Evidence-Based Measure (EBMs) Definitions

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1 Evidence-Based (EBMs) s This guide is a brief summary of the most commonly-used EBMs. All information is based on the MedInsight Evidence Based s (EBMs) User Guide (October 2015), compiled in a way most useful to our members. For further information on the EBM measure you are interested in, pleased refer to the MedInsight User Guide pages listed next to the specific measure in the Table of Contents. Table of Contents Access/Availability of Care Children and Adolescent s Access to Primary Care Practitioners (MedInsight Page 7) Avoidable Procedure Page Number 3 4 Accidental Puncture or Laceration Rate in Adults (MedInsight Page 47) Bilateral Cardiac Catheterization Rate in Adults (MedInsight Page 24) MRI of Lumbar Spine for Low Back Pain (MedInsight Page 38) Behavioral Health Antidepressant Medication (MedInsight Page 11) 5-6 Follow-Up Care for Children Prescribed ADHD Medication (MedInsight Page 14) Cardiovascular Conditions LDL-C Screening (Cholesterol for Patients with Cardiovascular Conditions) (MedInsight Page 17) 7-8 CAD Patients Prescribed a Lipid Lowering Medication (MedInsight Page 19) In-Hospital Congestive Heart Failure Mortality (MedInsight Page 23) Persistence of Beta-Blocker Treatment After a Heart Attack, 25 (MedInsight Page 25) Diabetes HbA1c Testing (MedInsight Page 26) 9 Eye Exam (Retinal) (MedInsight Page 26) LDL-C Screening (MedInsight Page 26) Medical Attention for Nephropathy (MedInsight Page 26) Effectiveness of Care Follow-Up to Hospitalization for Mental Illness (MedInsight Page 13 Appropriate Testing for Children with Pharyngitis (MedInsight Page 67 Accidental Puncture or Laceration (Pediatric) (MedInsight Page 50) Death in Low Mortality DRGs (MedInsight Page 42) Iatrogenic Pneumothorax in Adults (MedInsight Page 46) Iatrogenic Pneumothorax in Children (MedInsight Page 56) Pressure Ulcer Rates in Adults (MedInsight Page 43) Pressure Ulcer Rates in Children (MedInsight Page 53) 2016 The Advisory Board Company 1

2 Table of Contents, Continued Medication Annual Monitoring for Patients on Persistent Medications (MedInsight Page 29) Heart Failure- ACE or ARB Therapy for Left Ventricular Systolic Dysfunction (LVSD) (MedInsight Page 35) Muscoskeletal Conditions Use of Imaging Studies for Low Back Pain (MedInsight Page 39) Prevention and Screening Breast Cancer (MedInsight Page 58) Cervical Cancer (MedInsight Page 59) Childhood Immunization Status (MedInsight Page 60) Chlamydia Screening in Women (MedInsight Page 62) Glaucoma Screening in Older Adults (MedInsight Page 64) Immunizations for Adolescents (MedInsight Page 65) Lead Screening in Children (MedInsight Page 66) Respiratory Conditions Appropriate Treatment for Children with Upper Respiratory Infection (MedInsight Page 68) Avoidance of Antibiotic Treatments in Adults with Acute Bronchitis (MedInsight Page 69) Use of Appropriate Medications for People with Asthma (MedInsight Page 70) Use of Medication Generic Prescriptions: Use of Services ADHD (MedInsight Page 31) AHT (MedInsight Page 32) SSRI (MedInsight Page 33) STATIN (MedInsight Page 34) Adolescent Well-Care Visits (MedInsight Page 72) Ambulatory Care, 73 Well-Child Visits: First 15 Months of Life (MedInsight Page 92) Well-Child Visits First 3-6 Years of Life (MedInsight Page 93) Women s Health Prenatal & Postpartum Care (MedInsight Page 10) Incidence of Episiotomy (MedInsight Page 40) Page Number The Advisory Board Company 2

