Appendix G
Starter Set of Measures

TABLE G-1 AQA Ambulatory Care Measures (26 measures)

Prevention Measures

1. Breast cancer screening

Percentage of women who had a mammogram during the measurement year prior to the measurement year

2. Colorectal cancer screening

Percentage of adults who had an appropriate screening for colorectal cancer. One or more of the following: FOBT during measurement year; flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year; DCBE during the measurement year or the four years prior; colonoscopy during the measurement year or nine years prior

3. Cervical cancer screening

Percentage of women who had one or more Pap tests during the measurement year or the two years prior

4. Tobacco use

Percentage of patients who were queried about tobacco use one or more times during the two-year measurement period

5. Advising smokers to quit

Percentage of patients who received advice to quit smoking

6. Influenza vaccination

Percentage of patients (ages 50–64 years) who received an influenza vaccination (Note: NQF also preliminarily approved this measure for patients 65+)

7. Pneumonia vaccination

Percentage of patients who ever received a pneumococcal vaccine

Coronary Artery Disease (CAD)

8. Drug therapy for lowering LDL cholesterol

Percentage of patients with CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines)

9. Beta-blocker treatment after heart attack

Percentage of patients hospitalized with acute myocardial infarction (AMI) who received an ambulatory prescription for beta-blocker therapy (within 7 days



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 204
Performance Measurement: Accelerating Improvement Appendix G Starter Set of Measures TABLE G-1 AQA Ambulatory Care Measures (26 measures) Prevention Measures 1. Breast cancer screening Percentage of women who had a mammogram during the measurement year prior to the measurement year 2. Colorectal cancer screening Percentage of adults who had an appropriate screening for colorectal cancer. One or more of the following: FOBT during measurement year; flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year; DCBE during the measurement year or the four years prior; colonoscopy during the measurement year or nine years prior 3. Cervical cancer screening Percentage of women who had one or more Pap tests during the measurement year or the two years prior 4. Tobacco use Percentage of patients who were queried about tobacco use one or more times during the two-year measurement period 5. Advising smokers to quit Percentage of patients who received advice to quit smoking 6. Influenza vaccination Percentage of patients (ages 50–64 years) who received an influenza vaccination (Note: NQF also preliminarily approved this measure for patients 65+) 7. Pneumonia vaccination Percentage of patients who ever received a pneumococcal vaccine Coronary Artery Disease (CAD) 8. Drug therapy for lowering LDL cholesterol Percentage of patients with CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines) 9. Beta-blocker treatment after heart attack Percentage of patients hospitalized with acute myocardial infarction (AMI) who received an ambulatory prescription for beta-blocker therapy (within 7 days

OCR for page 204
Performance Measurement: Accelerating Improvement   discharge) (Note: this measure was not reviewed by the NQF and therefore it is not approved) 10. Beta-blocker treatment—post–myocardial infarction Percentage of patients hospitalized with AMI who received persistent beta-blocker treatment (6 months after discharge) (Note: this measure was not reviewed by the NQF and therefore it is not approved) Heart Failure 11. ACE inhibitor/ARB therapy Percentage of patients with heart failure who also have LVSD who were prescribed ACE inhibitor or ARB therapy. Angiotensin receptor blocker (ARB) drugs are collected under this measure 12. LVF assessment Percentage of patients with heart failure with quantitative or qualitative results of LVF assessment recorded Diabetes NOTE: These measures were not approved during the NQF expedited review, as NQF has taken previous action on diabetes measures 13. HbA1c management Percentage of patients with diabetes with one or more A1c test(s) conducted during the measurement year 14. HbA1c management control Percentage of patients with diabetes with most recent A1c level greater than 9.0% (poor control) 15. Blood pressure management Percentage of patients with diabetes who had their blood pressure documented in the past year less than 140/90 mmHg 16. Lipid measurement Percentage of patients with diabetes with at least one low density lipoprotein cholesterol (LDL-C) test (or ALL component tests) 17. LDL cholesterol level (<130 mg/dL) Percentage of patients with diabetes with most recent LDL-C less than 100 mg/dL or less than 130 mg/dL 18. Eye exam Percentage of patients who received a retinal or dilated eye exam by an eye-care professional (optometrist or ophthalmologist) during the reporting year or during the prior year if patient is at low risk for retinopathy. A patient is considered low risk if all three of the following criteria are met: (1) the patient is not taking insulin; (2) has an A1c less than 8.0%; and (3) has no evidence of retinopathy in the prior year Asthma 19. Use of appropriate medications for people with asthma Percentage of individuals who were identified as having persistent asthma during the year prior to the measurement year and who were appropriately prescribed asthma medications (e.g. inhaled corticosteroids) during the measurement year 20. Pharmacologic therapy Percentage of all individuals with mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment

