressio or thoughts of suicidality withi 6 moths Falls ad Mobility Problems 1. ALL VEs should have documetatio that they were asked aually about the occurrece of recet falls. 2. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of a basic fall history (circumstaces, medicatios, chroic coditios, mobility, alcohol itake) withi 3 moths of the report (or withi 4 weeks of the report, if the most recet fall occurred i the past 4 weeks). 3. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of orthostatic vital sigs (blood pressure ad pulse) withi 3 moths of the report (or withi 4 weeks of the report, if the most recet fall occurred i the past 4 weeks). 4. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of receipt of a eye exam i the past year, or evidece of visual acuity testig withi 3 moths of the report. 5. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of a basic gait, balace, ad stregth evaluatio withi 3 moths of the report (or withi 4 weeks of the report, if the most recet fall occurred i the past 4 weeks). Log for X X X E I X X X E I

27 6. IF a VE has ew or worseig difficulty with ambulatio, balace, or mobility, THEN there should be documetatio of a basic gait, balace, ad stregth evaluatio withi 3 moths of the report. 7. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of a assessmet of cogitive status i the past 6 moths or withi 3 moths of the report (or withi 4 weeks of the report, if the most recet fall occurred i the past 4 weeks). 8. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of a assessmet ad modificatio of home hazards recommeded i the past year or withi 3 moths of the report. 9. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year ad is takig a bezodiazepie, THEN there should be documetatio of a discussio of related risks ad assistace offered to reduce/discotiue bezodiazepie use. 10. IF a VE demostrates decreased balace/proprioceptio or icreased postural sway AND does ot have a assistive device, THEN a evaluatio/prescriptio for a assistive device should be offered withi 3 moths. 11. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year AND has a assistive device, THEN there should be documetatio of a assistive device review i the past 6 moths or withi 3 moths of the report (or withi 4 weeks of the report, if the most recet fall occurred i the past 4 weeks). Log for X X X E I

28 12. IF a VE is foud to have a problem with gait, balace, stregth, or edurace, THEN there should be documetatio of a structured/supervised exercise program offered i the past 6 moths or withi 3 moths of the report. Hearig Loss 1. ALL VEs should have a aual evaluatio of hearig status. 2. ALL VEs should have a evaluatio of hearig status as part of the iitial evaluatio. 3. IF a VE has a self-reported hearig problem or fails a hearig screeig, THEN s/he should be referred for formal evaluatio by a otolarygologist/audiologist withi 3 moths. 4. IF a VE is a hearig aid cadidate (by audiometry), THEN s/he should be offered rehabilitatio with a hearig aid. 5. IF a VE has a coductive hearig loss (by audiometry), THEN the patiet should be offered a referral to a otolarygologist. 6. IF a VE has profoud bilateral sesorieural hearig loss that has ot respoded to hearig aid rehabilitatio, THEN s/he should be offered referral for cochlear implatatio. 7. IF audiometry ad formal evaluatio reveal that a VE s hearig loss would ot beefit from a hearig aid (or caot afford it) or treatmet from a otolarygologist OR has persistet hearig hadicap, THEN s/he should be offered hearig rehabilitatio or a assistive listeig device (telephoe amplifiers, TTY/TDD devices, televisio headphoes, ifrared systems, lighted telephoes, door kock alert systems, vibratig clocks, or smoke detectors with strobe lights). Log for X X X X X X X X X E I

29 Heart Failure 1. IF a VE has a left vetricular ejectio fractio (LVEF) <40%, THEN s/he should receive a ACE ihibitor (or a ARB if ACEI itolerat). 2. IF a VE is ewly diagosed with heart failure, THEN s/he should have a history take at diagosis/hospitalizatio that documets the followig: Symptoms of volume overload Curret symptoms of chest pai/agia Prior myocardial ifarctio, coroary artery disease, or revascularizatio Hypertesio Diabetes Hypercholesterolemia Valvular heart disease Thyroid disease Alcohol use Smokig Curret medicatios NYHA fuctioal class or other descriptio of fuctioal status 3. IF a VE is ewly diagosed with heart failure, THEN s/he should have a physical examiatio at diagosis/hospitalizatio that documets the followig: Weight Blood pressure ad heart rate Lug examiatio Cardiac examiatio Abdomial examiatio er extremity examiatio. Log for

30 4. IF a VE is ewly diagosed with heart failure, THEN s/he should udergo the followig studies withi 1 moth of diagosis if ot doe i the prior 3 moths: Chest x-ray Electrocardiogram Complete blood cout Serum electrolytes Blood urea itroge Creatiie Glucose Albumi Liver fuctio tests Thyroid stimulatig hormoe Urialysis 5. IF a VE is ewly diagosed with heart failure or has kow heart failure with a uexplaied cliical deterioratio, THEN s/he should have a evaluatio of left vetricular fuctio. 6. IF a VE is hospitalized with heart failure, THEN s/he should have the followig performed withi 1 day: serum electrolytes, creatiie ad blood urea itroge. 7. IF a VE has heart failure ad LVEF <40%, THEN s/he should be treated with a betablocker kow to prolog survival (carvedilol, metoprolol or bisoprolol). 8. IF a VE has heart failure, LVEF <40% ad o atrial fibrillatio, THEN s/he should ot be treated with a 1 st - or 2 d -geeratio calcium chael blocker. 9. IF a VE has heart failure ad LVEF <40%, THEN s/he should ot be treated with a type I atiarrhythmic aget uless a implatable cardioverter defibrillator is i place. Log for

31 10. IF a VE with heart failure is takig digoxi ad has sigs of toxicity, THEN a digoxi level should be checked or digoxi discotiued withi 1 week. 11. IF a VE is ewly diagosed or hospitalized with heart failure, THEN patiet couselig i the followig areas should be provided ad documeted: Medicatio use, dosage, itervals, side effects -salt diet Exercise/physical activity Smokig cessatio Weight moitorig Symptom maagemet Avoidig/miimizig use of NSAIDs Progosis/ed-of-life issues 12. IF a VE has heart failure, THEN the followig physical exam elemets should be documeted at each primary care/cardiology outpatiet visit: Weight Blood pressure Heart rate Assessmet of volume overload Hospital Care & Surgery 1. IF a hospitalized VE is at very high risk for veous thrombosis, THEN s/he should be o DVT prophylaxis (pharmacologic or sequetial/itermittet compressio). 2. IF a VE has moderate-high risk for edocarditis ad a high-risk procedure is plaed, THEN edocarditis prophylaxis should be give. 3. IF a hospitalized VE has a ew temporary cetral veous catheter placed, THEN the medical record should documet that maximal barrier precautios were used. Log for

32 4. IF a hospitalized VE has a temporary cetral veous catheter placed, THEN there should be daily documetatio of examiatio of lie site for sigs of ifectio ad cotiued eed for the cetral lie. 5. IF a hospitalized VE has a idwellig bladder catheter placed, THEN the idicatio or cotiued eed for the catheter should be documeted at least every 3 days util its removal. 6. IF a hospitalized VE has a suspected/defiite diagosis of delirium, acute cofusioal state, or reduced level of cosciousess, THEN there should be a documeted attempt to attribute the altered metal state to a potetial etiology. 7. IF a VE who is ambulatory as a outpatiet is hospitalized for >48 hours AND is ot receivig itesive or palliative care, THEN there should be a pla to icrease mobility withi 48 hours of admissio. 8. IF a VE falls durig hospitalizatio, THEN the followig should be documeted withi 24 hours: Presece or absece of prodromal symptoms Review of medicatios or drugs potetially cotributig to the fall. 9. IF a hospitalized VE is tube fed, THEN there should be documetatio of a pla to reduce risk of aspiratio. 10. IF a VE is mechaically vetilated, THEN the medical record should documet a pla to reduce the risk of vetilator-associated peumoia. 11. IF a VE is admitted to the hospital for peumoia, THEN atibiotics should be admiistered withi 4 hours of arrival. Log for X X X symptoms E (prodromal symptoms) I

33 12. IF a VE is admitted to the hospital with commuity-acquired peumoia with hypoxia (O 2 sat <90%), THEN oxyge should be admiistered. 13. IF a VE hospitalized with commuityacquired peumoia is switched from pareteral to oral atimicrobial therapy, THEN the oral medicatio should have equivalet/ ear-equivalet bioavailability OR there should be documetatio of the followig: Sigs of cliical improvemet Ability to tolerate other oral medicatios/food/fluids Hemodyamic stability: Heart rate < 100, SBP > 90, Respiratory rate < 24, Temperature 37.8 C (100 F), O 2 sat > 90% o RA 14. IF a VE with commuity-acquired peumoia is discharged home, THEN the patiet should have bee hemodyamically stable o the day before ad the day of discharge. 15. IF a VE is discharged from the hospital, THEN the hospital record should cotai a assessmet of: Level of idepedece Need for home health services Patiet ad caregiver readiess for discharge time ad locatio. PREOPERATIVE CARE 16. IF a VE is to have a ipatiet or outpatiet elective surgery, THEN there should be documetatio of the patiet s capacity to uderstad the risks/beefits of the proposed procedure before the operative coset form is preseted for sigature. Log for I X I I I X I I

34 17. IF a VE is to have elective major surgery, THEN the followig should be discussed preoperatively: Patiet priorities/prefereces regardig treatmet optios Operative risks Aticipated postoperative fuctioal outcome Advace directive ad/or desigated surrogate decisio maker. 18. IF a VE is to have elective major surgery, THEN a pulmoary review of systems (i.e. history of smokig, baselie exercise tolerace, history of COPD/asthma) ad chest auscultatio should be performed preoperatively. 19. IF a VE is to have elective major surgery, THEN a assessmet of cardiovascular risk should be performed preoperatively. 20. IF a VE is to have elective major surgery, THEN the presece/absece of diabetes should be documeted preoperatively. 21. IF a diabetic VE is to have elective major surgery, THEN the diabetes regime ad adequacy of diabetes cotrol should be documeted preoperatively. 22. IF a VE is to have elective major surgery, THEN s/he should be screeed for risk factors for the developmet of postoperative delirium withi 8 weeks prior to surgery. 23. IF a VE has elective major surgery, THEN prophylactic atibiotics should be admiistered withi 1 hour before icisio (2 hours for vacomyci /fluoroquioloe) AND discotiued withi 24 hours after the ed of surgery. Log for