3 Access/Availability of Care Children and Adolescents Access to Primary Care Practitioners: The percentage of members 12 months 19 years of age who had a visit with a PCP. The organization reports four separate percentages for each product line: Months 25 Months- 6 Years 7-11 Years Years None. The Percentage of Members Months of Age Who Had a Visit with a PCP The percentage of members months of age who had a visit with a PCP. The Percentage of Members 25 Months-6 Years of Age Who Had a Visit with a PCP The Percentage of Members 7-11 Years of Age Who Had a Visit with a PCP The percentage of members 25 months - 6 years of age who had a visit with a PCP. The percentage of members 7-11 years of age who had a visit with a PCP. The Percentage of Members Years of Age Who Had a Visit with a PCP The percentage of members years of age who had a visit with a PCP The Advisory Board Company 3

4 Avoidable Procedures Accidental Puncture of Laceration Rate: The percentage of discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM code denoting accidental cut, puncture, perforation, or laceration during a procedure in any secondary diagnosis field. All inpatient discharges during the measurement year for members aged 18 years and above as of the beginning of the measurement year, excluding: Discharges with a principal diagnosis denoting accidental cut, puncture, perforation, or laceration, or secondary diagnosis present on admission; Discharges with ICD-10 code for spine injury; Discharges with Major Diagnostic Category 14 code in any positions (pregnancy, childbirth, and puerperium) or Discharges missing the following information: Gender Age Quarter Year Principal Diagnosis Accidental Puncture or Laceration in Adults Number of discharges with Secondary Diagnosis of Accidental Cut, Puncture, Perforation, or Laceration. Bilateral Cardiac Catheterization Rate: Percent of discharges with heart catheterizations in any procedure field with simultaneous right and left heart (bilateral) heart catheterizations. An inpatient discharge with coronary heart disease requiring cardiac catheterization. Bilateral Cardiac Catheterization Rate Number of discharges with simultaneous right and left heart catheterizations performed MRI of Lumbar Spine for Low Back Pain: The percentage of Magnetic Resonance Imaging (MRI) of the lumbar spine studies with a diagnosis of low back pain on the imaging claim, and for which the patient did not have prior claims-based evidence of antecedent conservative therapy. Cases with MRI of the lumbar spine studies with a diagnosis of low back pain in any position on the imaging claim. MRI of Lumbar Spine for Low Back Pain Number of claims without an antecedent conservative therapy in any position on a claim within the timeframe specified prior to MRI The Advisory Board Company 4

5 Behavioral Health Antidepressant Medication : The percentage of members 18 years of age and older with a diagnosis of major depression and were treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported: Effective Acute Phase Treatment- The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks). Effective Continuation Phase Treatment- The percentage of members who remained on an antidepressant medication for at least 180 days (6 months). An outpatient visit, intensive outpatient encounter or partial hospitalization with any diagnosis of major depression; or An ED visit with any diagnosis of major depression; or An inpatient (acute or non-acute) encounter with any diagnosis of major depression. Exclude members who did not have a diagnosis of major depression in an inpatient, outpatient, ED, intensive outpatient or partial hospitalization setting during the 60 days prior to the IPSD (inclusive) through 60 days after the IPSD (inclusive). Exclude members who filled a prescription for an antidepressant medication 105 days prior to the IPSD. Antidepressant Medication, Acute Phase Antidepressant Medication, Continuation Phase The percentage of members 18 years of age and older who were diagnosed with a new episode of major depression and treated with antidepressant medication, and who remained on an antidepressant medication treatment, acute phase. The percentage of members 18 years of age and older who were diagnosed with a new episode of major depression and treated with antidepressant medication, and who remained on an antidepressant medication treatment, continuation phase The Advisory Board Company 5

6 Behavioral Health (Continued) Follow-Up Care for Children Prescribed ADHD Medication: The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported: Initiation Phase- The percentage of members 6 12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase. Continuation and Maintenance (C&M) Phase- The percentage of members 6 12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. Initiation Phase: Identify all children in the specified age range who were dispensed an ADHD medication during the 12-month Intake Period. Test for Negative Medication History. Exclude members who had an acute inpatient encounter for mental health or chemical dependency during the 30 days after the IPSD. C&M Phase: Identify all members who meet the eligible population criteria for Rate 1 Initiation Phase. Determine if the member filled a sufficient number of prescriptions to provide continuous medication treatment for at least 210 days out of the 300-day period after the IPSD. The definition of continuous medication treatment allows gaps in medication treatment, up to a total of 90 days during the 300-day (10-month) period. Regardless of the number of gaps, the total gap days may be no more than 90. Exclude members who had an acute inpatient encounter for mental health or chemical dependency during the 300 days (10 months) after the IPSD. Follow-Up Care for Children Prescribed ADHD Medication, Continuation & Maintenance Phase Follow-Up Case for Children Prescribed ADHD Medication, Initiation Phase The percentage of children 6-12 newly on ADHD drugs who had a follow up visit within 30 days of initiation. The percentage of children 6-12 newly on ADHD drugs who had 2 follow up visits in the continuation and maintenance phase The Advisory Board Company 6