OCR for page 204
Performance Measurement: Accelerating Improvement Depression 21. Antidepressant medication management—Acute Phase Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug during the entire 84-day (12-week) Acute Treatment Phase 22. Antidepressant medication management—Continuation Phase Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug for at least 180 days (6 months) Prenatal Care 23. Screening for Human Immunodeficiency Virus Percentage of patients who were screened for HIV infection during the first or second prenatal visit 24. Anti-D immune globulin Percentage of D (Rh) negative, unsensitized patients who received anti-D immune globulin at 26–30 weeks gestation Quality Measures Addressing Overuse or Misuse 25. Appropriate treatment for children with upper respiratory infection (URI) Percentage of patients who were given a diagnosis of URI and were not dispensed an antibiotic prescription on or 3 days after the episode date 26. Appropriate testing for children with pharyngitis Percentage of patients who were diagnosed with pharyngitis, prescribed an antibiotic and who received a group A streptococcus test for the episode TABLE G-2 HQA Acute Care Measures (20 measures) NQF Endorsed Measures (39) Hospital Quality Alliance Publicly Reported Measures on CMS’ Hospital Compare Acute Coronary Syndrome 1. Aspirin at arrival for acute myocardial infarction (AMI) 2. Aspirin prescribed at discharge for AMI 3. Beta-blocker at arrival for AMI 4. Beta-blocker prescribed at discharge for AMI 5. AMI inpatient mortality   6. Angiotensin converting enzyme inhibitor (ACEI) for left ventricular systolic dysfunction (LVSD) 7. Percutaneous coronary intervention (PCI) within 120 minutes of arrival for AMI 8. Thrombolytic agent within 30 minutes of arrival for AMI 9. PCI volume   10. PCI mortality (risk-adjusted)   11. Coronary artery bypass graft (CABG) using internal mammary artery  

OCR for page 204
Performance Measurement: Accelerating Improvement NQF Endorsed Measures Hospital Quality Alliance Publicly Reported Measures on CMS’ Hospital Compare 12. CABG volume   13. CABG mortality (risk adjusted) Heart Failure 14. Left ventricular function (LVF) assessment 15. Detailed discharge instructions 16. ACEI for LVSD Patient Safety 17. Urinary catheter-associated urinary tract infection for intensive care unit patients   18. Central line catheter-associated blood stream infection for intensive care unit patients 19. Ventilator-associated pneumonia for intensive care unit patient 20. Patient falls (per 1,000 patient days) Pediatric Conditions 21. Use of relievers for inpatient asthma   22. Use of systemic corticosteroids for inpatient asthma 23. Neonate immunization administration Pneumonia 24. Oxygenation assessment 25. Initial antibiotic consistent with current recommendations 26. Blood culture collected prior to first antibiotic administration 27. Influenza screen or vaccination   28. Pneumonia screen or pneumococcal vaccination for adults over 65 29. Antibiotic timing Pregnancy/Childbirth/Neonatal Conditions 30. Vaginal birth after cesarean delivery rate   31. Cesarean delivery rate 32. Third- or fourth-degree laceration 33. Neonatal mortality Smoking Cessation 34. Smoking cessation advice/counseling for AMI patients 35. Smoking cessation advice/counseling for heart failure patients 36. Smoking cessation advice/counseling for pneumonia patients Surgical Complications 37. Timing of antibiotic administration (surgical patients) 38. Selection of antibiotic administration (surgical patients)   39. Duration of prophylaxis (surgical patients) Starter set measures.