35 24. IF a VE with coroary artery disease has elective major surgery, THEN pre-operative beta blockade should be cosidered ad if iitiated, it should be cotiued util discharge. 25. IF a VE has sustaied a hip fracture, THEN a aticoagulat regime should be started. 26. IF a VE is to have a total hip replacemet, THEN a aticoagulatio regime should be started preoperatively or o the eveig after surgery. POSTOPERATIVE CARE 27. IF a VE who was ambulatory as a outpatiet has major surgery ad is ot i itesive care, THEN ambulatio should be performed by postoperative day IF a diabetic VE has major surgery, THEN blood sugar should be kept below 200 o day of surgery ad first 2 postoperative days (or the chart should reflect attempts to achieve this). 29 IF a VE has major surgery, THEN a daily screeig exam for delirium should be performed for the first 3 days after surgery. 30. IF a VE has major surgery, THEN assessmet of cogitio ad fuctioal status prior to discharge, i compariso to preoperative levels, should be performed. Hypertesio 1. IF a asymptomatic VE without the diagosis of hypertesio (HTN) has a elevated systolic blood pressure (BP) measuremet, THEN a repeat BP measuremet should occur as follows: mm Hg: Withi 6 moths mm Hg: Withi 2 moths 180mm Hg: Withi 1 moth Log for X X X E I

36 2. IF a VE without a diagosis of HTN has a systolic BP of >140mm Hg o 2 cosecutive visits, THEN the diagosis of HTN should be documeted OR home/24-hour ambulatory blood pressure moitorig should be ordered withi 2 moths or documeted as doe i the past 2 years. 3. IF a VE is ewly diagosed with HTN, THEN cardiovascular disease/risk assessmet should be performed withi 3 moths (if ot doe i the prior 3 moths) icludig: History: Myocardial ifarctio, agia, cardiomyopathy, aortic aeurysm, peripheral arterial disease, stroke, trasiet ischemic disease, hypercholesterolemia, family history of early coroary artery disease, smokig Exam: Murmurs or gallops, peripheral arterial exam, peripheral edema, weight, BMI, waist circumferece Review of systems: Chest pai, shortess of breath, trasiet visio/ eurologic symptoms, octural dyspea, leg pai Laboratory: Blood glucose ad serum lipids ECG 4. IF a VE is ewly diagosed with HTN, THEN a assessmet of real fuctio should be performed withi 3 moths (if ot doe i the prior 3 moths). 5. IF a VE is ewly diagosed with HTN, THEN the quatity ad frequecy of alcohol itake should be documeted withi 3 moths (if ot doe i the prior 3 moths). 6. IF a VE is ewly diagosed with HTN AND is takig a NSAID or COX-2 ihibitor, THEN there should be documetatio withi 6 moths of dose reductio, a attempt to use a alterative medicatio, or justificatio for cotiued use. Log for X

37 7. IF a VE is ewly diagosed with HTN, THEN a discussio of goal BP OR risks of prologed HTN should be documeted withi 3 moths. 8. IF a VE is ewly diagosed with HTN, THEN a o-pharmacologic itervetio (e.g. diet, exercise, weight loss, reduced alcohol) should be recommeded withi 3 moths (if ot doe i the prior 3 moths). 9. IF a VE with HTN has persistet (o 2 cosecutive visits) elevatio of systolic BP above goal*, THEN a itervetio (pharmacologic, lifestyle, compliace, etc.) should occur or there should be documetatio of a reversible cause or other justificatio for the elevatio. *Goal systolic BP (mm Hg): - Diabetes/chroic real disease Home ambulatory moitorig All other patiets-140 or other specified goal 10. IF a VE with HTN has persistet (o 2 cosecutive visits) elevatio of systolic BP above goal* cotiuously for > 6 moths, THEN there should be documetatio of the suspected reaso why the target was ot reached AND efforts to address the limitatio *Goal systolic BP (mm Hg): - Diabetes/chroic real disease Home ambulatory moitorig All other patiets-140 or other specified goal 11. IF a VE without target orga damage has a diastolic BP 120mm Hg, THEN immediate therapy ad/or referral to emergecy room/hospital should occur. Log for

38 12. IF a VE s HTN medicatio regime is chaged (ew medicatio or dose chage) AND withi 1 week s/he reports dizziess, sycope/ear sycope, ear-fall or fall, THEN s/he should be evaluated for orthostatic hypotesio at the time of the report (or withi 1 week if outside the office) OR the medicatio regime chaged. 13. IF a VE with HTN has ischemic heart disease, THEN treatmet with a beta-blocker should be recommeded OR documetatio why ot. 14. IF a VE with HTN has a history of heart failure, left vetricular hypertrophy, ischemic heart disease, chroic kidey disease or CVA, THEN s/he should be treated with a ACEI or ARB OR documetatio why ot. Ischemic Heart Disease 1. IF a VE has a BMI 25, THEN risk factors for cardiovascular disease should be assessed. 2. IF a VE has a acute coroary sydrome, THEN s/he should be give aspiri withi 1 hour of presetatio. 3. IF a VE has o-st elevatio acute coroary sydrome (ustable agia or o- ST elevatio AMI), ad CABG is ot plaed, THEN s/he should be treated with aspiri ad clopidogrel for at least 3 moths. 4. IF a VE has a acute coroary sydrome, THEN s/he should be give a beta-blocker withi 12 hours. 5. IF a VE has a myocardial ifarctio (STEMI or NSTEMI) complicated by heart failure or LVEF <40%, THEN s/he should be give a ACE ihibitor/arb withi 36 hours of presetatio AND advised to cotiue this treatmet for >4 weeks. 6. IF a VE is hospitalized with a acute myocardial ifarctio (STEMI or NSTEMI), THEN a assessmet of left vetricular Log for

39 fuctio (LVEF) should be performed i the hospital or withi 7 days of discharge. 7. IF a VE is hospitalized with acute coroary sydrome, did ot udergo agiography, ad does ot have cotraidicatios to revascularizatio, THEN s/he should be offered o-ivasive stress testig before or withi 2 weeks of discharge. 8. IF a VE has a diagosis of acute myocardial ifarctio, THEN s/he should be screeed for depressio withi 3 moths. 9. IF a VE has a ST-segmet elevatio AMI, THEN s/he should be offered reperfusio therapy. 10. IF a VE has sigificat left mai or 3- vessel coroary artery disease ad LVEF <50%, THEN s/he should be offered revascularizatio. 11. ALL VEs with ischemic heart disease should have a fastig cholesterol evaluatio (LDL, HDL ad triglycerides) at least every 2 years. 12. IF a VE with ischemic heart disease has a LDL >100 mg/dl, THEN s/he should be offered cholesterol lowerig medicatio. 13. IF a VE with ischemic heart disease is ot takig warfari, THEN s/he should be offered daily aspiri or other atiplatelet therapy. 14. IF a VE has had a myocardial ifarctio (STEMI or NSTEMI), THEN s/he should be offered a beta-blocker ad advised to cotiue treatmet for 2 years followig ifarctio. 15. IF a VE has ischemic heart disease, THEN s/he should be offered ACE ihibitor/arb therapy ad advised to cotiue the treatmet idefiitely. 16. IF a VE with ischemic heart disease smokes, THEN there should be documetatio of smokig cessatio couselig aually. Log for X X X E I X X I E X X I E X X I E X X I E 17. IF a VE has had a myocardial ifarctio X

40 (STEMI or NSTEMI) or CABG i the past year, THEN s/he should be offered cardiac rehabilitatio (formal program or its compoets). 18. IF a female VE with ischemic heart disease is curretly takig combiatio estroge/ progesteroe therapy, THEN she should be couseled about possible icreased cardiovascular risk OR this therapy should be discotiued. Medicatio Use 1. ALL VEs should have a up-to-date medicatio list readily available i the medical record, accessible by all healthcare providers, ad icludig over-the-couter medicatios. 2. ALL VEs should have a aual drug regime review. 3. IF a VE is prescribed a drug, THEN the prescribed drug should have a clearly defied idicatio. 4. IF a VE is prescribed a drug, THEN the VE (or a caregiver) should receive appropriate educatio about its use. 5. IF a VE is prescribed a ogoig medicatio for a chroic medical coditio, THEN there should be a documetatio of respose to therapy. 6. IF a VE receives a ew prescriptio for warfari, THEN s/he should receive educatio about diet ad drug iteractios ad the risk of bleedig complicatios OR referred to a aticoagulatio cliic. 7. IF a VE is prescribed warfari, THEN a iteratioal ormalized ratio (INR) should be determied withi 4 days after iitiatio of therapy ad at least every 6 weeks thereafter. 8. IF a VE is prescribed a ACE ihibitor, THEN s/he should have serum creatiie ad potassium moitored withi 2 weeks after iitiatio of therapy ad at least yearly thereafter. Log for

41 9. IF a VE is prescribed a loop diuretic, THEN s/he should have electrolytes checked withi 2 weeks after iitiatio ad at least yearly thereafter. 10. IF a VE requires a ew aalgesic, THEN s/he should ot be prescribed propoxyphee. 11. IF a VE is takig a bezodiazepie (>1 moth), THEN there should be aual documetatio of discussio of risks ad attempt to taper ad discotiue the bezodiazepie. 12. ALL VEs should ot be prescribed ay medicatio with strog aticholiergic effects if alteratives are available. 13. IF a VE does ot require seizure cotrol, THEN barbiturates should ot be used. 14. IF a VE requires aalgesia, THEN meperidie should ot be prescribed. 15. IF a VE receives ketorolac THEN it should ot be prescribed for >5 days. 16. IF a VE receives prescriptio pharmacological treatmet for back or eck pai, THEN cyclobezaprie, methocarbamol, carisoprodol, chlorzoxasoe, orpheadie, tizaidie, or metaxoloe should ot be prescribed for >1 week. 17. IF a VE has had a recet stroke or myocardial ifarctio, has peripheral arterial disease, or acute coroary sydrome that will be treated medically or with a percutaeous agioplasty, ad the patiet requires atiplatelet therapy, THEN clopidogrel should be prescribed rather tha ticlopidie. 18. IF a VE has iro deficiecy aemia, THEN o more tha 1 tablet daily of lowdose oral iro should be prescribed 19. IF a VE is started o a atipsychotic drug, THEN there should be documetatio of a assessmet of respose withi 1moth. 20. IF a VE is prescribed chroic high-dose acetamiophe ( 3 grams/day) OR a VE with Log for X X X I E X X X I E X X X I E

