Performance Measurements
Breast Cancer Screening
A HEDIS®-like measure
Description: The percentage of women 40-69 years of age (as of 12/31 of the measurement year) who had a mammogram to screen for breast cancer.
Administrative Specification
Denominator: The eligible population.
Numerator: One or more mammograms during the measurement year or the year prior to the measurement year.
Cervical Cancer Screening
A HEDIS®-like measure
Description: The percentage of women 21-64 years of age (as of 12/31 of the measurement year) who received one of more Pap tests to screen for cervical cancer.
Administrative Specification
Denominator: The eligible population
Numerator: One or more Pap tests during the measurement year or the two years prior to the measurement year.
Chlamydia Screening in Women
A HEDIS®-like measure
Description: The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year.
Event/Diagnosis: 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.
Administrative Specification
Denominator: The eligible population.
Numerator: At least one Chlamydia test during the measurement year as documented through administrative data. A woman is counted as having had a test if she had a claim/encounter with a service data during the measurement year.
Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)
A HEDIS®-like measure
Description: 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 June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge.
Definition:
Treatment days (covered days): The actual number of calendar days covered with prescriptions within the specified 180-day measurement interval (i.e. a prescription of 90 days supply dispensed on the 100th day will have 80 days counted in the 180-day interval).
Eligible Population:
Event/Diagnosis: Discharged alive from an acute inpatient settling 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 though June 30 of the measurement year, the organization should only include the first discharge.
Administrative Specification
Denominator: The eligible population.
Numerator: A 180-day course of treatment with beta-blockers.
Identify all members in the denominator population whose dispensed days supply is ≥135 days in the 180 days following discharge. Persistence of treatment for this measure is defined as at least 75 percent of the days supply filled.
To determine continuity of treatment during the 180-days period, sum the number of allowed gap days to the number of treatment days for a maximum of 180 days (i.e., 135 treatment days + 45 gap days = 180 days); identify all prescriptions filled with 180 days of the Discharge Date.
To account for members who are on beta-blockers prior to admission, the organization should factor those prescriptions into adherence rates if the actual treatment days fall within the 180 days following discharge.
Comprehensive Diabetes Care (CDC)
A HEDIS®-like measure
Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following:
• Hemoglobin A1c (HbA1c) testing • LDL-C screening
• Eye exam (retinal) performed • Medical attention for nephropathy
Eligible Population:• Eye exam (retinal) performed • Medical attention for nephropathy
Event/Diagnosis: Two methods identify members with diabetes: pharmacy data and claim/encounter data. The organization must use both to identify the eligible population, but a member only needs to be identified in one 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.
Pharmacy Data: Members who were dispensed insulin or oral hypoglycemics/antihypercglycemics during the measurement year or year prior to the measurement year on an ambulatory basis.
Administrative Specification
Denominator: A systematic sample drawn from the eligible population for each product line.
Numerators:
HbA1c testing: An HbA1c test performed during the measurement years as identified by administrative data or medical record review.
Eye Exam: An eye screening for diabetic retinal disease as identified by administrative data or medical record review. This includes diabetics who had one of the following.
• A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year, or
• A negative retinal exam ( no evidence of retinopathy) by an eye care professional in the year prior to the measurement year
LDL-C Screening: An LDL-C test performed during the measurement year as identified by claim/encounter or automated laboratory data or medical record review.• A negative retinal exam ( no evidence of retinopathy) by an eye care professional in the year prior to the measurement year
Medical attention for nephropathy: A nephropathy screening test during the measurement year or evidence of nephropathy during the measurement year as documented through administrative data.
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
A HEDIS®-like measure
Description: The percentage of children 3 months -18 years of age who were given diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.
Calculation: The measure if reported as an inverted rate [1 – (numerator/eligible population)]. A higher rate indicates appropriate treatments of children with URI (i.e., the proportion for whom antibiotics were not prescribed).
Definitions:
Episode Date: The date of service for any outpatient or ED visit during the Intake period with only a diagnosis of URI. Excludes claims/encounters with more than one diagnosis.
IESD Index Episode Start Date: The earliest Episode Date during the Intake period that meets all of the following criteria.
• A 30-day Negative Medication History prior to the Episode Date
• A Negative Competing Diagnosis on or 3 days after the Episode Date
• The member was continuously enrolled 30 days prior to the Episode date through 3 days after the Episode Date
Negative Medication History: To qualify for Negative Medication History, the following criteria must be met.
• A Negative Competing Diagnosis on or 3 days after the Episode Date
• The member was continuously enrolled 30 days prior to the Episode date through 3 days after the Episode Date
• A period of 30 days prior to the Episode Date during which time the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug
• No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date
A prescription is considered active if the “days supply” indicated on the date when the member filled the prescription is the number of days or more between that date and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the Intake Period.• No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date
Negative Competing Diagnosis: The Episode date and three days following the Episode Date during which the member had no claims/encounters with any competing diagnosis.
Administrative Specification
Denominator: The eligible population.
Numerator: Dispensed prescription for antibiotic medication on or three days after the IESD.
Appropriate Testing for Children with Pharyngitis (CWP)
A HEDIS®-like measure
Description: 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).
Definitions:
Episode Date: The date of service for any outpatient or ED visits during the Intake period with only a diagnosis of pharyngitis. Exclude claims/encounters with more than one diagnosis.
IESD Index Episode Start Date: The earliest Episode Date during the Intake period that meets all of the following criteria:
• Linked to a dispensed antibiotic prescription on or during the three days after the Episode Date.
• A 30-day Negative Medication History prior to the Episode Date
• The member was continuously enrolled 30 days prior to the Episode Date through 3 days after the Episode Date
Negative Medication History: To qualify for Negative Medication History, the following criteria must be met.
• A 30-day Negative Medication History prior to the Episode Date
• The member was continuously enrolled 30 days prior to the Episode Date through 3 days after the Episode Date
• A period of 30 days prior to the Episode Date during which time the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug
• No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date
• No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date
A prescription is considered active if the “days supply” indicated on the date when the member filled the prescription is the number of days or more between that date and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the Intake Period.
Administrative Specification
Denominator: The eligible population.
Numerator: A group A streptococcus test in the seven-day period from three days prior to the IESD through three days after the IESD.