OCR for page 204
Performance Measurement: Accelerating Improvement TABLE G-3 HEDIS 2005 Measures Effectiveness of Care Childhood immunization statusH Estimates the percentage of children enrolled in managed care plans who turned 2 years old during measurement year and had the following vaccinations: 4 doses of DTP or DTAP (diphtheria-tetanus); 3 doses of OPV or IPV (polio); 1 dose MMR (measles-mumps-rubella); 2 doses of Hib (Haemophilus influenza type b), 3 doses of hepatitis B and one varicella vaccination Adolescent immunization statusH Percentage of enrolled adolescents who turn 13 years old during the measurement year who had a second dose of MMR and three hepatitis B vaccinations, and one varicella vaccination by their 13th birthday Appropriate treatment for children with upper respiratory infection (URI)A Percentage of children 3 months–18 years of age who were given a diagnosis of URI and who did not receive an antibiotic prescription for that episode of care within 3 days of the visit Appropriate testing for children with pharyngitisA Percentage of children 2–18 years of age who were diagnosed with pharyngitis, prescribed an antibiotic and who received a Group A streptococcus test Colorectal cancer screeningH Percentage of adults 50–80 years of age who have had appropriate screening for colorectal cancer. The screening criteria can be met with any one of four tests: a fecal occult blood test (FOBT) during the measurement year; a flexible sigmoidoscopy within the last 5 years (the measurement year or the 4 years prior to the measurement year); a double contrast barium enema within the last 5 years; or a colonoscopy within the last 10 years (the measurement year or the 9 years prior to the measurement year) Breast cancer screeningH Percentage of women aged 52–69 years (as of Dec 31 of the measurement year) who had at least one mammogram in the past 2 years Cervical cancer screeningH Percentage of women aged 21–64 years (as of Dec 31 of the measurement year) who were enrolled in a health plan and who had one Pap test in the past 3 years Chlamydia screening in womenA Percentage of sexually active female plan members who had at least one test for chlamydia during the previous year. The measure is collected separately for women aged 16–20 and 21–25 years Osteoporosis management in women who had a fractureA Percentage of women 67 years of age and older who suffered a fracture and who had either a bone mineral density test or prescription for a drug to treat or prevent osteoporosis in the 6 months after the date of the fracture. Applies only to Medicare plans Controlling high blood pressureH In the percentage of enrolled adults aged 46–85 years who have diagnosed hypertension and whose blood

OCR for page 204
Performance Measurement: Accelerating Improvement   pressure was adequately controlled. Adequate control was defined as a blood pressure of 140/90 or lower. Both the systolic and diastolic pressure must have been at or under these thresholds for the person’s blood pressure to be considered controlled Beta-blocker treatment after a heart attackH Percentage of members 35 years and older who were hospitalized and discharged alive during the measurement year with a diagnosis of a heart attack and who received a prescription for a beta-blocker upon discharge Persistence of beta-blocker treatment after a heart attackA The percentage of members 35 years and older who were discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of a heart attack and who received persistent beta-blocker treatment. Persistent treatment is defined as receiving treatment for 6 mos after the discharge Cholesterol management after acute cardiovascular eventH, C Percentage of health plan members 18–75 years of age who had evidence of an acute cardiovascular event and whose LDL-C was screenedH; controlled to less than 130 mg/dLC in the year following the event; and controlled to less than 100 mg/dLC Comprehensive diabetes careH, C Percentage of members with type 1 and type 2 diabetes who were 18–75 years old and, during the measurement year, had a hemoglobin A1c (HbA1c) test H; an HbA1c level greater than 9 C; a serum cholesterol level (LDL-C) screening H; a cholesterol level (LDL-C) controlled to less than 130mg/dL C; their cholesterol level controlled to less than 100 mg/dL C; an eye exam H; and a screening for kidney disease H Use of appropriate medications for people with asthmaA Percentage of enrolled members 5–56 years of age who were identified as having persistent asthma and who were prescribed appropriate medication. Measure is also collected separately for children (aged 5–9), adolescents (aged 10–17), and adults (aged 18–56) Follow-up after hospitalization for mental illnessA Percentage of members 6 years of age and older who had a follow-up visit after being discharged for an inpatient mental health stay. Includes hospitalizations for depression, schizophrenia, attention deficit disorder, and personality disorders. Measure looks at both 7-day and 30-day follow-up rates Antidepressant medication managementA Three components of the measure estimate: Optimal Practitioner Contacts: Percentage of adult members who received antidepressant medication and had at least 3 follow-up visits during the 12-week