42 liver disease is prescribed chroic acetamiophe THEN s/he should be advised of the risk of liver toxicity. 21. IF a VE is prescribed a NSAID (oselective or selective), THEN gastroitestial bleedig risks should be discussed ad documeted. 22. IF a VE is prescribed low-dose ( 325 mg/day) aspiri, THEN gastroitestial bleedig risks should be discussed ad documeted. 23. IF a VE with a risk factor for gastroitestial bleedig (age 75, peptic ulcer disease, history GI bleedig, warfari use, chroic glucocorticoid use) is treated with a o-selective NSAID, THEN s/he should be treated cocomitatly with either misoprostol or a proto pump ihibitor. 24. IF a VE with >2 risk factors for gastroitestial bleedig (age 75, peptic ulcer disease, history GI bleedig, warfari use, chroic glucocorticoid use) is treated with daily aspiri, THEN s/he should be treated cocomitatly with either misoprostol or a proto pump ihibitor Osteoarthritis 1. IF a VE has symptomatic osteoarthritis of kee/hip, THEN pai should be assessed whe ew to a primary care or musculoskeletal disease practice ad aually. 2. IF a VE has symptomatic osteoarthritis of the kee/hip, THEN fuctioal status should be assessed whe ew to a primary care or musculoskeletal disease practice ad aually. 3. IF a ambulatory VE has symptomatic osteoarthritis of the kee/hip for >3 moths AND is able to exercise, THEN a directed/supervised muscle stregtheig or aerobic exercise program should be recommeded ad activity reviewed aually. Log for X

43 4. IF a VE has symptomatic osteoarthritis of the hip/kee ad has difficulty walkig that makes activities of daily livig difficult for >3 moths, THEN the eed for ambulatory assistive devices should be assessed. 5. IF a VE has symptomatic osteoarthritis ad has difficulty with o-ambulatory activities of daily livig, THEN the eed for activities of daily livig assistive devices should be assessed. 6. IF a VE is started o pharmacologic therapy to treat OA, THEN acetamiophe should be tried first. 7. IF a VE has severe symptomatic osteoarthritis of the kee/hip despite osurgical therapy, THEN a referral to a orthopedic surgeo should be made. Osteoporosis 1. ALL VEs at a iitial primary care visit should be couseled about itake of calcium ad vitami D, ad weight-bearig exercises. 2. ALL female VEs without a diagosis of osteoporosis should have documetatio that they were offered a DXA sca. 3. IF a male VE without a diagosis of osteoporosis has ay of the followig risk factors for osteoporosis, > 3 moths of systemic glucocorticoid treatmet Primary hyperparathyroidism Osteoporosis i a first degree relative Hypogoadism GNRH atagoist use Osteopeia o x ray Log for X X X E I X X X E I THEN a DXA sca should be performed 4. IF a female VE has a ew o-pathologic fracture, THEN she should be treated for osteoporosis OR a DXA sca should be performed.

44 5. IF a VE has a ew hip fracture or udergoes kyphoplasty or vertebroplasty, THEN a DXA sca should be performed OR pharmacologic therapy for osteoporosis should be prescribed withi 6 moths. 6. IF a VE without osteoporosis is takig 7.5 mg/day of predisoe (or equivalet) for 1 moth, THEN s/he should be prescribed calcium ad vitami D supplemets. 7. IF a VE without osteoporosis is takig 7.5 mg/day of predisoe (or equivalet) for 3 moths, THEN s/he should be prescribed bisphosphoate therapy. 8. IF a female VE is ewly diagosed with osteoporosis, THEN she should receive a workup icludig the followig: Medicatio use Alcohol use CBC Liver fuctio tests Real fuctio Calcium Phosphorus Vitami D 25-OH TSH 9. IF a ambulatory VE has a ew diagosis of osteoporosis, THEN there should be documetatio of advice to exercise withi 3 moths. 10. IF a VE has osteoporosis, THEN s/he should be prescribed calcium ad vitami D supplemets. 11. IF a female VE has osteoporosis, THEN she should be treated with bisphosphoates, raloxifee, calcitoi, hormoe replacemet therapy or teriparatide (if this is a ew diagosis, withi 3 moths). 12. IF a male VE has osteoporosis ad is hypogoadal ad has o history of prostate cacer, THEN he should be prescribed Log for X

45 testosteroe therapy. 13. IF a male VE has osteoporosis, THEN he should be treated with bisphosphoates, calcitoi or PTH or, if hypogoadal, testosteroe (if this is a ew diagosis, withi 3 moths). Pai Maagemet 1. IF a VE presets for a iitial evaluatio THEN a qualitative ad quatitative assessmet for persistet pai should be documeted (if cogitively impaired, a stadardized pai scale, behavioral assessmet or proxy report of pai should be used). 2. ALL VEs should be screeed for persistet pai aually. 3. IF a VE presets for a cacer-related physicia visit, icludig visits for chemotherapy or radiatio, THEN pai should be assessed. 4. IF a outpatiet VE with cacer presets with severe pai (score >5 o a 0-10 scale or similar quatifiable measuremet), THEN a adjustmet of pai treatmet should occur. 5. IF a hospitalized VE has a ew moderate/severe pai complait THEN the medical record should idicate that a itervetio ad follow-up assessmet of the pai occurred withi 4 hours 6. IF a VE is ew to a primary care practice ad has persistet pai, THEN there should be documetatio of patiet educatio withi 6 moths that explais the likely cause of symptoms ad how to use medicatio or other therapies. 7. IF a VE with persistet pai is treated with opioids, THEN 1 of the followig should be prescribed/oted: Stool softeer or laxative Icreased fiber, stool-softeig foods Documetatio of the potetial for Log for

46 costipatio ad/or why bowel treatmet is ot eeded. 8. IF a VE is started o ew opioid therapy for persistet pai, THEN efficacy ad side effects should be assessed withi 1 moth. Pressure Ulcers 1. IF a VE who is admitted to a hospital is uable to repositio him/herself or has limited ability to do so, THEN risk assessmet for pressure ulcers usig a stadardized scale should be performed upo admissio, ad if at risk, assessmet repeated at least every 48 hours thereafter. 2. IF a VE is admitted to a skilled ursig facility, THEN risk assessmet for pressure ulcers usig a stadardized scale should be performed upo admissio ad every week durig the first 4 weeks, ad every 3 moths thereafter. 3. IF a VE is admitted to a home health care orgaizatio, THEN risk assessmet for pressure ulcers usig a stadardized scale should be performed upo admissio, ad if at risk, the weekly for 4 weeks, ad every other week thereafter. 4. IF a VE is idetified as at risk for pressure ulcer developmet OR presets with a pressure ulcer, THEN prevetive itervetios should be istituted that address pressure reductio (or maagemet of tissue loads) AND repositioig eeds 5. IF a VE who is at risk for pressure ulcer developmet or has a pressure ulcer also demostrates malutritio, THEN a utritioal assessmet to idetify utritioal deficiecies AND utritio support should be provided Log for

47 6. IF a VE presets with a pressure ulcer, THEN the pressure ulcer should be assessed for the followig woud characteristics: Locatio Depth ad stage Size Woud bed (e.g., ecrotic tissue, exudates, woud edges for udermiig ad tuelig, presece or absece of graulatio ad epithelializatio) 7. IF a VE has a pressure ulcer, THEN s/he should be assessed for pressure ulcer pai daily i the hospital ad at each outpatiet visit, AND the pai treated, if preset. 8. IF a VE presets with a full-thickess pressure ulcer covered with ecrotic debris or eschar (UNLESS dry eschar presets o the heel), THEN debridemet itervetios usig sharp, mechaical, ezymatic, biosurgery, or autolytic procedures should be istituted withi 24 hours 9. IF a VE presets with a pressure ulcer that is clea or free of ecrotic tissue, THEN woud cleasig with ormal salie or a ocytotoxic cleaser should be istituted at each dressig chage. 10. IF a VE presets with a clea fullthickess or partial-thickess pressure ulcer, THEN a moisture retetive topical dressig such as thi film dressigs, hydrocolloids, hydrogels, foams, or algiates, should be provided for treatmet AND NOT dry gauze i ay form. Log for

48 11. IF a VE with a full-thickess stage III or IV pressure ulcer presets with systemic sigs ad symptoms of ifectio, such as elevated temperature, elevated white blood cout, ad/or cofusio ad agitatio, AND it is likely the sepsis is due to the woud, THEN the pressure ulcer should be debrided to elimiate ecrotic debris withi 24 hours AND a tissue biopsy, eedle aspiratio, or quatitative swab after debridemet should be obtaied for bacterial culture ad appropriate systemic atibiotics iitiated. 12. IF a VE presets with a clea fullthickess stage III or IV pressure ulcer at 2 to 4 weeks post-treatmet with o improvemet i ulcer status (e.g., decrease i surface area, depth, or by stadardized woud healig tool score), THEN the appropriateess of the treatmet pla ad/or presece of complicatios should be reassessed. 13. IF a VE presets with a partial-thickess stage II pressure ulcer at 1 to 2 weeks posttreatmet with o improvemet i ulcer status, THEN the appropriateess of the treatmet pla ad/or presece of complicatios should be reassessed. Screeig ad io 1. IF a VE has ot received a booster after age 49, THEN s/he should receive a Td booster. 2. All VEs should be offered a aual iflueza vacciatio. 3. ALL VEs should have documetatio whether they have received a peumococcal vacciatio, ad if so, at what age. 4. IF a VE has ot received a peumococcal vacciatio or received it >5 years ago ad prior to age 65, THEN s/he should be offered peumococcal vacciatio. 5. ALL VEs should be screeed for alcohol misuse withi 3 moths of eterig a ew primary care practice. Log for X X I E

49 6. IF a VE misuses alcohol, THEN s/he should be couseled to decrease itake or be referred to a alcohol program withi 3 moths. 7. ALL VEs should be screeed for tobacco use withi 3 moths of eterig a ew primary care practice. 8. IF a VE uses tobacco, THEN s/he should be couseled to quit withi 3 moths ad aually. 9. IF a VE is ready to quit usig tobacco, THEN there should be documetatio of a quit date, discussio of therapies to aid cessatio, ad a follow-up visit withi 1 moth of the quit date. 10. ALL VEs should have a assessmet of activity level (with ecouragemet to be active) aually. 11. IF a female VE is o hormoe therapy, THEN there should be documetatio that the risks ad beefits were discussed sice Jauary ALL o-wheelchair boud VEs should have their height, weight, ad BMI documeted withi 3 moths of the iitial primary care visit. 13. IF a VE is obese (BMI 30 kg/m2), THEN s/he should be advised to lose weight aually. 14. IF a female VE has had a total hysterectomy ad has a Pap smear, THEN the reaso for the Pap smear should be documeted. 15. IF a VE presets with cotusios, burs, bite marks, geital or rectal trauma, pressure ulcers or BMI <17.5 with o cliical explaatio, THEN s/he should be asked about possible mistreatmet or referred to a social worker for assessmet of mistreatmet. Log for X X I E X X I E X X I E