7 Cardiovascular Conditions Cholesterol for Patients with Cardiovascular Conditions: The percentage of members years of age who were discharged alive for AMI, coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year, who had each of the following during the measurement year: LDL-C Screening LDL-C Control (<100mg/dL) Members are identified for the eligible population in two ways: by event or by diagnosis. A member only needs to be identified by one to be included in the measure. Event Any of the following during the year prior to the measurement year meet criteria: AMI- Discharged alive from an acute inpatient setting with an AMI CABG- Discharged alive from an acute inpatient setting with a CABG PCI- Members who had PCI in any setting Diagnosis Identify members as having IVD who met at least one of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years. At least one outpatient visit with an IVD diagnosis; or At least one acute inpatient encounter with an IVD diagnosis LDL-C Screening The percentage of members years of age with diabetes (type 1 and type 2) who had a LDLC test performed during the measurement year. Coronary Artery Disease (CAD) Patients Prescribed a Lipid Lowering Medication: Percentage of patients with CAD who were prescribed with a lipid-lowering therapy. Diagnosis of Coronary Artery Disease CAD Patients Prescribed a Lipid Lowering Medication Patients age 18 to 75 with coronary artery disease (CAD) who had a prescription filled for a lipid lowering medication The Advisory Board Company 7

8 Cardiovascular (Continued) Inpatient Quality Indicator #16- Heart Failure Mortality Rate: In-hospital deaths per 1,000 hospital discharges with heart failure as a principal diagnosis for patients ages 18 years and older. There are two rates created by this measure one that is risk adjusted, and one that is not risk-adjusted. Primary Diagnosis of Heart Failure in an inpatient setting in the measurement year. In- Hospital Congestive Heart Failure Mortality Rate Number of discharges with a discharge status of death. Persistence of Beta-Blocker Treatment After a Heart Attack: The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. Discharged alive from an acute inpatient setting with an AMI from July 1 of the year prior to the measurement year through June 30 of the measurement year. If a member has more than one episode of AMI from July 1 of the year prior to the measurement year through June 30 of the measurement year, organizations should only include the first discharge. Persistence of Beta-Blocker Treatment After a Heart Attack The percentage of members 18 and older during the measurement year who were hospitalized from July 1 of the prior year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge The Advisory Board Company 8

9 Diabetes Comprehensive Diabetes Care: The percentage of members years of age with diabetes (type 1 and type 2) who had each of the following: Hemoglobin A1c (HbA1c) testing Eye exam (retinal) performed LDL-C control (<100 mg/dl) Medical attention for nephropathy There are two ways to identify members with diabetes: by claim/encounter data and by pharmacy data. The organization must use both methods to identify the eligible population, but a member only needs to be identified by one method to be included in the measure. Members may be identified as having diabetes during the measurement year or the year prior to the measurement year. Claim/Encounter Data: Members who met any of the following criteria during the measurement year or the year prior to the measurement year (count services that occur over both years): At least two outpatient visits, observation visits, or non-acute inpatient encounters on different dates of service, with a diagnosis of diabetes (visit type need not be the same for the two visits); At least one acute inpatient encounter with a diagnosis of diabetes; or At least one ED visit with a diagnosis of diabetes Pharmacy Data: Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis during the measurement year or the year prior to the measurement year. HbA1c Testing Eye Exam LDL-C Screening Medical Attention for Nephropathy An HbA1c test performed during the measurement year, as identified by claim encounter or automated laboratory data. An eye screening for diabetic retinal disease as identified by administrative data. An LDL-C test (LDL-C Tests Value Set) performed during the measurement year, as identified by claim/encounter or automated laboratory data. A nephropathy screening test or evidence of nephropathy, as documented through administrative data The Advisory Board Company 9