OCR for page 204
Performance Measurement: Accelerating Improvement   acute treatment phase after diagnosis of a new episode of depression Continuation Phase: Percentage of eligible members who remained on antidepressant medication continuously the 6 months after diagnosis of a new episode of depression Acute Phase: Percentage of adult members who remained on antidepressant medication during the entire 12-week acute treatment phase after diagnosis of a new episode of depression Glaucoma screening in older adultsA The percentage of Medicare members 65 years and older without a prior diagnosis of glaucoma or glaucoma suspect who received a glaucoma eye exam in the last two years by an eye-care professional for early identification of persons with glaucomatous conditions. An eye-care professional is an ophthalmologist or optometrist Use of imaging studies for low back painA This measure assesses whether imaging studies (plain X-ray, MRI, CT scan) are overused in evaluating patients with acute low back pain Medical assistance with smoking cessationS Three components: (1) Percentage of smokers or recent quitters who received advice to quit smoking from their practitioner; (2) Percentage whose practitioner discussed smoking cessation medications; and (3) Percentage whose practitioner discussed smoking cessation strategies Flu shots for adults (ages 50–64)S The percentage of commercial members 50–64 years of age as of September 1 of the measurement year who received an influenza vaccination between September 1 of the measurement year and the date on which the CAHPS 3.0H Adult Survey was completed Flu shots for older adultsS The percentage of Medicare members 65 years of age and older as of January 1 of the measurement year who received an influenza vaccination from September 1–December 31 of the year prior to the measurement year Pneumonia vaccination status for older adultsS The percentage of Medicare members 65 years of age and older as of January 1 of the measurement year who received a pneumococcal vaccine Medicare Health Outcomes SurveyS This measure provides a general indication of how well a Medicare MCO manages the physical and mental health of its members. The survey measures each member’s physical and mental health status at the beginning and the end of a 2-year period

OCR for page 204
Performance Measurement: Accelerating Improvement   A 2-year change score is calculated and each member’s physical and mental health status is categorized as better, the same, or worse than expected, taking into account risk adjustment factors. MCO-specific results are assigned as percentages of members whose health status was better, the same, or worse than expected Management of urinary incontinence in older adultsS Discussing Urinary Incontinence. The percentage of Medicare members 65 years of age and older who reported having a problem with urine leakage in the last 6 months and who discussed their urine leakage problem with their current practitioner Receiving Urinary Incontinence Treatment. The percentage of Medicare members 65 years of age and older who reported having a urine leakage problem in the last 6 months and who received treatment for their current urine leakage problem Physical activity in older adultsS Discussing Physical Activity. The percentage of Medicare members 65 years of age and older who had a doctor’s visit in the last 12 months and who spoke with a doctor or other health provider about their level of exercise or physical activity Advising Physical Activity. The percentage of Medicare members 65 years of age and older who had a doctor’s visit in the last 12 months and who received advice to start, increase, or maintain their level of exercise or physical activity Access/Availability of Care Adults’ access to preventive/ambulatory health servicesA The percentage of enrollees 20–44, 45–64, and 65 years of age and older who had an ambulatory or preventive care visit. The MCO reports the percentage of: Medicaid and Medicare enrollees who had an ambulatory or preventive care visit during the measurement year Commercial enrollees who had an ambulatory or preventive care visit during the measurement year or the 2 years prior to the measurement year Children and adolescents’ access to primary care practitionersA The percentage of enrollees 12–24 months, 25 months–6 years, 7–11 years, and 12–19 years of age who had a visit with an MCO primary care practitioner. The MCO reports: children 12–24 months and 25 months–6 years of age who had a visit with an MCO primary care practitioner during the measurement year