50 16. ALL VEs ew to a primary care practice should receive the elemets of a comprehesive geriatric assessmet (CGA) withi 3 moths. 17. IF a VE receives the elemets of a CGA that idetifies a problem, THEN the problem should be addressed withi 3 moths. Sleep Disorders 1. ALL VEs should be aually screeed for sleep problems. 2. IF a VE reports a sleep problem, THEN a targeted sleep history should be documeted withi 6 moths 3. IF a VE has a sleep problem, THEN a discussio of sleep hygiee should be documeted withi 6 moths. 4. IF a VE has daytime sleepiess AND observed apeas or loud sorig, THEN s/he should be referred for sleep evaluatio withi 6 moths. 5. IF a VE has sleep disordered breathig based o polysomography, THEN a discussio of treatmet optios should be documeted withi 6 moths. 6. IF a VE has octural limb movemets durig sleep AND frequet awakeigs or excessive daytime sleepiess, THEN treatmet or referral to a sleep specialist should occur withi 6 moths. 7. IF a VE has sleep problems, THEN s/he should ot be treated with sleep aids cotaiig atihistamies. 8. IF a VE is ew to a primary care practice ad is chroically (> 3 moths) takig a over-the-couter sleep aid cotaiig atihistamie for sleep problems, THEN advice to discotiue the medicatio should be documeted withi 6 moths. Log for X X X X X X I E

51 9. IF a VE is ew to a primary care practice ad is chroically (> 3 moths) takig a bezodiazepie for sleep problems, THEN advice to taper off ad discotiue the medicatio should be documeted withi 6 moths. 10. IF a VE has pai that disturbs his/her ability to fall asleep or maitai sleep, THEN pharmacologic/opharmacologic pai maagemet should be recommeded Stroke & A fib 1. IF a VE has a ew TIA or ischemic stroke i the vascular territory of the carotid artery, THEN a carotid artery imagig study should be doe or documetatio that the patiet is ot a carotid procedure cadidate. 2. IF a VE has a symptomatic carotid steosis >70%, THEN the medical record should documet a discussio of risks ad beefits of carotid procedures or that the patiet is ot a carotid procedure cadidate or that a carotid edarterectomy caot be doe with <6% 30-day morbidity ad mortality rate. 3. IF a VE has chroic atrial fibrillatio ad is medium to high-risk for stroke, THEN aticoagulatio should be offered. 4. IF a VE has chroic atrial fibrillatio, medium to high-risk for stroke, ad has a cotraidicatio to aticoagulatio, THEN atiplatelet therapy should be prescribed. 5. IF a VE is prescribed aticoagulats for atrial fibrillatio, THEN there should be documetatio that the goal of iteratioal ormalized ratios (INR) is or reaso for other goal. 6. IF a VE has had a TIA or ischemic stroke, THEN outpatiet atiplatelet or aticoagulat therapy should be prescribed withi 3 moths after stroke/tia or eterig a ew practice. Log for X X I E

52 7. IF a VE has a ew TIA or ischemic stroke, THEN there should be documetatio of a fastig low-desity lipoprotei (LDL) level. 8. IF a VE has a ew TIA or stroke, THEN smokig status should be documeted. 9. IF a VE has a TIA or stroke ad is a curret smoker, THEN smokig cessatio couselig should be documeted aually. 10. IF a ambulatory VE has had a TIA or stroke ad is ot physically active, THEN couselig to icrease physical activity should be documeted aually. 11. IF a VE has a ew TIA or stroke THEN assessmet of alcohol itake should be documeted, ad if positive for alcohol itake, alcohol itake reassessed aually. 12. IF a VE has had a TIA or stroke AND cosumes 5 driks of alcohol per day, THEN s/he should be couseled to decrease cosumptio to <2 driks per day, ad this should be documeted aually. 13. IF a female VE has had a TIA or stroke ad is takig hormoe replacemet therapy, THEN hormoe replacemet therapy should be discotiued or a reaso (other tha stroke prevetio) documeted. 14. IF a VE presets with a ew TIA or stroke, THEN educatio of the patiet (or caregiver) about stroke symptoms ad risk factors should be documeted withi 6 moths. 15. IF a VE is hospitalized with a ew acute ischemic stroke, THEN aspiri should be give withi 48 hours (if ot already o aticoagulat therapy). 16. IF a VE is hospitalized with a acute stroke ad iclusio ad exclusio criteria are met, THEN thrombolytic therapy should be offered. Log for X X I E X X X I E

53 17. IF a VE with a ew stroke is started o itraveous tpa for thrombolysis, THEN iclusio ad exclusio criteria should be met. 18. IF a VE presets with a ew stroke THEN presece or absece of depressio should be documeted withi 3 moths. 19. IF a VE presets with a ew stroke ad has resultig laguage difficulties, THEN a referral for speech therapy should be made withi 1 moth. 20. IF a VE presets with a ew stroke, THEN presece or absece of dysphagia should be documeted i the hospital record. 21. IF a VE presets with a ew stroke, THEN o discharge the patiet should have a rehabilitatio pla or documetatio of o residual fuctioal deficit from the ew stroke. Uderutritio 1. ALL VEs should be weighed at each primary care visit ad weights documeted i the medical record. 2. ALL VEs i stable health states should take 800 IU (or equivalet) of vitami D supplemetatio daily. 3. IF a VE is hospitalized, THEN evaluatio of oral itake should be documeted durig the hospitalizatio. 4. IF a VE has ivolutary weight loss of 10% of body weight i 1 year, THEN weight loss (or a related disorder) should be documeted i the medical record as recogitio of uderutritio as a potetial problem. Log for X X X E I X X X X for I I

54 5. IF a VE has ivolutary weight loss of 10% i 1 year or hypoalbumiemia (<3.5 g/dl), THEN s/he should be evaluated for potetially reversible causes of poor utritioal itake icludig assessmet of: Detal status (e.g., referece to detitio, gum health, detal referral) Food security (e.g., fiacial status, social work referral) Food-related fuctioal status (e.g., ability to feed, prepare meals) Appetite ad itake (e.g., 72-hour calorie cout, dietitia referral) Swallowig ability (e.g., bedside swallowig study, swallowig study referral) Dietary restrictios (e.g., low salt or low protei diet). 6. IF a VE has ivolutary weight loss of 10% i 1 year or hypoalbumiemia (< 3.5 g/dl), THEN s/he should be evaluated for potetially relevat comorbid coditios, icludig assessmet of: Medicatios associated with decreased appetite Depressio Cogitive impairmet Thyroid fuctio Scree for cacer Diabetes Malabsorptio 7. IF a hospitalized VE is uable to take food orally for >48 hours, THEN alterative alimetatio (e.g., eteral or pareteral) should be implemeted or documeted why ot. Log for

55 8. IF a VE has a ew stroke ad fails a swallowig scree for dysphagia, THEN s/he should be offered swallowig traiig. 9. IF a hospitalized VE is malourished or at risk, THEN s/he should receive oral protei ad eergy supplemetatio of 400 kcal/day for 35 days. Uriary Icotiece 1. ALL VEs should have documetatio of the presece or absece of uriary icotiece (UI) durig the iitial evaluatio. 2. ALL VEs should have documetatio of the presece or absece of UI every 2 years. 3. IF a VE has UI, THEN there should be documetatio aually of whether the UI is bothersome to the patiet ad/or caregiver. 4. IF a VE has ew UI or established UI with bothersome symptoms, THEN a targeted history should be documeted. 5. IF a VE has ew UI, THEN a targeted physical examiatio should be documeted. 6. IF a VE has ew UI or established UI with bothersome symptoms, THEN a urialysis (or dipstick UA) AND a urie culture, if the urialysis demostrates pyuria or hematuria, should be obtaied. 7. IF a vulerable elder has a post-void residual > 300 cc, THEN s/he should have a serum creatiie withi 72 hours ad (if o reversible causes foud) referred to a cliicia with urological expertise withi 2 moths. 8. IF a VE with UI has a PVR of betwee 200cc ad 300cc, THEN real fuctio should be assessed withi 3 moths. 9. IF a VE has ew UI or established UI with bothersome symptoms AND the UI is treated with medicatio or surgery, THEN classificatio of the type of/suspected reaso(s) for UI should be documeted. Log for X X X X for X X for X for X I I X I I 10. IF a VE has ew UI or established UI E I E I

56 with bothersome symptoms, THEN treatmet optios should be discussed withi 3 moths. 11. IF a VE is treated for UI, THEN respose to treatmet should be documeted withi 3 moths. 12. IF a cogitively itact, ambulatory VE has stress, urge, or mixed UI, THEN behavioral/lifestyle treatmet should be offered. 13. IF a female VE udergoes surgery for stress UI, THEN urodyamic ivestigatios should be performed prior to surgery. 14. IF a female VE has stress UI ad udergoes a procedure or surgery for UI, THEN oe of the followig should be performed or offered: (1) surgical correctio with either of the followig: ope retrograde suspesio or a slig procedure (icludig tesio-free vagial tape or TVT), or (2) periurethral bulkig aget. 15. IF a VE has cliically sigificat uriary retetio ad a log-term (>1 moth) urethral catheter is placed, THEN there should be documetatio of justificatio for its use. Visio 1. ALL VEs should have a comprehesive eye exam every 2 years. 2. IF a VE has sudde-oset severe visual chages, THEN s/he should be see by a eye care professioal withi 24 hours. 3. IF a VE has ew oset eye pai, grossly visible coreal lesios, or severe purulet discharge, THEN s/he should udergo a basic eye examiatio withi 72 hours. Log for X X X for X for E E

