Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act (2004)

STRUCTURAL MEASURES

PROCESS MEASURES

Counseling and testing

HIVQUAL

Counseling on high-risk behaviors

RAND

Tobacco use assessment

HIVQUAL

CD4+ cell count

HCSUS

CD4+ cell count

IHI

CD4+ cell count

UHC

CD4+ cell count and HIV viral load

FACCT

CD4+ cell count and HIV viral load

IDSA

CD4+ cell count and HIV viral load

QUERI

CD4+ cell count and HIV viral load

RAND

CD4+ cell count and HIV viral load

RAND

CD4+ cell count and HIV viral load

UHC

Cervical cancer

EQHIV

Pregnant women

The number of pregnant women with counseling offered and testing performed during the prenatal period

All

Counseled regarding high risk behavior at time of HIV diagnosis and within one month of presentation with an initial infection of STD

All

Number of patients with whom tobacco use was discussed during the past year

All

At least one CD4+ cell count determination per studied 6 month interval, by chart review or interview

All

Percent with CD4+ cell count taken in the past 6 months

All

Semi-annual CD4+ cell count attainment (most recent 6 months)

1) If CD4+ cell count > 300 cells/µL; 2) If CD4+ cell count <300 cells/µL

1) CD4+ cell count and HIV viral load every 6 months; 2) CD4+ cell count and HIV viral load every 3 months

Patients being followed actively (having at least 1 visit in last 6 months)

Percent with CD4+ cell count and HIV viral load; every 3–4 months when CD4+ cell count is <350/µL or every 6–7 months when CD4+ cell count is >350/µL

1) Patients on HAART; 2) All

1) CD4+ cell count or HIV viral load test every 3 months; 2) CD4+ cell count or HIV viral load test every 6 months

CD4+ cell count > 300 cells/µL

Offer of CD4+ test (count or percent) and HIV viral load every 6 months

patients with detectable HIV viral loads

Offer HIV viral load every 4 months

All

1 each (CD4+ cell count and HIV viral load) in 2 consecutive 6-month periods

All females

Documentation of Pap smear or colposcopy

Cervical cancer

EQHIV

Cervical cancer

FACCT

Cervical cancer

HCSUS

Cervical cancer

IDSA

Cervical cancer

IHI

Cervical cancer

UHC

Cervical cancer and other pelvic disease

HIVQUAL

Complete blood count

FACCT

Complete blood count, CD4+ cell count, HIV viral load

RAND

Complete blood count, CD4+ cell count, HIV viral load

RAND

Cytomegalovirus disease

FACCT

Cytomegalovirus disease

HCSUS

Cytomegalovirus disease

RAND

Hepatitis A

QUERI

Hepatitis B

FACCT

Hepatitis B

QUERI

Hepatitis B

UHC

Hepatitis B and C

IHI

Hepatitis C

EQHIV

Hepatitis C

EQHIV

Hepatitis C

FACCT

Females with abnormal Pap smear

Repeat of Pap smear

All females

Annual Pap smear

All females

All Pap smears according to guidelines (currently baseline, 6 months, and every 12 months thereafter if normal)

HIV-infected adult and adolescent women being followed

Percent who had at least one Pap smear done in the past year

All females

Percent with Pap smear in last 6 months

All females

Percent with Pap smear (between 9/2000 and 9/2001)

All females 18 years or older AND sexually active female patients 13 to 18 years of age

Number of patients with a pelvic exam recorded in the last year (pelvic exam includes Pap smear; chlamydia screen; gonorrhea test)

All

Complete blood count at first visit

All

Offer baseline laboratories (complete blood count, HIV viral load, CD4+ cell count) within one month of initial diagnosis

Patients on antiretroviral therapy

Offer CD4+ cell count or percent, HIV viral load and complete blood count within past 4 months

1) All; 2) CD4+ cell count less than 200 cells/µL

1) Cytomegalovirum IgG determination; 2) Annual fundoscopic exam

All, as indicated

Fundoscopic exam by eye care provider

Lowest recorded CD4+ cell count of less than 100 cells/µL

Receipt of yearly fundoscopic exam

All

Receipt of hepatitis A test (ever)

All

Hepatitis B antibody determination

All

Receipt of hepatitis B test (ever)

All

Hepatitis B serology attainment (ever)

All

Percent with hepatitis B & C screening

All

Hepatitis C status was known (whether positive or negative)