OCR for page 204
Performance Measurement: Accelerating Improvement   children 7–11 and adolescents 12–19 years of age who had a visit with an MCO primary care practitioner during the measurement year or the year prior to the measurement year Prenatal and postpartum careH Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the MCO in the first trimester or within 42 days of enrollment in the MCO Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery Annual dental visitA The percentage of enrolled members 2–21 years of age who had at least one dental visit during the measurement year. This measure applies only if dental care is a covered benefit in the MCO’s Medicaid contract Initiation and engagement of alcohol and other drug dependence treatmentA This measure calculates two rates using the same population of members with Alcohol and Other Drug (AOD) dependence: Initiation of AOD Dependence Treatment: The percentage of adults diagnosed with AOD dependence who initiate treatment through either: an inpatient AOD admission, or an outpatient service for AOD dependence and additional AOD services within 14 days Engagement of AOD Treatment is an intermediate step between initially accessing care (initiation treatment) and completing a full course of treatment. This measure is designed to assess the degree to which members engage in treatment with two additional AOD services within 30 days after initiation Claims timelinessA The percentage of all claims received by the MCO or its claims processing centers January 1 through December 1 of the measurement year that were paid or denied within 30 calendar days of receipt. This includes all MCO claims delegates (e.g., keying centers, clearinghouses) Call answer timelinessA The percentage of calls received by the MCO’s member services call centers (during member services operating hours) during the measurement year that were answered by a live voice within 30 seconds Call abandonmentA The percentage of calls received by the MCO’s member services call centers (during member services operating hours) during the measurement year that were abandoned by the caller before being answered by a live voice

OCR for page 204
Performance Measurement: Accelerating Improvement Satisfaction with the Experience of Care CAHPS 3.0H Adult SurveyS This measure assesses commercial and Medicaid members’ satisfaction with the MCO. Results summarize member experiences through ratings, composites, and individual question summary rates Four global rating questions reflect overall satisfaction with the following: Rating of All Health Care Rating of Health Plan Rating of Personal Doctor Rating of Specialist Seen Most Often Six composite scores summarize responses in key areas: Claims Processing Courteous and Helpful Office Staff Customer Service Getting Care Quickly Getting Needed Care How Well Doctors Communicate CAHPS 3.0H Child SurveyS This measure assesses parents’ satisfaction with their child’s MCO. Results summarize member experiences through ratings, composites, and individual question summary rates Four global rating questions reflect overall satisfaction with the following: Rating of All Health Care Rating of Health Plan Rating of Personal Doctor Rating of Specialist Seen Most Often Six composite scores summarize responses in key areas: Claims Processing Courteous and Helpful Office Staff Customer Service Getting Care Quickly Getting Needed Care How Well Doctors Communicate Children with Chronic ConditionsS This measure assesses parents’ satisfaction with their child’s MCO for the population of children with chronic conditions. Six composites summarize satisfaction with basic components of care essential for successful treatment, management, and support of children with chronic conditions: Access to Prescription Medicines Access to Specialized Services Family Centered Care: Personal Doctor or Nurse Who Knows Child