57 4. IF a VE has primary ope-agle glaucoma, THEN s/he should have a eye exam aually that icludes measuremets of visual acuity ad itraocular pressure, documetatio of optic erve examiatio, slit lamp evaluatio, visual field testig, ad documetatio of target itraocular pressure. 5. IF a VE with age-related macular degeeratio has a eye examiatio, THEN the degree of maculopathy (umber ad size of macular druse, presece of geographic atrophy or choroidal eovascular membraes) should be documeted. 6. IF a VE is diagosed with a cataract that limits his/her ability to carry out eeded/desired activities, THEN cataract extractio should be offered. 7. IF a VE has cataract surgery, THEN there should be a follow-up ocular examiatio withi 48 hours. 8. IF a VE who has bee prescribed a ocular therapeutic regime (e.g. topical ophthalmologic medicatios) is hospitalized or i a ursig home, THEN there should be documetatio that the therapeutic regime was admiistered as prescribed. 9. IF a VE with fuctioal visual deficits has subjective improvemet o refractio, THEN s/he should receive a primary or a updated prescriptio for corrective leses. 10. IF a VE who uses corrective leses for ay activities of daily livig (for either ear or distace visio) is hospitalized or i a ursig home AND the corrective leses are at the hospital or ursig home, THEN the corrective leses should be accessible. Log X X for X for X X for X for for Cotiuity ad coordiatio meas that the itervetio aims to maitai cotiuity across time or providers. met meas that the itervetio aims to improve the patiet s coditio or treat symptoms; < 6 mos, iate 6-24 moths. io care aims to avoid adverse evets, icludig ehacig safety ad prevetig fuctioal declie; < 6 mos, iate 6-24 moths, Log >24 moths. E E E E

58 s refer to patiet ad caregiver, ot to the healthcare system or providers. Examples of burdes: history, most exams, simple testig, blood drawig, medicatios erate complex testig (CT, MRI, PET), colooscopy, referrals that etail complex testig, warfari therapy, pelvic exam major surgery, chemotherapy, radiatio therapy Care process may ot apply to or because the expected beefit is small or the expected beefit is low probability or other possible approaches to the problem are available, makig the priority of the care process low give the burdes of or. =poor progosis (life expectacy of 6 moths or less), =advaced demetia. I=iclude the quality idicator for patiet with this coditio, E=exclude the quality idicator for patiet with this coditio.

59 Appedix 2: d ACOVE-3 Quality Idicators for Patiets with Advaced Demetia, Poor Progosis, or Decisios for Hospitalizatio or Surgery Descriptio of QI Hospitalizatio* Surgery* BPH 5. IF a male VE presetig with ew or worseig LUTS E E E E has a history of lower tract urologic surgery or urethral trauma (icludig traumatic catheterizatios), THEN he should be referred to a urologist withi 2 moths 6. IF a male VE has ew microhematuria (>3 RBCs/hpf) E E E E ad a egative urie culture (or has 1 positive ad 1 egative urialysis), THEN a repeat urialysis should be performed withi 1 moth. 7. IF a male VE has uexplaied gross hematuria or microhematuria (>3 RBCs/hpf o 2 of 3 urialyses) ad a egative urie culture, THEN he should have the followig withi 3 moths: serum creatiie, upper urologic tract imagig, ad referral to a urologist or ephrologist. E E E E 9. IF a male VE with presumed BPH has bladder stoes, uriary retetio (>1 episode), uriary tract ifectio or real failure with hydroephrosis, THEN the patiet should be referred to a urologist. Breast Cacer 1. IF a female VE is less tha age 70, THEN she should be offered mammographic screeig for breast cacer every 2 years. E E E E (except uriary retetio ) (except uriary retetio ) (except uriary retetio) (except uriary retetio) 4. IF a female VE has a ew diagosis of breast cacer, I I E E

60 THEN there should be documetatio of a discussio regardig: surgical optios ad goals of therapy; posttreatmet quality of life; fuctioal outcomes; risk ad beefits of adjuvat therapy. 5. IF a female VE is diagosed with locally ivasive breast cacer, THEN tumor size, grade, ad margis should be recorded after surgery. 7. IF a female VE is diagosed with locally ivasive breast cacer ad chemotherapy is plaed, THEN at the time of diagosis HER-2/eu receptor status should be evaluated. 8. IF a female VE is diagosed with locally ivasive breast cacer, chemotherapy is plaed, ad she has a score of 2+ for HER-2/eu over-expressio by immuohistochemistry testig, THEN HER-2/eu receptor status should be cofirmed by fluorescece isitu hybridizatio (FISH). 9. IF a female VE with locally ivasive breast cacer has ay of the followig: (a) symptoms of boe pai, (b) elevated serum alkalie phosphatase, (c) tumor size >5cm, or (d) positive lymph odes, THEN radiographic boe imagig should be performed durig the stagig work-up. 10. IF a female VE is diagosed with early stage locally ivasive breast cacer (Stage I-III) ad chemotherapy is plaed, THEN the patiet should udergo axillary stagig with either a setiel lymph ode biopsy or a complete axillary lymph ode dissectio at the time of Hospitalizatio* Surgery* (surgical (surgical optios) optios) I I I --- E E I I (except boe pai) (except boe pai) E E E E

61 surgery. 12. IF a female VE is diagosed with ductal carcioma i-situ or early stage ivasive breast cacer, THEN breast-coservig surgery should be offered. 13. IF a female VE with locally ivasive breast cacer is treated with a mastectomy, THEN she should be offered breast recostructio. 14. IF a female VE is diagosed with early stage ivasive breast cacer ad udergoes a lumpectomy, THEN breast radiatio therapy should be discussed. 15. IF a female VE is diagosed with ivasive breast cacer with a tumor >5cm OR 4 positive lymph odes ad udergoes mastectomy, THEN postoperative radiatio therapy should be discussed withi 2 moths after surgery or after chemotherapy. 16. IF a female VE is diagosed with estroge receptorpositive locally ivasive breast cacer of >1 cm size, THEN adjuvat hormoal therapy should be offered. Hospitalizatio* Surgery* E E E E E E E E

62 Hospitalizatio* Surgery* 17. IF a female VE with a life expectacy >5 years is diagosed with locally ivasive breast cacer with 4 positive lymph odes, THEN adjuvat chemotherapy should be offered. 18. IF a female VE with ormal cardiovascular fuctio ad a life expectacy >5 years is diagosed with locally ivasive breast cacer with positive lymph odes ad HER-2/eu receptor over-expressio, THEN adjuvat chemotherapy with trastuzumab should be offered. 22. IF a female VE has symptomatic multifocal metastatic hormoe-refractory breast cacer OR symptomatic hormoe receptor-egative breast cacer with extesive visceral metastasis, THEN treatmet with systemic chemotherapy should be offered. 23. IF a female VE with ormal cardiac fuctio with HER-2/eu-positive metastatic breast cacer is treated with systemic chemotherapy, THEN trastuzumab should be offered. COPD 1. IF a VE presets with ocardiac exertioal dyspea, chroic cough ( 6 moths), wheeze or 2 episodes/year of brochitis, THEN s/he should have spirometry. Colorectal Cacer Care 1. IF a VE is less the age 70, THEN there should be E E E E documetatio that the optio of colorectal cacer screeig was discussed. 4. IF a VE has a ew diagosis of colorectal cacer ad

63 is a cadidate for therapy, THEN s/he should have a pretreatmet CEA level. 5. IF a VE with a ew diagosis of colo or rectal cacer is a cadidate for elective resectio of the primary tumor ad has a elevated (or ukow) CEA, THEN pretreatmet imagig with a CT sca (or similar imagig) of the abdome ad pelvis should be doe. 6. IF a VE has a ew diagosis of rectal cacer with a ormal CEA ad is a cadidate for elective resectio of the primary tumor, THEN pelvic imagig should be performed by ultrasoud (EUS or TRUS), MRI or CT. 7. IF a VE has a ew diagosis of colorectal cacer ad is a cadidate for potetial cure, THEN s/he should have a total coloic exam prior to surgery. 8. IF a VE uderwet colorectal cacer resectio for cure ad total coloic examiatio was ot performed preoperatively (e.g. due to a obstructig lesio), THEN total coloic examiatio should be performed withi 6 moths after surgery. 9. IF a VE has a ew diagosis of colorectal cacer, THEN there should be documetatio of a discussio regardig: surgical optios ad goals of surgery; post treatmet quality of life; fuctioal outcomes; risks ad beefits of adjuvat therapy (if colo cacer) or eoadjuvat therapy (if rectal cacer) 10. IF a VE udergoes surgery for colorectal cacer, THEN a qualified physicia (e.g. surgeo, ocologist, radiatio ocologist) should discuss with the Hospitalizatio* Surgery* E E E E E E E E E E E E I I E (surgical optios) E (surgical optios) I I

64 patiet/caregiver fial pathology (e.g., stage, status of lymph odes, margis), ad idicatios for further treatmet (e.g., chemotherapy, radiatio therapy). 13. IF a VE with a ew diagosis of rectal cacer is to be treated surgically, THEN the surgeo should preoperatively (or pre-eoadjuvat therapy) assess the mass (e.g., digital rectal exam or flexible sigmoidoscopy). 14. IF a VE with a ew diagosis of colorectal cacer is to have elective abdomial perieal resectio or other procedure with plaed creatio of a ostomy, THEN the ostomy should be sited preoperatively ad documeted i the medical record (e.g. eterostomal therapy ote or operative ote). 15. IF a VE has stage III colo cacer, THEN adjuvat chemotherapy should be give withi 4 moths of surgery. 16. IF a VE is thought to have stage II or III mid-low rectal cacer ad is a cadidate for surgery, THEN preoperative eoadjuvat chemotherapy ad radiatio therapy should be give. 17. IF a VE had surgical resectio for stage II or III rectal cacer ad did ot receive eoadjuvat radiatio ad/or chemotherapy, THEN postoperative adjuvat chemotherapy ad/or radiatio therapy should be provided withi 4 moths of surgery. 18. IF a VE with > stage I colorectal cacer uderwet resectio for cure, THEN a history ad physical Hospitalizatio* Surgery* I I I I