All

Appropriate hepatitis C screening

All

Hepatitis C antibody determination

Hepatitis C

HIVQUAL

Hepatitis C

HIVQUAL

Hepatitis C

HIVQUAL

Hepatitis C

QUERI

Hepatitis C

UHC

HIV Specialist Visits

HIVQUAL

Lipid screening (for disease and drug related metabolic abnormalities)

HIVQUAL (optional measure)

Lipid screening (for disease and drug related metabolic abnormalities)

QUERI

Oral Health / Dental exam

HIVQUAL (optional measure)

Outpatient visits

IHI*

Outpatient visits

EQHIV

Syphilis

FACCT

Syphilis

HCSUS

Syphilis

HIVQUAL

Syphilis

HIVQUAL

Syphilis

HIVQUAL

All

The number of patients for whom hepatitis C was document in the medical record

HCV+ patients

The number for whom alcohol counseling and HCV education was provided

All

The number of patients for whom hepatitis A status was documented.

All

Receipt of hepatitis C test (ever)

All

Hepatitis C serology attainment (ever)

All; with exception of those either incarcerated or hospitalized and with no ambulatory clinic visits during 4-month review period

Number of patients who are seen by an HIV specialist at least once every 4 months

Patients receiving antiretroviral therapy

The number of patients for whom lipid screen was performed during the past year

Patients on protease inhibitors (PI) or nonnucleoside reverse transcriptase inhibitors (NNRTI) for consecutive months

Receipt of lipid panel testing

All

The number of patients with a dental exam documented during the past year

All

Percent with visit(s) in last 3 months

All

Have outpatient visits in 3 or 4 quarter during review period.

All

Serologic test for syphilis measured at least once

All

Any serologic test for syphilis performed

All patients 18 years or older AND sexually active patients 13 to 18 years of age

The number of patients for whom syphilis screening was performed in the last year

Patients with reactive RPR/VDRL

Number with RPR/VDRL titer result verified (FTA-ABS)

Patients with positive serology

Number of patients that have been addressed in the chart

Syphilis

QUERI

Syphilis

RAND

Toxoplasmosis

FACCT

Toxoplasmosis

HCSUS

Toxoplasmosis

QUERI

Toxoplasmosis

RAND

Toxoplasmosis

UHC

Tuberculosis

EQHIV

Tuberculosis

EQHIV

Tuberculosis

FACCT

Tuberculosis

HCSUS

Tuberculosis

HIVQUAL

Tuberculosis

IDSA

Tuberculosis

IHI

HIV viral load

HCSUS

HIV viral load

HIVQUAL

HIV viral load

IHI

HIV viral load

RAND

HIV viral load

UHC

All

Receipt of VDRL test ever

All

Documented serologic test for syphilis (VDRL or RPR)

All

Toxoplasma IgG antibody measured at least once

All

Toxoplasma IgG antibody determination noted in chart

All

Receipt of toxoplasmosis test (ever)

All

Toxoplasmosis serology should be documented

All

Toxoplasmosis serology attainment ever

All

Documentation of PPD (skin test for TB) during the review period

All

Documentation of PPD (skin test for TB) during the review period and that it was actually read

All

PPD (skin test for TB) if no prior positive test

All

1) PPD (skin test for TB) ever documented in chart or by interview. 2) periodic PPD tests (skin test for TB) documented in chart or by interview

All

The number of patients whose PPD (skin test for TB) was placed and results read during the past year

HIV-infected persons being followed

Percent who had a documented tuberculin skin test at any time

All

Percent with PPD (skin test for TB)

All

At least one HIV viral load determination per measured 6 month interval, by chart review or interview

All; with exception of those either incarcerated or hospitalized and with no ambulatory clinic visits during 4-month review period

The number of patients for whom HIV viral load test was performed every 4 months

All

Percent with HIV viral load tests taken in past 3 months

Patients on antiretroviral therapy

Offer HIV viral load measurement within 2 months of initiation or change in antiretroviral treatment

All

Semi-annual HIV viral load attainment (most recent 6 months)

Appropriate management of patients on antiretroviral therapy (ART)

HIVQUAL

Appropriate management of patients on ART

HIVQUAL

Appropriate management of patients on ART

HIVQUAL

Provision of adherence counseling and/or monitoring

IHI*

Provision of adherence counseling and/or monitoring

HIVQUAL

Provision of adherence counseling and/or monitoring

IHI

Provision of adherence counseling and/or monitoring

RAND

Provision of adherence counseling and/or monitoring

UHC

Provision of indicated ART

IHI*

Patients who are receiving ART therapy, received ART therapy in the past, or are eligible for ART therapy based on New York State ART therapy guidelines; virologically stable