OCR for page 204
Performance Measurement: Accelerating Improvement   Family Centered Care: Shared Decision Making Family Centered Care: Getting Needed Information Coordination of Care ECHO 3.0H Survey for MBHOsS A standardized survey that assesses MBHO enrollee experiences with behavioral health care, including mental health and chemical dependency services Results are summarized through ratings, composites, and question summary rates: Global Question Rating. Rating of Counseling and Treatment Composite Scores. Getting Treatment Quickly How Well Clinicians Communicate Access to Treatment and Information from the MBHO Informed About Treatment Options Question Summary Rates. Office Wait Times Informed About Medication Side Effects Received Information About Managing Condition Informed About Patient Rights Ability to Refuse Medicine or Treatment Health Plan StabilityA Practitioner turnoverA From the MCO provider database: the percentage of primary care physicians affiliated with the MCO as of December 31 of the year prior to the measurement year who were not affiliated with the MCO as of December 31 of the measurement year the percentage of nonphysician primary care practitioners affiliated with the MCO as of December 31 of the year prior to the measurement year who were not affiliated with the MCO as of December 31 of the measurement year For the Medicaid product line only, the MCO also reports the same percentages for the following practitioners: OB/GYN and other prenatal care practitioners chemical dependency practitioners mental health practitioners dentists Years in business/total membershipA The number of years since licensure (the number of years that each product line has existed) and the number of members enrolled as of December 31 of the measurement year. The number of years of operation

OCR for page 204
Performance Measurement: Accelerating Improvement   should be considered when evaluating the MCO’s financial profile. For example, a new MCO may have a greater level of debt than a more mature MCO, and financial profiles may vary according to MCO type (e.g., staff model HMO, POS, IPA) Use of ServiceA Frequency of ongoing prenatal careH The percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year and received <21 percent, 21–40 percent, 41–60 percent, 61–80 percent or ≥81 percent of the expected number of prenatal care visits, adjusted for gestational age and the month that the member enrolled in the MCO. This measure uses the same denominator and deliveries as the Prenatal and Postpartum Care measure. For these deliveries, the MCO: identifies the actual number of prenatal care visits rendered while they were enrolled in the MCO identifies the number of expected visits calculates the ratio of received-to-expected visits reports an unduplicated count of deliveries had <21 percent; 21–40 percent, 41–60 percent, 61–80 percent or ≥81 percent of the number of expected visits, adjusted for the month the member enrolled and the MCO and gestational age. The MCO reports five rates Well-child visits in the first 15 months of lifeH The percentage of enrolled members who turned 15 months old during the measurement year and who had the following number of well-child visits with a primary care practitioner during their first 15 months of life: zero; one; two; three; four; five; six or more Well-child visits in the third, fourth, fifth, and sixth years of lifeH The percentage of members who were three, four, five, or six years of age during the measurement year who received one or more well-child visits with a primary care practitioner during the measurement year Adolescent well-care visitsH The percentage of enrolled members who were 12–21 years of age who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year Frequency of selected proceduresA This measure provides a summary of the number and rate of several frequently performed procedures—myringotomy, tonsillectomy, nonobstetric dialation and curettage, hysterectomy, cholecystectomy, laminectomy/diskectomy, angioplasty, cardiac catheterization, coronary artery bypass graft, pros

OCR for page 204
Performance Measurement: Accelerating Improvement   tatectomy, reduction of fracture of femur, total hip replacement, total knee replacement, partial excision of large intestine, carotid endarterectomy These procedures often show wide regional variation and have generated concern regarding potentially inappropriate utilization For Medicaid members, the MCO reports the absolute number of procedures and the number of procedures per 1,000 member months For commercial and Medicare members, the MCO reports the absolute number of procedures and the number of procedures per 1,000 members per year Inpatient utilization—general hospital/acute careA This measure summarizes utilization of acute inpatient services in the following categories: total services medicine surgery maternity Nonacute care, mental health and chemical dependency services, as well as newborn care, are excluded. Medical and surgical services are reported separately because the factors influencing utilization in these two categories vary. This method also facilitates comparisons between ambulatory surgery utilization (refer to the Ambulatory Care measure) and inpatient surgery utilization Ambulatory careA This measure summarizes utilization of ambulatory services in the following categories: outpatient visits emergency department visits ambulatory surgery/procedures performed in hospital, outpatient facilities or freestanding surgical centers observation room stays that result in discharge (observation room stays resulting in an inpatient admission are counted in the Inpatient Utilization—General Hospital/Acute Care measure) Inpatient utilization—nonacute careA This measure summarizes utilization of nonacute inpatient care in hospice, nursing home, rehabilitation, SNF, transitional care and respite. These data exclude services with a principal diagnosis of mental health and chemical dependency Discharge and average length of stay—maternity careA Utilization of maternity-related care for enrolled females who had live births during the measurement year, reported for total deliveries, vaginal deliveries and Cesarean section (C-section) deliveries