10 Effectiveness of Care Follow-Up After Hospitalization for Mental Illness: The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: The percentage of discharges for which the member received follow-up within 30 days of discharges; and The percentage of discharges for which the member received follow-up within 7 days of discharge. Discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness on or between January 1 and December 1 of the measurement year. Use only facility claims to identify discharges. Do not use diagnoses from professional claims to identify discharges. The denominator for this measure is based on discharges, not on members. If members have more than one discharge, include all discharges on or between January 1 and December 1 of the measurement year. 7-Day Follow Up 30-Day Follow Up Members in denominator who had a mental health follow-up visit within 7 days of the inpatient discharge. Members in denominator who had a mental health follow-up visit within 30 days of the inpatient discharge. Appropriate Testing for Children with Pharyngitis: The percentage of children 2 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic, and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). Outpatient or ED visit with only a diagnosis of pharyngitis, and a dispensed antibiotic for that episode of care during the Intake Period. Appropriate Testing for Children With Pharyngitis Children 2-18 years of age with a pharyngitis diagnosis, dispensed an antibiotic and received a group A streptococcus (strep) test The Advisory Board Company 10

11 Effectiveness of Care (Continued) Accidental Puncture or Laceration Rate (Pediatric): Accidental punctures or lacerations (secondary diagnosis) during procedure per 1,000 discharges for patients under the age of 18 years. All surgical and medical discharges for members aged below 18 defined by specific DRGs or MS-DRGs, excluding: Overall Discharges with principal diagnosis denoting accidental cut, puncture, perforation, or laceration; Discharges where there is a secondary diagnosis present on admission; Normal newborn; Neonate with birth weight less than 500 grams (Birth Weight Category 1); MDC 14 (pregnancy, childbirth, and puerperium); Discharges with ICD-9-CM code for spine surgery; and Discharges missing the following information: o Gender o Age o Quarter o Year o Principal Diagnosis Risk Category 1 From the overall discharges identified above, discharges with MS DRG codes for: MDC 2 (eye) MDC 3 (ear, nose, mouth, and throat) MDC 9 (skin, subcutaneous tissue, and breast) MDC 19 (mental diseases and disorders) MDC 22 (burns) MDC 23 (factors influencing health status) Risk Category 2 From the overall discharges identified above, discharges with MS DRG codes for: MDC 4 (respiratory system) MDC 5 (circulatory system) MDC 17 (myeloproliferative diseases and disorders [poorly differentiated neoplasms]) Risk Category 3 Form the overall discharges identified above, discharges with MS DRG codes for: MDC 11 (kidney and urinary tract) MDC 12 (male reproductive system) MDC 13 (female reproductive system) Risk Category 4 From the overall discharges identified above, discharges with MS DRG codes for: MDC 0/99 (ungroupable) MDC 16 (blood and blood forming organs and immunological disorders) MDC 18 (infectious and parasitic diseases and disorders) MDC 25 (human immunodeficiency virus infection) Risk Category 5 From the overall discharges identified above, discharges with MS DRG codes for: MDC 1 (nervous system) MDC 8 (musculoskeletal system and connective tissue) MDC 21 (injuries, poison, and toxic effects of drugs) MDC 24 (multiple significant trauma) Risk Category 6 From the overall discharges identified above, discharges with MS DRG codes for: From the overall discharges identified above, discharges with MS DRG codes for: MDC 6 (digestive system) MDC 7 (hepatobiliary system and pancreas) MDC 10 (endocrine, nutritional, and metabolic system) Risk Category 9 From the overall discharges identified above, discharges with MS DRG codes that do not meet the inclusion rules for Risk Categories 1-6. Accidental Puncture of Laceration in Children Number of discharges with Secondary Diagnosis of Accidental Cut, Puncture, Perforation, or Laceration The Advisory Board Company 11

