ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUP OVERVIEW

ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUP OVERVIEW 2014 PQRS OPTIONS F MEASURES GROUPS: 2014 PQRS MEASURES IN ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUP: #204. Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic #226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention #236. Controlling High Blood Pressure #241. Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (< 100 mg/dl) INSTRUCTIONS F REPTING: It is not necessary to submit the measures group-specific intent G-code for registry-based submissions. However, the measures group specific intent G-code has been created for registry only measure groups for use by registries that utilize claims data. G8547: I intend to report the Ischemic Vascular Disease (IVD) Measures Group Report the patient sample method: 20 Patient Sample Method via registries: 20 unique patients (a majority of which must be Medicare Part B FFS patients) meeting patient sample criteria for the measures group during the reporting period (January 1 through December 31, 2014 July 1 through December 31, 2014). Patient sample criteria for the IVD Measures Group are patients aged 18 years and older with a specific diagnosis of IVD accompanied by a specific patient encounter patients aged 18 years and older with a coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI): One of the following diagnosis codes indicating ischemic vascular disease: ICD-9-CM [for use 1/1/2014 9/30/2014]: 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.2, 414.8, 414.9, 429.2, 433.00, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31, 433.80, 433.81, 433.90, 433.91, 434.00, 434.01, 434.10, 434.11, 434.90, 434.91, 440.1, 440.20, 440.21, 440.22, 440.23, 440.24, 440.29, 440.4, 444.01, 444.09, 444.1, 444.21, 444.22, 444.81, 444.89, 444.9, 445.01, 445.02, 445.81, 445.89 ICD-10-CM [for use 10/1/2014-12/31/2014]: I20.0, I20.1, I20.8, I20.9, I21.11, I21.19, I21.21, I21.29, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.89, I25.9, I63.00, I63.011, I63.012, I63.019, I63.02, I63.031, I63.032, I63.039, I63.09, I63.10, I63.111, I63.112, I63.119, I63.12, I63.131, I63.132, I63.139, I63.19, I63.20, I63.211, I63.212, I63.219, I63.22, I63.231, I63.232, I63.239, I63.29, I63.30, I63.311, I63.312, I63.319, I63.321, I63.322, I63.329, I63.331, I63.332, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.419, I63.421, I63.422, I63.429, I63.431, I63.432, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.519, I63.521, I63.522, I63.529, I63.531, I63.532, I63.539, I63.541, I63.542, I63.549, I63.59, I63.6, I63.8, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.92, I74.01, I74.09, I74.10, I74.11, I74.19, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I75.89 Page 125 of 342

Diagnosis for acute myocardial infarction: (ICD-9-CM) [for use 01/1/2014-09/30/2014]: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91 (ICD-10-CM) [for use 10/01/2014-12/31/2014]: I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4 Accompanied by: One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402 One of the following coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) surgical procedure codes: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937, 92941, 92943 Report a numerator option on all applicable measures within the IVD Measures Group for each patient within the eligible professional s patient sample. Instructions for qualifying numerator option reporting for each of the measures within the Ischemic Vascular Disease (IVD) Measures Group are displayed on the next several pages. The following composite Quality Data Code (QDC) has been created for registries that utilize claims data. This QDC may be reported in lieu of individual QDCs when all quality clinical actions for all applicable measures within the group have been performed. Composite QDC G8552: All quality actions for the applicable measures in the Ischemic Vascular Disease (IVD) Measures Group have been performed for this patient To report satisfactorily the IVD Measures Group requires all applicable measures for each patient within the eligible professional s patient sample to be reported a minimum of once during the reporting period. Measures groups containing a measure with a 0% performance rate will not be counted as satisfactorily reporting the measures group. The recommended clinical quality action must be performed on at least one patient for each measure within the measures group reported by the eligible professional. Performance exclusion quality-data codes are not counted in the performance denominator. If the eligible professional submits all performance exclusion quality-data codes, the performance rate would be 0/0 and would be considered satisfactorily reporting. If a measure within a measures group is not applicable to a patient, the patient would not be counted in the performance denominator for that measure (e.g., Preventive Care Measures Group - Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older would not be applicable to male patients according to the patient sample criteria). If the measure is not applicable for all patients within the sample, the performance rate would be 0/0 and would be considered satisfactorily reporting. NOTE: The detailed instructions in this specification apply exclusively to the reporting and analysis of the included measures under the measures groups option. Page 126 of 342

Measure #204 (NQF 0068): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic DESCRIPTION: Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antithrombotic during the measurement period NUMERAT: Patients who have documentation of use of aspirin or another antithrombotic therapy Numerator Instructions: Oral antithrombotic therapy consists of aspirin, clopidogrel, combination of aspirin and extended release dipyridamole, prasugrel, ticagrelor or ticlopidine. NUMERAT NOTE: The performance period for this measure is 12 months. Numerator Options: Aspirin or another antithrombotic therapy used (G8598) Aspirin or another antithrombotic therapy not used, reason not given (G8599) Page 127 of 342