OCR for page 204
Performance Measurement: Accelerating Improvement Births and average length of stay, newbornsA This measure summarizes utilization information about newborns discharged during the measurement year and reports information for total newborns, well newborns and complex newborns Newborns are identified and reported separately from maternity members. Newborn care is care provided from birth to discharge to home. If a newborn is transferred from one hospital to another and has never gone home, the care is still newborn care. Newborn care that is rendered after the baby has been discharged should be reported in Table IPU-A (Inpatient Utilization—General Hospital/Acute Care) Include newborns delivered in an inpatient setting and at birthing centers. For newborns delivered in birthing centers, count one day of stay Some MCOs do not keep separate records on well newborns that leave the hospital at the same time as their mothers. The MCO must develop a methodology to estimate the number of well newborns for whom the MCO does not produce separate discharge records. For example, the mother’s length of stay can be used as a proxy for the well newborn’s length of stay. The MCO must provide documentation for the approach used Mental health utilization—inpatient discharges and average length of stayA This measure summarizes utilization of inpatient mental health services, stratified by age and sex Mental health utilization—percentage of members receiving servicesA The number and percentage of members receiving the following during the measurement year: any mental health services (includes inpatient, intermediate or ambulatory) inpatient mental health services intermediate mental health services ambulatory mental health services Report in each category the number of members who received the respective service and, of all enrollees with a mental health benefit, the percentage who received the respective service; report this information by age and sex. This measure gives an overview of the extent to which different levels of mental health services are utilized Chemical dependency utilization—inpatient discharges and average length of stayA This measure summarizes utilization of inpatient chemical dependency services, stratified by age and sex

OCR for page 204
Performance Measurement: Accelerating Improvement Identification of alcohol and other drug servicesA The number and percentage of members with an alcohol and other drug (AOD) claim. AOD claims contain a diagnosis of AOD abuse or dependence and a specific AOD-related service during the measurement year, in the following categories: any chemical dependency services (includes inpatient, intermediate, ambulatory) Reported by age and sex: the number of members in each category who received the service from all enrollees with a chemical dependency benefit, the percentage of members who received the service Outpatient drug utilizationA A summary of the data on outpatient utilization of drug prescriptions (total cost of prescriptions; average cost of prescriptions per member per month [PMPM]; total number of prescriptions; average number of prescriptions per member per year [PMPY]) during the measurement year, stratified by age Cost of Care Informed Health Care Choices Health Plan Descriptive InformationA   Board certificationA The percentage of the following physicians who are board certified: primary care physicians OB/GYN physicians pediatric physician specialists geriatricians all other physician specialists Board certification refers to the various specialty certification programs of the American Board of Medical Specialties and the American Osteopathic Association. The MCO should report separately for each product as of December 31 of the measurement year Total enrollment by percentageA This measure provides an overview of the mix of MCO membership. The MCO reports the percentage of total member months contributed by each product by age and sex during the measurement year Medicaid: Members enrolled through a contract between the state Medicaid agency and the MCO. Members eligible for Medicaid and Medicare should be counted under both products Commercial: Members enrolled through an employer group policy or individual policy Medicare: Members enrolled through a contract between CMS and the MCO. Members eligible