12 Effectiveness of Care (Continued) Death Rate in Low-Mortality Diagnosis Related Groups (DRGs): The mortality rate in DRGs that historically have a mortality rate below 0.5%. All inpatient facility discharges, 18 years and older or MDC 14 (pregnancy, childbirth, and puerperium), in DRGs or MS-DRGs with less than 0.5% mortality rate. Exclude: Discharges with any listed ICD-9-CM diagnosis codes for trauma; Discharges with any listed ICD-9-CM diagnosis codes for cancer; Discharges with any listed ICD-9-CM diagnosis codes or any listed ICD-9-CM procedure codes for immunocompromised state; Discharges resulting in a transfer to an acute care facility (discharge disposition 2); and Discharges missing the following information: o Gender o Age o Quarter o Year o Principal Diagnosis Death in Low Mortality DRGs Number of discharges with disposition of deceased or death. Iatrogenic Pneumothorax in Adults: Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 surgical and medical discharges for patients ages 18 years and older. All discharges defined by specific surgical and medical DRGs or MS-DRGs, excluding: Discharges with a primary diagnosis of iatrogenic pneumothorax or secondary diagnosis present on admission; Discharges with a diagnosis of chest trauma or pleural effusion in any position on the claim; Discharges with an ICD-9-CM procedure code of thoracic surgery, lung or pleural biopsy, diaphragmatic surgery repair, OR cardiac surgery in any position on the claim; Discharges with Major Diagnostic Category 14 code in any position on the claim (pregnancy, childbirth, and puerperium); or Discharges missing the following information: o Gender o Age o Quarter o Year o Principal Diagnosis Iatrogenic Pneumothorax in Adults Number of discharges with a Secondary Diagnosis of Iatrogenic Pneumothorax age The Advisory Board Company 12

13 Effectiveness of Care (Continued) Iatrogenic Pneumothorax in Children: Iatrogenic pneumothorax cases (secondary diagnosis) per 1,000 discharges for patients aged below 18 years. All surgical and medical discharges defined by specific DRGs, excluding: Discharges of neonates with birth weight less than 2500 grams; Discharges with a primary diagnosis of iatrogenic pneumothorax or secondary diagnosis present on admission; Discharges with a diagnosis of chest trauma or pleural effusion in any position on the claim; Discharges with an ICD-9-CM procedure code of thoracic surgery, lung or pleural biopsy, diaphragmatic surgery repair, OR cardiac surgery in any position on the claim; Discharges of normal newborns; Discharges with Major Diagnostic Category 14 code in any position on the claim (pregnancy, childbirth, and puerperium); and Cases missing one of the following at discharge: o Gender o Age o Quarter o Year o Principal Diagnosis Iatrogenic Pneumothorax in Children Number of discharges with a Secondary Diagnosis of Iatrogenic Pneumothorax under age 18. Pressure Ulcer Rate in Adults: The number of discharges among cases over 18 years of age with an ICD-9-CM code of pressure ulcer in any secondary diagnosis field, and ICD-9-CM code of pressure ulcer stage III or IV (or unstageable) in any secondary diagnosis field. Surgical or medical discharges for members, excluding: Discharges with length of stay less than 5 days; Discharges with any ICD-9-CM procedure codes for Discharges with principal (primary) ICD-9-CM diagnosis code of pressure ulcer; debridement or pedicle graft before or on the same day as the major operating room procedure (surgical cases only); Discharges with any secondary ICD-9-CM diagnosis codes Discharges with any ICD-9-CM procedure codes for for pressure ulcer present on admission or any secondary ICD-9-CM diagnosis codes for pressure ulcer stage III or IV debridement or pedicle graft as the major operating room procedure (surgical cases only); present on admission; Discharges that resulted from a transfer from another Discharges with MDC 9 (skin, subcutaneous tissue, and hospital or other healthcare facility; breast); Discharges with a transfer from a skilled nursing facility Discharges with MDC 14 (pregnancy, childbirth, and (SNF) or intermediate care facility (ICF); puerperium); Transfer from another healthcare facility; or Discharges with any ICD-9-CM diagnosis codes for Discharges missing the following information: hemiplegia, paraplegia, or quadriplegia; o Gender Discharges with any ICD-9-CM diagnosis codes for spina o Age bifida or anoxic brain damage; o Quarter o Year o Principal Diagnosis Pressure Ulcer Rates in Adults Number of discharges with ICD-9-CM code of pressure ulcer in any secondary diagnosis field and ICD-9-CM code of pressure ulcer stage III or IV (or unstagable) in any secondary diagnosis field The Advisory Board Company 13