65 examiatio should be performed every 6 moths for the first 2 years after surgery ad aually durig years 3 to IF a VE with > stage I colorectal cacer uderwet resectio for cure, THEN a CEA level should be performed every 3 moths for the first 2 years after surgery ad aually durig years 3 to IF a VE uderwet colorectal cacer resectio for cure, THEN a colooscopy should be performed withi 3 years after surgery. 21. IF a VE had prior colorectal cacer resectio for cure ad has a elevated CEA > 7.5 (cofirmed by retestig if <10), THEN further workup should be iitiated (e.g. colooscopy, radiological imagig). Cotiuity ad iatio of Care 16. IF a VE is deaf or does ot speak Eglish, THEN a iterpreter or traslated materials should be utilized to facilitate commuicatio Demetia 2. ALL VEs should be evaluated aually for chages i memory ad fuctio. 3. IF a VE screes positive for demetia, THEN the physicia should documet a objective cogitive evaluatio that tests 2 cogitive domais. 10. IF a VE has bee diagosed with mild to moderate Alzheimer s disease, mild to moderate vascular demetia, or Lewy body demetia, THEN there should Hospitalizatio* Surgery* E I I I E I I I (memory oly) E I I I

66 be a documeted discussio with the patiet ad/or caregiver about choliesterase ihibitor treatmet 11. IF a VE has mild to moderate vascular or mixed demetia, THEN s/he should receive stroke prophylaxis. Depressio 1. ALL VEs should have documetatio of a scree for depressio durig the iitial evaluatio ad aually. 2. IF a VE is admitted to a ursig home, THEN the patiet should be screeed for depressio withi 2 weeks of admissio ad aually. 3. IF a VE presets with 1 of the followig symptoms: sad mood, feelig dow; Isomia or difficulties with sleep; apathy or loss of iterest i pleasurable activities; complaits of memory loss; uexplaied weight loss 5% i the past moth or 10% i the past year; OR uexplaied fatigue or low eergy THEN the patiet should be asked about depressio, treated for depressio, or referred to a metal health professioal withi 2 weeks of presetatio. 4. IF a VE receives a diagosis of a ew depressio episode, THEN the medical record should documet at least 3 of the 9 Diagostic ad Statistical Maual (DSM- IV) target symptoms for major depressio withi 2 weeks of diagosis. 5. IF a VE receives a diagosis of a ew depressio episode, THEN the medical record should documet o the day of diagosis the presece or absece of suicidal Hospitalizatio* Surgery* E I I I E I I I E I I I E I I I E I I I

67 Hospitalizatio* Surgery* ideatio ad psychosis. 15. IF a VE is ewly treated for depressio, THEN the E I I I followig should be documeted at the first follow-up visit to the same physicia or to a metal health provider withi 4 weeks of treatmet iitiatio: degree of respose to at least 2 of the 9 DSM-IV target symptoms for major depressio AND medicatio side effects, if he or she is takig atidepressat medicatios 16. IF a VE is ewly treated for depressio ad has E I I I suicidal ideatio at a outpatiet visit, THEN at the ext follow-up visit, which must occur withi 1 week, documetatio should reflect askig about suicide risk. Diabetes Mellitus 1. IF a VE has diabetes, THEN glycated hemoglobi should be measured aually. 2. IF a VE has a elevated HgbA1c, THEN a therapeutic itervetio should occur: HgbA1c %: Withi 3 moths HgbA1c >11%: Withi 1 moth 3. IF a diabetic VE does ot have established real disease ad is ot receivig a ACE ihibitor or ARB, THEN a test for proteiuria should be doe aually. 4. IF a diabetic VE has proteiuria, THEN a ACE ihibitor or ARB should be prescribed. 5. IF a VE has diabetes, THEN a foot exam should be performed aually. 7. IF a diabetic VE is ot blid, ad did ot have

68 Hospitalizatio* Surgery* retiopathy o a previous examiatio, THEN s/he should have a retial eye examiatio performed by a specialist every 2 years. 8. IF a VE has diabetes, THEN blood pressure should be measured at each primary care visit. 9. IF a diabetic VE has a persistet (o 2 cosecutive visits) elevatio of systolic BP >130 mm Hg, THEN a itervetio (pharmacologic, lifestyle, compliace, etc.) should occur or there should be documetatio of a reversible cause/other justificatio for the elevatio. 10. IF a diabetic VE is ot o aticoagulat/atiplatelet therapy, THEN daily aspiri should be prescribed. 11. IF a diabetic VE has fastig LDL >130 mg/dl, THEN a pharmacologic or lifestyle itervetio should be offered withi 3 moths. Ed of life Care 6. IF a VE with severe demetia is admitted to the I I --- I hospital ad survives 48 hours, THEN withi 48 hours of admissio, the medical record should documet that the patiet s prefereces for care have bee cosidered OR a attempt was made to idetify them. 7. IF a VE is admitted to the itesive care uit ad I I --- I survives 48 hours, THEN withi 48 hours of itesive care uit admissio, the medical record should documet that the patiet s prefereces for care have bee cosidered OR a attempt was made to idetify them. 8. IF a hospitalized VE requires mechaical vetilatio I I --- I

69 (for > 48 hours), THEN withi 48 hours of the iitiatio of mechaical vetilatio, the medical record should documet the goals of care ad the patiet s preferece for mechaical vetilatio or why this iformatio is uavailable. 20. IF a VE is a caregiver for a spouse/sigificat other/depedet that is termially ill or has very limited fuctio, THEN the VE should be assessed for caregiver fiacial, physical, ad/or emotioal stress. 21. IF a VE's spouse/sigificat other dies, THEN the VE should be assessed for depressio or thoughts of suicidality withi 6 moths Falls ad Mobility Problems 4. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of receipt of a eye exam i the past year, or evidece of visual acuity testig withi 3 moths of the report. 7. IF a VE reports a history of 2 falls (or 1 fall with ijury) i the past year, THEN there should be documetatio of a assessmet of cogitive status i the past 6 moths or withi 3 moths of the report (or withi 4 weeks of the report, if the most recet fall occurred i the past 4 weeks). 12. IF a VE is foud to have a problem with gait, balace, stregth, or edurace, THEN there should be documetatio of a structured/supervised exercise Hospitalizatio* Surgery* E I I I E I I I E I I I E I I I

70 program offered i the past 6 moths or withi 3 moths of the report. Hearig Loss 1. ALL VEs should have a aual evaluatio of hearig status. 2. ALL VEs should have a evaluatio of hearig status as part of the iitial evaluatio. 3. IF a VE has a self-reported hearig problem or fails a hearig screeig, THEN s/he should be referred for formal evaluatio by a otolarygologist/audiologist withi 3 moths. 4. IF a VE is a hearig aid cadidate (by audiometry), THEN s/he should be offered rehabilitatio with a hearig aid. 5. IF a VE has a coductive hearig loss (by audiometry), THEN the patiet should be offered a referral to a otolarygologist. 6. IF a VE has profoud bilateral sesorieural hearig loss that has ot respoded to hearig aid rehabilitatio, THEN s/he should be offered referral for cochlear implatatio. 7. IF audiometry ad formal evaluatio reveal that a VE s hearig loss would ot beefit from a hearig aid (or caot afford it) or treatmet from a otolarygologist OR has persistet hearig hadicap, THEN s/he should be offered hearig rehabilitatio or a assistive listeig device (telephoe amplifiers, Hospitalizatio* Surgery* E E E E E E E E E I I I

71 TTY/TDD devices, televisio headphoes, ifrared systems, lighted telephoes, door kock alert systems, vibratig clocks, or smoke detectors with strobe lights). Heart Failure 1. IF a VE has a left vetricular ejectio fractio (LVEF) <40%, THEN s/he should receive a ACE ihibitor (or a ARB if ACEI itolerat). 5. IF a VE is ewly diagosed with heart failure or has kow heart failure with a uexplaied cliical deterioratio, THEN s/he should have a evaluatio of left vetricular fuctio. 6. IF a VE is hospitalized with heart failure, THEN s/he should have the followig performed withi 1 day: serum electrolytes; serum creatiie; blood urea itroge 7. IF a VE has heart failure ad LVEF <40%, THEN s/he should be treated with a beta-blocker kow to prolog survival (carvedilol, metoprolol or bisoprolol). Hospital Care & Surgery 1. IF a hospitalized VE is at very high risk for veous thrombosis, THEN s/he should be o DVT prophylaxis (pharmacologic or sequetial/itermittet compressio). 3. IF a hospitalized VE has a ew temporary cetral veous catheter placed, THEN the medical record should documet that maximal barrier precautios were used. 4. IF a hospitalized VE has a temporary cetral veous catheter placed, THEN there should be daily documetatio of examiatio of lie site for sigs of Hospitalizatio* Surgery* I I --- I I I --- I I I --- I I I --- I

72 ifectio ad cotiued eed for the cetral lie. 5. IF a hospitalized VE has a idwellig bladder catheter placed, THEN the idicatio or cotiued eed for the catheter should be documeted at least every 3 days util its removal. 6. IF a hospitalized VE has a suspected/defiite diagosis of delirium, acute cofusioal state, or reduced level of cosciousess, THEN there should be a documeted attempt to attribute the altered metal state to a potetial etiology. 7. IF a VE who is ambulatory as a outpatiet is hospitalized for >48 hours AND is ot receivig itesive or palliative care, THEN there should be a pla to icrease mobility withi 48 hours of admissio. 8. IF a VE falls durig hospitalizatio, THEN the followig should be documeted withi 24 hours: presece or absece of prodromal symptoms AND review of medicatios for drugs potetially cotributig to the fall. 9. IF a hospitalized VE is tube fed, THEN there should be documetatio of a pla to reduce risk of aspiratio. 11. IF a VE is admitted to the hospital for peumoia, THEN atibiotics should be admiistered withi 4 hours of arrival. 12. IF a VE is admitted to the hospital with commuityacquired peumoia with hypoxia (O 2 sat <90%), THEN oxyge should be admiistered. Hospitalizatio* Surgery* I I --- I I I --- I I I --- I E (prodromal symptoms) I --- I I I --- I I I --- I I I --- I

73 13. IF a VE hospitalized with commuity-acquired peumoia is switched from pareteral to oral atimicrobial therapy, THEN the oral medicatio should have equivalet/ ear-equivalet bioavailability OR there should be documetatio of the followig: sigs of cliical improvemet; ability to tolerate other oral medicatios/food/fluids; ad hemodyamic stability: Heart rate <100, SBP>90, Respiratory rate <24, Temperature 37.8 C (100 F), O 2 sat >90% o RA 16. IF a VE is to have a ipatiet or outpatiet elective surgery, THEN there should be documetatio of the patiet s capacity to uderstad the risks/beefits of the proposed procedure before the operative coset form is preseted for sigature. 17. IF a VE is to have elective major surgery, THEN the followig should be discussed preoperatively: patiet priorities/prefereces regardig treatmet optios; operative risks; aticipated post-operative fuctioal outcome; AND advace directive ad/or desigated surrogate decisio maker. 18. IF a VE is to have elective major surgery, THEN a pulmoary review of systems (i.e. history of smokig, baselie exercise tolerace, history of COPD/asthma) ad chest auscultatio should be performed preoperatively. 19. IF a VE is to have elective major surgery, THEN a assessmet of cardiovascular risk should be performed preoperatively. Hospitalizatio* Surgery* I I --- I I I I --- I I I I I I