Measure #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention DESCRIPTION: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user NUMERAT: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user Definitions: Tobacco Use Includes use of any type of tobacco Cessation Counseling Intervention Includes brief counseling (3 minutes or less) and/or pharmacotherapy NUMERAT NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation counseling report 4004F with 8P. Numerator Options: Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (4004F) Current tobacco non-user (1036F) Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason) (4004F with 1P) Tobacco screening tobacco cessation intervention not performed, reason not otherwise specified (4004F with 8P) Page 128 of 342

Measure #236 (NQF 0018): Controlling High Blood Pressure DESCRIPTION: Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension (HTN) within the first six months of the measurement period and whose blood pressure (BP) was adequately controlled (< 140/90 mmhg) during the measurement period NUMERAT: Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg) during the measurement period Numerator Instructions: To describe both systolic and diastolic blood pressure values, each must be reported separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure. Only blood pressure readings performed by a clinician in the provider office are acceptable for numerator compliance with this measure. Do not include blood pressure readings that meet the following criteria: - Blood pressure readings from the patient's home (including readings directly from monitoring devices). - Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole). - Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy). If no blood pressure is recorded during the measurement period, the patient s blood pressure is assumed not controlled. Numerator Options: Systolic pressure (Select one (1) code from this section): Most recent systolic blood pressure < 140 mmhg (G8752) Most recent systolic blood pressure 140 mmhg (G8753) AND Diastolic pressure (Select one (1) code from this section): Most recent diastolic blood pressure < 90 mmhg (G8754) Most recent diastolic blood pressure 90 mmhg (G8755) Documentation of end stage renal disease (ESRD), dialysis, renal transplant or pregnancy (G9231) No documentation of blood pressure measurement, reason not given (G8756) Page 129 of 342

Measure #241 (NQF 0075): Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (< 100 mg/dl) DESCRIPTION: Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had each of the following during the measurement period: a complete lipid profile and LDL-C was adequately controlled (< 100 mg/dl) NUMERAT: Patients who received at least one lipid profile (or ALL component tests) with most recent LDL-C < 100 mg/dl NUMERAT NOTE: The performance period for this measure is 12 months from the date of service. Numerator Options: Lipid panel results documented and reviewed (must include total cholesterol, HDL-C, triglycerides and calculated LDL-C) (G8593) Note: If LDL-C could not be calculated due to high triglycerides, count as complete lipid profile. AND Most recent LDL-C < 100 mg/dl (G8595) Lipid profile not performed, reason not given (G8594) Lipid panel results documented and reviewed (must include total cholesterol, HDL-C, triglycerides and calculated LDL-C) (G8593) AND Most recent LDL-C 100 mg/dl (G8597) Page 130 of 342

ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUP RATIONALE AND CLINICAL RECOMMENDATION STATEMENTS Measure #204 - Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic RATIONALE: Coronary heart disease (CHD) is a major cause of death in the United States in 2004, it was an underlying or contributing cause of death for 451,300 people (1 of every 5 deaths). Acute myocardial infarction (AMI) was as an underlying or contributing cause of death for 156,000 people (American Heart Association 2008). In addition, nearly 16 million people (or 7.3 percent of the American population) had CHD in 2005 (American Heart Association 2008). The cost of cardiovascular diseases and stroke in the United States for 2008 was estimated at $448.5 billion (American Heart Association 2008). This figure includes health expenditures (direct costs such as the cost of physicians and healthcare practitioners, hospital and nursing home services, medications, home health care and other medical durables) and lost productivity resulting from morbidity and mortality (indirect costs). AMI accounts for 18 percent of hospital discharges and 28 percent of deaths due to heart disease (National Heart, Lung, and Blood Institute 2000). Research has shown that costs associated with cardiovascular disease for hospitals are easily $156 billion (American Heart Association 2008). Aspirin treatments reduce MI in men (127 events per 100,000 person-years) and women (17 events per 100,000 person-years) (Grieving et al. 2008). While studies have shown warfarin to be more effective, aspirin is a safer, more convenient, and less expensive form of therapy (Patrono et al. 2004). Aspirin therapy has been shown to directly reduce the odds of cardiovascular events among men by 14 percent and among women by 12 percent (Berger et al. 2006). Aspirin use has been shown to reduce the number of strokes by 20 percent, MI by 30 percent, and other vascular events by 30 percent (Weisman and Graham 2002). CLINICAL RECOMMENDATION STATEMENTS: U.S. Preventive Sevices Task Force (2009): The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk (5-year risk of greater than or equal to 3 percent) for coronary heart disease (CHD). Discussions with patients should address both the potential benefits and harms of aspirin therapy. The USPSTF found good evidence that aspirin decreases the incidence of coronary heart disease in adults who are at increased risk for heart disease. They also found good evidence that aspirin increases the incidence of gastrointestinal bleeding and fair evidence that aspirin increases the incidence of hemorrhagic strokes. The USPSTF concluded that the balance of benefits and harms is most favorable in patients at high risk of CHD (5-year risk of greater than or equal to 3 percent) but is also influenced by patient preferences. USPSTF encourages men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage. They encourage women age 55 to 79 years to use aspirin when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. American Diabetes Association (2008): Use aspirin therapy (75-162 mg/day) as a primary prevention strategy in those with type 1 or 2 diabetes at increased cardiovascular risk, including those who are 40 years of age or who have additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). American Heart Association/American Stroke Association (2006): AHA/ASA: The use of aspirin is recommended for cardiovascular (including but not specific to stroke) prophylaxis among persons whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (a 10- year risk of cardiovascular events of 6% to 10%). Page 131 of 342