14 Effectiveness of Care (Continued) Pressure Ulcer Rate in Children: The percentage of discharges among cases under 18 years of age with an ICD-9-CM code of pressure ulcer in any secondary diagnosis field, and ICD-9-CM code of pressure ulcer stage III or IV (or unstageable) in any secondary diagnosis field while in an inpatient setting. Using only inpatient facility claims, all cases for members age 18 and under with a medical or surgical discharge, excluding: Cases with a length of stay less than 5 days; Cases with a primary or secondary diagnosis of pressure ulcer present on admission and a secondary diagnosis of pressure ulcer stage III or IV present on admission; Cases with a DRG in MDC 9 (skin, subcutaneous tissue, and breast); Cases with a procedure code for debridement or pedicle graft before or on the same day as the major operating room procedure (surgical cases only); Cases with a procedure code for debridement or pedicle graft as the only operating room procedure (surgical cases only); Cases transferred from another hospital (point of origin status 4); Cases transferred from a skilled nursing facility (SNF) or intermediate care facility (ICF) (point of origin status 5); Cases transferred from another healthcare facility (point of origin status 6); Cases with a DRG in MDC 14 (pregnancy, childbirth, and puerperium); Neonates; and Cases missing one of the following at discharge: o Gender o Age o Quarter o Year o Principal Diagnosis Pressure Ulcer Rates in Children Number of discharges with a secondary diagnosis of pressure ulcer AND a secondary diagnosis of pressure ulcer stage III or IV The Advisory Board Company 14

15 Medication Annual Monitoring for Patients on Persistent Medication: The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report each of the four rates separately and as a total rate. Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Annual monitoring for members on digoxin Annual monitoring for members on diuretics Annual monitoring for members on anticonvulsants; and Total rate (the sum of the four numerators divided by the sum of the four denominators). Members on persistent medications (i.e., members who received at least 180 treatment days of ambulatory medication in the measurement year). Treatment days are the actual number of calendar days covered with prescriptions within the measurement year (i.e., a prescription of 90 days supply dispensed on December 1 of the measurement year counts as 30 treatment days). Sum the days supply for all medications and subtract any days supply that extends beyond December 31 of the measurement year. Note: Medications dispensed in the year prior to the measurement year must be counted toward the 180 treatment days. Annual Monitoring for Members on ACE Inhibitors or ARBs Annual Monitoring for Members on Digoxin Annual Monitoring for Members on Diuretics Annual Monitoring for Members on Anticonvulsants The percentage of adults 18 and older who received at least 180 days of ACE or ARB drugs in the measurement year who had an annual monitoring test. The percentage of adults 18 and older who received at least 180 days of digoxin during the measurement year who had an annual monitoring test. The percentage of adults 18 and older who received at least 180 days of Diuretics during the measurement year who had an annual monitoring test. The percentage of adults 18 and older who received at least 180 days of Anticonvulsants during the measurement year who had relevant annual monitoring test(s) The Advisory Board Company 15

16 Medication (Continued) Heart Failure- ACE or ARB Therapy for Left Ventricular Systolic Dysfunction (LVSD): The percentage of adults with Congestive Heart Failure (CHF) and LVSD with received ACE or ARB drugs in the measurement year. Had evidence of the CHF diagnosis in the 24 months prior to the end of the measurement period. Evidence of the diagnosis must have one of the following: One or more acute care hospital stays with a principal diagnosis of CHF; or Two or more face-to-face encounters with a diagnosis of CHF. Members Age Years Old Who Had CHF and LVSD Who Received ACEI or ARB Drugs The percentage of adults with CHF and LVSD who received ACE or ARB drugs in the measurement year The Advisory Board Company 16

17 Muscoskeletal Conditions Use of Imaging Studies for Low Back Pain: The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, or CT scan) within 28 days of the diagnosis. Outpatient or ED visit with a primary diagnosis of low back pain. Use of Imaging Studies for Low Back Pain The percentage of adults with a primary diagnosis of low back pain who did not have an imaging study within 28 days of diagnosis The Advisory Board Company 17