74 20. IF a VE is to have elective major surgery, THEN the presece/absece of diabetes should be documeted preoperatively. 21. IF a diabetic VE is to have elective major surgery, THEN the diabetes regime ad adequacy of diabetes cotrol should be documeted preoperatively. 22. IF a VE is to have elective major surgery, THEN s/he should be screeed for risk factors for the developmet of postoperative delirium withi 8 weeks prior to surgery. 23. IF a VE has elective major surgery, THEN prophylactic atibiotics should be admiistered withi 1 hour before icisio (2 hours for vacomyci /fluoroquioloe) AND discotiued withi 24 hours after the ed of surgery. 24. IF a VE with coroary artery disease has elective major surgery, THEN pre-operative beta blockade should be cosidered ad if iitiated, it should be cotiued util discharge. 26. IF a VE is to have a total hip replacemet, THEN a aticoagulatio regime should be started preoperatively or o the eveig after surgery. 27. IF a VE who was ambulatory as a outpatiet has major surgery ad is ot i itesive care, THEN ambulatio should be performed by postop day IF a diabetic VE has major surgery, THEN blood sugar should be kept below 200 o day of surgery ad first 2 postoperative days (or the chart should reflect Hospitalizatio* Surgery* I I I I I I I I I I I I I I I I

75 attempts to achieve this). 29 IF a VE has major surgery, THEN a daily screeig exam for delirium should be performed for the first 3 days after surgery. 30. IF a VE has major surgery, THEN assessmet of cogitio ad fuctioal status prior to discharge, i compariso to preoperative levels, should be performed. Hypertesio 1. IF a asymptomatic VE without the diagosis of hypertesio has a elevated systolic blood pressure (BP) measuremet, THEN a repeat BP measuremet should occur as follows: mm Hg: Withi 6 moths mm Hg: Withi 2 moths 180mm Hg: Withi 1 moth 2. IF a VE without a diagosis of hypertesio has a systolic BP of >140mm Hg o 2 cosecutive visits, THEN the diagosis of hypertesio should be documeted OR home/24-hour ambulatory blood pressure moitorig should be ordered withi 2 moths or documeted as doe i the past 2 years. Hospitalizatio* Surgery* I I E I

76 3. IF a VE is ewly diagosed with hypertesio, THEN cardiovascular disease/risk assessmet should be performed withi 3 moths (if ot doe i the prior 3 moths) icludig: History (>3 elemets): Myocardial ifarctio, agia, cardiomyopathy, aortic aeurysm, peripheral arterial disease, stroke, trasiet ischemic disease, hypercholesterolemia, family history of early coroary artery disease, smokig, alcohol use Exam (>3 elemets): Murmurs or gallops, peripheral arterial exam, peripheral edema, weight, BMI, waist circumferece Review of systems (>3 elemets): Chest pai, shortess of breath, trasiet visio/ eurologic symptoms, octural dyspea, leg pai Laboratory: Blood glucose ad serum lipids ECG 4. IF a VE is ewly diagosed with hypertesio, THEN a assessmet of real fuctio should be performed withi 3 moths (if ot doe i the prior 3 moths). 5. IF a VE is ewly diagosed with hypertesio, THEN the quatity ad frequecy of alcohol itake should be documeted withi 3 moths (if ot doe i the prior 3 moths). 6. IF a VE is ewly diagosed with hypertesio AND is takig a NSAID or COX-2 ihibitor, THEN there should be documetatio withi 6 moths of dose Hospitalizatio* Surgery*

77 Hospitalizatio* Surgery* reductio, a attempt to use a alterative medicatio, or justificatio for cotiued use. 7. IF a VE is ewly diagosed with hypertesio, THEN a discussio of goal BP OR risks of prologed hypertesio should be documeted withi 3 moths. 8. IF a VE is ewly diagosed with hypertesio, THEN a o-pharmacologic itervetio (e.g. diet, exercise, weight loss, reduced alcohol) should be recommeded withi 3 moths (if ot doe i the prior 3 moths). 9. IF a VE with HTN has persistet (o 2 cosecutive visits) elevatio of systolic BP above goal*, THEN a itervetio (pharmacologic, lifestyle, compliace, etc.) should occur or there should be documetatio of a reversible cause or other justificatio for the elevatio. *Goal systolic BP: Diabetes or chroic real disease 130mm Hg Home ambulatory moitorig 135mm Hg All other patiets 140mm Hg or other specified goal 10. IF a VE with HTN has persistet (o 2 cosecutive visits) elevatio of systolic BP above goal* cotiuously for > 6 moths, THEN there should be documetatio of the suspected reaso why the target was ot reached AND efforts to address the limitatio *Goal systolic BP: Diabetes or chroic real disease 130mm Hg Home ambulatory moitorig 135mm Hg All other patiets 140mm Hg or other specified goal 11. IF a VE without target orga damage has a diastolic E E E E

78 BP 120mm Hg, THEN immediate therapy ad/or referral to emergecy room/hospital should occur. 13. IF a VE with hypertesio has ischemic heart disease, THEN treatmet with a beta-blocker should be recommeded OR documetatio why ot. 14. IF a VE with hypertesio has a history of heart failure, left vetricular hypertrophy, ischemic heart disease, chroic kidey disease or CVA, THEN s/he should be treated with a ACE ihibitor or ARB OR documetatio why ot. Ischemic Heart Disease 1. IF a VE has a BMI 25, THEN risk factors for cardiovascular disease should be assessed. 5. IF a VE has a myocardial ifarctio (STEMI or NSTEMI) complicated by heart failure or LVEF <40%, THEN s/he should be give a ACE ihibitor/arb withi 36 hours of presetatio AND advised to cotiue this treatmet for >4 weeks. 6. IF a VE is hospitalized with a acute myocardial ifarctio (STEMI or NSTEMI), THEN a assessmet of left vetricular fuctio (LVEF) should be performed before or withi 7 days of discharge. 7. IF a VE has acute coroary sydrome, did ot udergo agiography, ad does ot have cotraidicatios to revascularizatio, THEN s/he should be offered oivasive stress testig before or withi 2 weeks of discharge. Hospitalizatio* Surgery* E E --- I E E --- E

79 8. IF a VE has a diagosis of acute myocardial ifarctio, THEN s/he should be screeed for depressio withi 3 moths. 9. IF a VE has a ST-segmet elevatio AMI, THEN s/he should be offered reperfusio therapy. 10. IF a VE has sigificat left mai or 3-vessel coroary artery disease ad LVEF <50%, THEN s/he should be offered revascularizatio. 11. ALL VEs with ischemic heart disease should have a fastig cholesterol evaluatio (LDL, HDL ad triglycerides) at least every 2 years. 12. IF a VE with ischemic heart disease has a LDL >100 mg/dl, THEN s/he should be offered cholesterol lowerig medicatio. 13. IF a VE with ischemic heart disease is ot takig warfari, THEN s/he should be offered daily aspiri or other atiplatelet therapy. 14. IF a VE has had a myocardial ifarctio (STEMI or NSTEMI), THEN s/he should be offered a beta-blocker ad advised to cotiue treatmet for 2 years followig ifarctio. 15. IF a VE has ischemic heart disease, THEN s/he should be offered ACE ihibitor/arb therapy ad advised to cotiue the treatmet idefiitely. 16. IF a VE with ischemic heart disease smokes, THEN there should be documetatio of smokig cessatio couselig aually. Hospitalizatio* Surgery* E I I I E E E E E E E E I E I I I E I I I E I I I E I I

80 17. IF a VE has had a myocardial ifarctio (STEMI or NSTEMI) or CABG i the past year, THEN s/he should be offered cardiac rehabilitatio (formal program or its compoets). 18. IF a female VE with ischemic heart disease is curretly takig combiatio estroge/ progesteroe therapy, THEN she should be couseled about possible icreased cardiovascular risk OR this therapy should be discotiued. Medicatio Use 11. IF a VE is takig a bezodiazepie (>1 moth), THEN there should be aual documetatio of discussio of risks ad attempt to taper ad discotiue the bezodiazepie. 13. IF a VE does ot require seizure cotrol, THEN barbiturates should ot be used. 16. IF a VE receives prescriptio pharmacological treatmet for back or eck pai, THEN cyclobezaprie, methocarbamol, carisoprodol, chlorzoxasoe, orpheadie, tizaidie, or metaxoloe should ot be prescribed for >1 week. Osteoarthritis 3. IF a ambulatory VE has symptomatic osteoarthritis of the kee/hip for >3 moths AND is able to exercise, THEN a directed/supervised muscle stregtheig or aerobic exercise program should be recommeded ad activity reviewed aually. Hospitalizatio* Surgery* I E I I I E I I I E I I

81 4. IF a VE has symptomatic osteoarthritis of the hip/kee ad has difficulty walkig that makes activities of daily livig difficult for >3 moths, THEN the eed for ambulatory assistive devices should be assessed. 5. IF a VE has symptomatic osteoarthritis ad has difficulty with o-ambulatory activities of daily livig, THEN the eed for o-ambulatory assistive devices should be assessed. 7. IF a VE has severe symptomatic osteoarthritis of the kee/hip despite osurgical therapy, THEN a referral to a orthopedic surgeo should be made. Osteoporosis 1. ALL VEs at a iitial primary care visit should be couseled about itake of calcium ad vitami D, ad weight-bearig exercises. 2. ALL female VEs without a diagosis of osteoporosis should have documetatio that they were offered a DXA sca. 3. IF a male VE without a diagosis of osteoporosis has ay of the followig risk factors for osteoporosis, THEN a DXA sca should be performed: >3 moths of systemic glucocorticoid treatmet; primary hyperparathyroidism; osteoporosis i a 1 st -degree relative; hypogoadism; GNRH atagoist use; OR osteopeia o x ray 4. IF a female VE has a ew o-pathologic fracture, THEN the patiet should be treated for osteoporosis or a DXA sca should be performed. Hospitalizatio* Surgery* E I I I E I I I E E E E