American College of Clinical Pharmacy (2004): For long-term treatment after PCI, the guideline developers recommend aspirin, 75 to 162 mg/day. For long-term treatment after PCI in patients who receive antithrombotic agents such as clopidogrel or warfarin, the guideline developers recommend lower-dose aspirin, 75 to 100 mg/day. For patients with ischemic stroke who are not receiving thrombolysis, the guideline developers recommend early aspirin therapy, 160 to 325 mg/day. Measure #226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention RATIONALE: This measure is intended to promote adult tobacco screening and tobacco cessation interventions for those who use tobacco products. There is good evidence that tobacco screening and brief cessation intervention (including counseling and/or pharmacotherapy) is successful in helping tobacco users quit. Tobacco users who are able to stop smoking lower their risk for heart disease, lung disease, and stroke. CLINICAL RECOMMENDATION STATEMENTS: The following evidence statements are quoted verbatim from the referenced clinical guidelines: All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008) The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) (U.S. Preventive Services Task Force, 2009) Measure #236 - Controlling High Blood Pressure RATIONALE: Hypertension is a very significant health issue in the United States. Fifty million or more Americans have high blood pressure that warrants treatment, according to the National Health and Nutrition Examination Survey (NHANES) survey (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003). The United States Preventive Services Task Force (USPSTF) recommends that clinicians screen adults aged 18 and older for high blood pressure (United States Preventive Services Task Force 2007). Page 132 of 342

The most frequent and serious complications of uncontrolled hypertension include coronary heart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease, and retinopathy. The increased risks of hypertension are present in individuals ranging from 40 to 89 years of age. For every 20 mmhg systolic or 10 mmhg diastolic increase in blood pressure, there is a doubling of mortality from both ischemic heart disease and stroke (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003). Better control of blood pressure has been shown to significantly reduce the probability that these undesirable and costly outcomes will occur. The relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established. In clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence (35-40 percent), myocardial infarction incidence (20-25 percent) and heart failure incidence (>50 percent) (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003). CLINICAL RECOMMENDATION STATEMENTS: The United States Preventive Services Task Force (2007) recommends screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003): Treating systolic blood pressure and diastolic blood pressure to targets that are <140/90 mmhg is associated with a decrease in cardiovascular disease complications. Measure #241 - Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (< 100 mg/dl) RATIONALE: A 10 percent decrease in total cholesterol levels (population wide) may result in an estimated 30 percent reduction in the incidence of coronary heart disease (CHD) (Centers for Disease Control and Prevention 2000). Based on data from the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Less than half of persons who qualify for any kind of lipid-modifying treatment for CHD risk reduction are receiving it Less than half of even the highest-risk persons, those who have symptomatic CHD, are receiving lipid-lowering treatment Only about a third of treated patients are achieving their LDL goal; less than 20 percent of CHD patients are at their LDL goal (National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Pressure 2002) According to data from the Behavioral Risk Factor Surveillance System (BRFSS) from 1991 2003, the prevalence of cholesterol screening during the preceding 5 years increased from 67.3 percent in 1991 to 73.1 percent in 2003 (Centers for Disease Control and Prevention 2005). Between 1988 94 and 1999 2002, the age-adjusted mean total serum cholesterol level of adults20 years of age and older decreased from 206 mg/dl to 203 mg/dl, and LDL cholesterol levels decreased from 129 mg/dl to 123 mg/dl. The mean level of LDL cholesterol for American adults age 20 and older is 123 mg/dl (Carroll et al. 2005). However, even given this decrease, there is still a significant amount of room for improvement. CLINICAL RECOMMENDATION STATEMENTS: Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). (2001) AND Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. (2004) In high-risk persons, the recommended LDL-C goal is < 100 mg/dl. Page 133 of 342

An LDL-C goal of < 70 mg/dl is a therapeutic option on the basis of available clinical trial evidence, especially for patients at very high risk. If LDL-C is >100 mg/dl, an LDL-lowering drug is indicated simultaneously with lifestyle changes. If baseline LDL-C is < 100 mg/dl, institution of an LDL-lowering drug to achieve an LDL-C level < 70 mg/dl is a therapeutic option on the basis of available clinical trial evidence. If a high-risk person has high triglycerides or low HDL-C, consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. When triglycerides are > 200 mg/dl, non-hdl-c is a secondary target of therapy, with a goal 30 mg/dl higher than the identified LDL-C goal. The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders and recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. The USPSTF also strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease and recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Page 134 of 342