OCR for page 204
Performance Measurement: Accelerating Improvement   for both Medicare and Medicaid should also be counted under Medicare if the MCO has a Medicare contract Other: Members not classified as Medicaid, commercial, or Medicare Enrollment by product lineA This measure reports the total number of members enrolled for each product line stratified by age and sex Medicaid is reported in the member months contributed by enrollees during the measurement year, it is stratified by Medicaid eligibility category, age and sex. The MCO may report this information only if it is provided by the state Medicaid agency Medicare and commercial are reported in the number of member years contributed by enrollees during the measurement year, stratified by product line, age, and sex Unduplicated count of Medicaid membersA Provides state Medicaid agencies with information that enables them to calculate by age, sex, and Medicaid eligibility category the average number of months Medicaid beneficiaries spent in the MCO. The MCO reports an unduplicated count of the number of all Medicaid members enrolled during any part of the measurement year, stratified by age, sex, and eligibility category Diversity of Medicaid membershipA The number and percentage of Medicaid members enrolled at any time during the measurement year by race/ethnicity, Hispanic origin, and spoken language. The MCO may report this information only if is furnished to them by their state Medicaid agencies Weeks of pregnancy at time of enrollment in the MCOH The percentage of all enrolled women who delivered a live birth during the measurement year by the weeks of pregnancy at the time of their enrollment in the MCO, according to the following categories: prior to pregnancy (280 days or more prior to delivery) the first 12 weeks of pregnancy, including the end of the 12th week (279–196 days prior to delivery) the beginning of the 13th week through the end of the 27th week of pregnancy (195–91 days prior to delivery) the beginning of the 28th week of pregnancy or after (90 days or fewer prior to delivery) Medicare Advantage PPOs—data collection requirements. AAdministrative data. HHybrid (administrative specifications, optionally augmented by chart record abstraction). CChart abstraction—2008 target. SSurvey data.

OCR for page 204
Performance Measurement: Accelerating Improvement TABLE G-4 MDS Publicly Reported Measures on CMS’ Nursing Home Compare (15 measures) Long-Term Measures 1. Activities of daily living Percentage of residents whose need for help with daily activities has increased 2. Pain Percentage of residents who have moderate to severe pain 3 & 4. Pressure sores Percentage of high-risk residents who have pressure sores   Percentage of low-risk residents who have pressure sores 5. Restraint use Percentage of residents who were physically restrained 6. Depressed or anxious Percentage of residents who are more depressed or anxious 7. Incontinence Percentage of low-risk residents who lose control of their bowels or bladder 8. Indwelling catheters Percentage of residents who have/had a catheter inserted and left in their bladder 9. Bedfast Percentage of residents who spent most of their time in bed or in a chair 10. Ambulation/locomotion Percentage of residents whose ability to move about in and around their room got worse 11. Urinary tract infections Percentage of residents with a urinary tract infection 12. Weight loss Percentage of residents who lose too much weight Short-Stay Measures 13. Delirium symptoms Percentage of short-stay residents with delirium 14. Pain Percentage of short-stay residents who had moderate to severe pain 15. Pressure sores Percentage of short-stay residents with pressure sores TABLE G-5 OASIS Publicly Reported Measures on CMS’ Home Health Compare (11 measures) 1. Improvement in ambulation/locomotion Patients who get better at walking or moving around in a wheelchair safely 2. Improvement in transferring Patients who get better at getting in and out of bed 3. Improvement in toileting Patients who get better getting to and from the toilet 4. Improvement in pain interfering with activity Patients who have less pain when moving around 5. Improvement in bathing Patients who get better at bathing 6. Improvement in management of oral medications Patients who get better at taking their medications correctly (by mouth) 7. Improvement in upper body dressing Patients who get better at getting dressed 8. Stabilization in bathing Patients who stay the same (don’t get worse) at bathing 9. Acute care hospitalization Percentage of patients who had to be admitted to the hospital 10. Emergent care Percentage of patients who need urgent, unplanned medical care 11. Improvement in confusion frequency Patients who are confused less often

OCR for page 204
Performance Measurement: Accelerating Improvement TABLE G-6 NHQR’s ESRD Measures (5 measures) Process Percentage of dialysis patients registered on a waiting list for transplantation   Percentage of patients with treated chronic kidney failure who receive a transplant within 3 years of renal failure Outcome Percentage of hemodialysis patients with urea reduction ratio of 65 or greater   Percentage of patients with hematocrit of 33 or greater   Patient survival rate