18 Prevention & Screenings Breast Cancer Screening: The percentage of women years of age who had a mammogram to screen for breast cancer. None. Breast Cancer Screening Number of female members age who had a mammogram at least once within 24 months. Cervical Cancer Screening: The percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women age who can cervical cytology performed every 3 years None. Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years Cervical Cancer Screening The percentage of women years of age who received one or more Pap tests to screen for cervical cancer. Childhood Immunization Status: The percentage of children two years of age who had four diphtheria, tetanus, and acellular pertussis (DTaP); three polio (IPV); one measles, mumps, and rubella (MMR); three H influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two to three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. None. DTap Influenza Combination 2-Combination 10 Hepatitis A Hepatitis B The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines The Advisory Board Company 18

19 Prevention and Screening (Continued) Childhood Immunization Status (continued): HiB IPV MMR Pneumococcal Conjuagate Rotavirus VZW The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines. The percentage of children who turned 2 years during the measurement year and had specified vaccines Chlamydia Screening in Women: The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. Sexually active. Two methods identify sexually active women: pharmacy data and claim/encounter data. The organization must use both methods to identify the eligible population; however, a member only needs to be identified in one method to be eligible for the measure. Pharmacy Data Members who were dispensed prescription contraceptives during the measurement year. Claim/encounter Data- Members who had a claim or encounter indicating sexual activity during the measurement year. Chlamydia Screening in Women Ages Chlamydia Screening in Women Ages Chlamydia Screening in Women Ages The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. Glaucoma Screening in Older Adults: The percentage of Medicare members 65 years and older who received a glaucoma eye exam by an eye care professional for early identification of glaucomatous conditions. None. Glaucoma Screening in Older Adults The percentage of Medicare members 65 years and older who received a glaucoma eye exam by an eye care professional during the measurement year or the year prior to the measurement year The Advisory Board Company 19

20 Prevention & Screenings (Continued) Immunizations for Adolescents: The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids, and acellular pertussis vaccine (Tdap), or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday. The measure calculates a rate for each vaccine and one combination rate. None. One Tdap or Td Vaccine One Meningococcal Conjugate or Meningococcal Polysaccharide Vaccine Combination of One MEN Vaccine and One Tdap Vaccine or Td Vaccine The percentage of adolescents 13 years of age who had Tdap/Td vaccine by their 13th birthday. The percentage of adolescents 13 years of age who had Meningococcal vaccine by their 13th birthday The percentage of adolescents 13 years of age who had both Meningococcal and Tdap/Td vaccines by their 13th birthday. Lead Screening in Children: The percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. None. Lead Screening in Children The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday The Advisory Board Company 20

21 Respiratory Conditions Use of Appropriate Medications for People with Asthma: The percentage of members 5 64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. Identify members as having persistent asthma who met at least one of the following criteria during both the measurement year and the year prior to the measurement year (criteria need not be the same across both years): At least one ED visit with a principal diagnosis of asthma; At least one acute inpatient encounter with a principal diagnosis of asthma; At least four outpatient visits or observation visits on different dates of service, with any diagnosis of Asthma and at least two asthma medication dispensing events (visit type need not be the same for the four visits); and At least four asthma medication dispensing events. Ages 5-11 Ages Ages Ages The percentage of members years of age having persistent asthma who were appropriately prescribed medication. The percentage of members years of age having persistent asthma who were appropriately prescribed medication. The percentage of members years of age having persistent asthma who were appropriately prescribed medication. The percentage of members years of age having persistent asthma who were appropriately prescribed medication. Ages 5-64 The percentage of members 5-64 years of age having persistent asthma who were appropriately prescribed medication. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis: The percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Outpatient or ED visit with any diagnosis of acute bronchitis during the Intake Period. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Children 3 months-18 years of age with a upper respiratory infection diagnosis and were not dispensed an antibiotic prescription on or three days after the Episode Date. Appropriate Treatment for Children with Upper Respiratory Infection: The percentage of children 3 months 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. Outpatient or ED visit with only a diagnosis of URI during the Intake Period. Appropriate Treatment for Children with URI Children 3 months-18 years of age with a upper respiratory infection diagnosis and were not dispensed an antibiotic prescription on or three days after the Episode Date The Advisory Board Company 21