82 8. IF a female VE is ewly diagosed with osteoporosis, THEN she should receive a workup icludig the followig: medicatio use, alcohol use, CBC, liver fuctio tests, real fuctio, calcium, phosphorus, vit D 25 OH ad TSH. 9. IF a ambulatory VE has a ew diagosis of osteoporosis, THEN there should be documetatio of advice to exercise withi 3 moths. 10. IF a VE has osteoporosis, THEN s/he should be prescribed calcium ad vitami D supplemets. 11. IF a female VE has osteoporosis, THEN she should be treated with bisphosphoates, raloxifee, calcitoi, hormoe replacemet therapy or PTH (if this is a ew diagosis, withi 3 moths). 12. IF a male VE has osteoporosis ad is hypogoadal ad has o history of prostate cacer, THEN he should be prescribed testosteroe therapy. 13. IF a male VE has osteoporosis, THEN he should be treated with bisphosphoates, calcitoi or PTH or, if hypogoadal, testosteroe (if this is a ew diagosis, withi 3 moths). Pressure Ulcers 1. IF a VE who is admitted to a hospital is uable to repositio him/herself or has limited ability to do so, THEN risk assessmet for pressure ulcers usig a stadardized scale should be performed upo admissio, ad if at risk, assessmet repeated at least every 48 hours thereafter.. Hospitalizatio* Surgery* I I --- I

83 8. IF a VE presets with a full-thickess pressure ulcer covered with ecrotic debris or eschar (UNLESS dry eschar presets o the heel), THEN debridemet itervetios usig sharp, mechaical, ezymatic, biosurgery, or autolytic procedures should be istituted withi 24 hours. 11. IF a VE with a full-thickess stage III or IV pressure ulcer presets with systemic sigs ad symptoms of ifectio, such as elevated temperature, elevated white blood cout, ad/or cofusio ad agitatio, AND it is likely the sepsis is due to the woud, THEN the pressure ulcer should be debrided to elimiate ecrotic debris withi 24 hours AND a tissue biopsy, eedle aspiratio, or quatitative swab after debridemet should be obtaied for bacterial culture ad appropriate systemic atibiotics iitiated. Screeig ad io 1. IF a VE has ot received a booster after age 49, THEN s/he should receive a Td booster. 5. ALL VEs should be screeed for alcohol misuse withi 3 moths of eterig a ew primary care practice. 6. IF a VE misuses alcohol, THEN s/he should be couseled to decrease itake or be referred to a alcohol program withi 3 moths. 7. ALL VEs should be screeed for tobacco use withi 3 moths of eterig a ew primary care practice. 8. IF a VE uses tobacco, THEN s/he should be couseled to quit withi 3 moths ad aually. Hospitalizatio* Surgery* I I E E I I E E I E I I I E I I I E I I I E I I

84 10. ALL VEs should have a assessmet of activity level (with ecouragemet to be active) aually. 11. IF a female VE is o hormoe therapy, THEN there should be documetatio that the risks ad beefits were discussed sice Jauary IF a VE is obese (BMI 30 kg/m2), THEN s/he should be advised to lose weight aually. 16. ALL VEs ew to a primary care practice should receive the elemets of a comprehesive geriatric assessmet (CGA) withi 3 moths. 17. IF a VE receives the elemets of a CGA that idetifies a problem, THEN the problem should be addressed withi 3 moths. Sleep Disorders 3. IF a VE has a sleep problem, THEN a discussio of sleep hygiee should be documeted withi 6 moths (e.g., bedtime avoidace of caffeie, icotie ad alcohol; exercise ear bedtime; light, oise ad temperature i sleep eviromet; avoidace of heavy meals withi 1 hour of bedtime; bedtime fluid itake; daytime aps; time i bed; ad regular sleep schedule). 4. IF a VE has daytime sleepiess AND observed apeas or loud sorig, THEN s/he should be referred for sleep evaluatio withi 6 moths. 5. IF a VE has sleep disordered breathig based o polysomography, THEN a discussio of treatmet optios should be documeted withi 6 moths. Hospitalizatio* Surgery* E E E I E E E E

85 6. IF a VE has octural limb movemets durig sleep AND frequet awakeigs or excessive daytime sleepiess, THEN treatmet or referral to a sleep specialist should occur withi 6 moths. 8. IF a VE is ew to a primary care practice ad is chroically (> 3 moths) takig a over-the-couter sleep aid cotaiig atihistamie for sleep problems, THEN advice to discotiue the medicatio should be documeted withi 6 moths. 9. IF a VE is ew to a primary care practice ad is chroically (> 3 moths) takig a bezodiazepie for sleep problems, THEN advice to taper off ad discotiue the medicatio should be documeted withi 6 moths. Stroke & A Fib 1. IF a VE has a ew TIA or ischemic stroke attributable to the carotid artery, THEN a carotid artery imagig study should be doe or documetatio that the patiet is ot a carotid procedure cadidate. 2. IF a VE has a symptomatic carotid steosis >70%, THEN the medical record should documet a discussio of risks ad beefits of carotid procedures OR the patiet is ot a carotid procedure cadidate or a carotid edarterectomy caot be doe with <6% 30-day morbidity ad mortality rate. 3. IF a VE has chroic atrial fibrillatio ad is medium to high-risk for stroke, THEN aticoagulatio should be offered. Hospitalizatio* Surgery* E E E E I E I I I E I I E E E E E E E E

86 Hospitalizatio* Surgery* 7. IF a VE has had a TIA or ischemic stroke, THEN there should be documetatio of a fastig low-desity lipoprotei (LDL) level. 8. IF a VE has a ew TIA or stroke, THEN smokig status should be documeted. 9. IF a VE has a TIA or stroke ad is a curret smoker, I E I I THEN smokig cessatio couselig should be documeted aually. 10. IF a ambulatory VE has had a TIA or stroke ad is ot physically active, THEN couselig to icrease physical activity should be documeted aually. 11. IF a VE has a ew TIA or stroke THEN assessmet of alcohol itake should be documeted, ad if positive for alcohol itake, alcohol itake reassessed aually. 12. IF a VE has had a TIA or stroke AND cosumes 5 driks of alcohol per day, THEN s/he should be couseled to decrease cosumptio to <2 driks per day, ad this should be documeted aually. 13. IF a female VE has had a TIA or stroke ad is takig hormoe replacemet therapy, THEN hormoe replacemet therapy should be discotiued or a reaso (other tha stroke prevetio) documeted. 14. IF a VE presets with a ew TIA or stroke, THEN I E I I educatio of the patiet (or caregiver) about stroke symptoms ad risk factors should be documeted withi 6 moths. 15. IF a VE is hospitalized with a ew acute ischemic I I --- I

87 stroke, THEN aspiri should be give withi 48 hours (if ot already o aticoagulat therapy). 16. IF a VE is hospitalized with a acute stroke ad iclusio ad exclusio criteria are met, THEN thrombolytic therapy should be offered. 17. IF a VE with a ew stroke is started o itraveous tpa for thrombolysis, THEN iclusio ad exclusio criteria should be met. 18. IF a VE presets with a ew stroke THEN presece or absece of depressio should be documeted withi 3 moths. 19. IF a VE presets with a ew stroke ad has resultig laguage difficulties, THEN a referral for speech therapy should be made withi 1 moth. 21. IF a VE presets with a ew stroke, THEN o discharge the patiet should have a rehabilitatio pla or documetatio of o residual fuctioal deficit from the ew stroke. Uderutritio 2. ALL VEs i stable health states should take 800 IU of vitami D supplemetatio daily. 3. IF a VE is hospitalized, THEN evaluatio of oral itake should be documeted durig the hospitalizatio. Hospitalizatio* Surgery* E E I I --- I E I I I I I --- I

88 7. IF a hospitalized VE is uable to take food orally for >48 hours, THEN alterative alimetatio (e.g., eteral or pareteral) should be implemeted or documeted why ot. 8. IF a VE has a ew stroke ad fails a swallowig scree for dysphagia, THEN s/he should be offered swallowig traiig. 9. IF a hospitalized VE is malourished or at risk, THEN s/he should receive oral protei ad eergy supplemetatio of 400 kcal/day for 35 days. Uriary Icotiece 5. IF a VE has ew UI, THEN a physical exam of the followig should be documeted: mobility, abdomial exam, cogitive status exam, geital system exam (wome: pelvic exam ad estroge status of vulvovagial tissues; me: prostate), rectal for impactio/mass, assessmet of volume status 7. IF a VE has a post-void residual >300 cc, THEN s/he should have a serum creatiie withi 72 hours ad (if o reversible causes foud) referred to a urologist withi 2 moths. 12. IF a cogitively itact, ambulatory VE has stress, urge, or mixed UI, THEN behavioral/lifestyle treatmet should be offered. 13. IF a vulerable female elder udergoes surgery for stress UI, THEN urodyamic ivestigatios should be performed prior to surgery. Hospitalizatio* Surgery* I I --- I E E --- I E E E E I I

89 14. IF a female VE has stress UI ad udergoes a procedure or surgery for UI, THEN oe of the followig should be performed or offered: (1) periurethral bulkig aget, or (2) surgical correctio with either of the followig: ope retrograde suspesio or a slig procedure. Visio 1. ALL VEs should have a comprehesive eye exam every 2 years. 4. IF a VE has primary ope-agle glaucoma, THEN s/he should have a eye exam aually that icludes measuremets of visual acuity ad itraocular pressure, documetatio of optic erve examiatio, slit lamp evaluatio, visual field testig, ad documetatio of target itraocular pressure. 5. IF a VE with age-related macular degeeratio has a eye examiatio, THEN the degree of maculopathy (umber ad size of macular druse, presece of geographic atrophy or choroidal eovascular membraes) should be documeted. 6. IF a VE is diagosed with a cataract that limits his/her ability to carry out eeded/desired activities, THEN cataract extractio should be offered. Hospitalizatio* Surgery* I I E E I E =advaced demetia, =poor progosis (life expectacy of 6 moths or less). I=iclude the quality idicator for patiet with this coditio, E=exclude the quality idicator for patiet with this coditio.

90 *For Hospitalizatio ad Surgery decisios, --- meas that the quality idicator caot apply because of the decisio ot to be hospitalized or have surgery. Oly a portio of the quality idicator is excluded from applicatio to patiets with the specified coditio or preferece.

91 Figure 1.

92 Figure 2.