22 Use of Medication Generic Prescriptions- ADHD Medications: The percentage of generic prescriptions for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) compared to all ADHD prescriptions for members aged 18 years and above in the measurement year. At least one ADHD medication prescribing event during the measurement year. Generic ADHD Medication Use The percentage of ADHD prescription fills that were filled as Generic. Generic Prescriptions- Antihypertension Medications: The percentage of generic prescriptions for antihypertensive medications compared to all antihypertensive prescriptions for members aged 18 years and above in the measurement year. At least one prescribing event for an antihypertensive medication during the measurement year. Generic AHT Medication Use The percentage of AHT prescription fills that were filled as Generic. Generic Prescriptions- SSRIs: The percentage of generic Selective Serotonin Reuptake Inhibitors (SSRIs) prescriptions compared to all SSRI prescriptions for members aged 18 years and above in the measurement year. At least one prescribing event of SSRI during the measurement year. Generic SSRIs Medication Use The percentage of SSRI prescription fills that were filled as Generic. Generic Prescriptions- STATIN: The percentage of generic statin prescriptions compared to all statin prescriptions for members aged 18 years and above in the measurement year. At least one statin prescribing event during the measurement year. Generic STATIN Medication Use The percentage of STATIN prescription fills that were filled as Generic The Advisory Board Company 22

23 Use of Services Adolescent Well-Care Visits: The percentage of enrolled members years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. None. Adolescent Well-Care Visits The percentage of members years of age who had a well-care visit with a PCP or an OB/GYN in the measurement year. Ambulatory Care: This measure summarizes utilization of ambulatory care in the following categories: Outpatient Visits ED Visits None. Adults Access to Preventive/Ambulatory Health Services (20-44) Adults Access to Preventive/Ambulatory Health Services (45-64) Adults Access to Preventive/Ambulatory Health Services (Age 20+) Adults Access to Preventive/Ambulatory Health Services (65+) Members aged who had an ambulatory or preventive care visit Members aged who had an ambulatory or preventive care visit. Members aged who had an ambulatory or preventive care visit. Members age 65+ who had an ambulatory or preventive care visit The Advisory Board Company 23

24 Use of Services (Continued) Well-Child Visits in the First 15 Months of Life: The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP during their first 15 months of life: No well-child visits One well-child visits Two well-child visits Three well-child visits Four well-child visits Five well-child visits Six or More well-child visits None. Zero Well-Child Visits Children who had 0 well-child visits with a primary care practitioner during their first 15 months of life. One Well-Child Visits Children who had 1 well-child visit with a primary care practitioner during their first 15 months of life. Two Well-Child Visits Children who had 2 well-child visits with a primary care practitioner during their first 15 months of life Three Well-Child Visits Children who had 3 well-child visits with a primary care practitioner during their first 15 months of life. Four Well-Child Visits Children who had 4 well-child visits with a primary care practitioner during their first 15 months of life. Five Well-Child Visits Children who had 5 well-child visits with a primary care practitioner during their first 15 months of life. Six or More Well-Child Visits Children who had 6 or more well-child visits with a primary care practitioner during their first 15 months of life. Well-Child Visits in the Third, Fourth, Fifth and Sixth Year of Life: The percentage of members 3 6 years of age who had one or more well-child visits with a PCP during the measurement year. None. Well- Child Visits in the 3 rd, 4 th, 5 th and 6 th Years of Life Members 3-6 who had one or more well-child visits with a primary care practitioner 2016 The Advisory Board Company 24

25 Women s Health Prenatal and Postpartum Care: The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. Delivered a live birth on or between November 6 of the year prior to the measurement year and November 5 of the measurement year. Post Partum Care Prenatal Care Number of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. Number of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. Incidence of Episiotomy: The percentage of vaginal deliveries (excluding those coded with shoulder dystocia) during which an episiotomy is performed. All discharges with a diagnosis of vaginal delivery in any position on the claim, excluding discharges with a primary or secondary diagnosis of shoulder dystocia during delivery. Incidence of Episiotomy Number of episiotomy procedures performed on women undergoing a vaginal delivery (excluding those with shoulder dystocia) during the measurement year The Advisory Board Company 25

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