The number of stable patients for whom HIV viral load is monitored every 4 months

Patients who are receiving ART therapy, received ART therapy in the past, or are eligible for ART therapy based on New York State ART therapy guidelines; virologically unstable

One of the following four management options is documented in the medical record in every 4-month period that the patient is considered unstable: (1) regimen was changed and HIV viral load assay performed within 8 weeks of decision; (2) justification provided not to change therapy and HIV viral load assay performed within 8 weeks of decision; (3) documentation that patient decides not to take medication and HIV viral load assay performed within 4 months; (4) decision made to discontinue therapy and planned clinical follow-up plan noted in record within 4 months

Patients who are receiving ART therapy, received ART therapy in the past, or are eligible for ART therapy based on New York State ART therapy guidelines; end stage or patients with no other therapeutic options

The number of patients for whom a follow-up clinic visit is recorded every 4 months

Patients on HAART

Percent with adherence counseling/intervention at their last visit

Patients prescribed antiretroviral therapy

Adherence is measured and described quantitatively at least once every 4 months

Patients on HAART

Percent who self-report adherence to prescribed regimen according to some standard method (3 months)

Patients started on protease inhibitors

Documented counseling regarding compliance with therapy within 1 month of the start of therapy.

Patients on antiretroviral therapy

Documentation of adherence to ART at most recent visit

All

Percent on HAART

Provision of indicated ART

EQHIV

Provision of indicated ART

EQHIV

Provision of indicated ART

FACCT

Provision of indicated ART

HCSUS

Provision of indicated ART

IDSA

Provision of indicated ART

IHI

Provision of indicated ART

QUERI

Provision of indicated ART

RAND

Patients with CD4+ <500 cells/µL or HIV viral load >20,000 copies

On HAART (defined as three or more antiretroviral medications)

Patients with CD4+ <500 cells/µL or HIV viral load >20,000 copies

On ART (defined as two or more antiretroviral medications)

Patients with AIDS diagnosis or symptomatic HIV disease; or patients with no symptoms, but CD4+ cell count <500 cells/µL or HIV viral load >20,000 (using RT-PCR)

Initiation of ART—Preferred treatment (1 highly active protease inhibitor + 2 nucleoside reverse transcriptase inhibitor) or Alternative treatment (1 nonnucleoside reverse transcriptase inhibitor or Saquinavir + 2 nucleoside reverse transcriptase inhibitor)

Proportion of patients with indications for antiretroviral therapy according to prevailing DHHS guidelines (CD4-cell count <350/µL or HIV viral load >30,000 at the time of the study) documented by chart review or interview over a 6-month period

Receipt of any DHHS recommended combination antiretroviral regimen during that time period or in the following 3 months

Patients with CD4+ cell count count <350/µL now or in the past

Percent who have taken part in a discussion about prescription of HAART, as indicated in the medical record.

Patients on HAART

Percent who are on first HAART regimen

Patients with CD4+ cell count < 350/µL and/or HIV viral load >20,000 copies

Percent on HAART for at least 3 out of 6 months (not necessarily consecutive)

Patients with any of the following conditions: CD4+ cell count count ≥ 500 cells/µL and HIV viral load > 30,000 copies; CD4+ cell count count 350–499 and HIV viral load >10,000 copies; CD4+ cell count count <300; any AIDS-defining condition; thrush

Receive adequate antiretroviral treatment (or be enrolled in a clinical trial with documentation of informed consent) within 1 month of conditions being met

Provision of indicated ART

RAND

Provision of indicated ART

UHC

Provision of indicated ART

UHC

Regimen change

IHI

Hepatitis B

FACCT

Hepatitis B

UHC

Influenza

EQHIV

Influenza

FACCT

Influenza

HCSUS

Influenza

IDSA

Influenza

UHC

Mycobacterium avium complex (MAC)

FACCT

Mycobacterium avium complex (MAC)

HCSUS

Mycobacterium avium complex (MAC)

IDSA

Mycobacterium avium complex (MAC)

QUERI

All

Protease inhibitors should not be prescribed concurrently with astemizole, terfenadine, rifampin, or cisapride.

Patients with CD4+ <200 cells/µL

Taking at least three antiretroviral agents

Patients on antiretroviral therapy

Regimen contains at least three antiretroviral agents

All

Percent who had their medication regimen changed in the last month

Hepatitis B antigen and antibody negative

Received three injection series of hepatitis B vaccine

All patients without prior infection

Hepatitis B vaccination series completed or in progress

All

Documentation of influenza vaccine during review period. Patient refused was included as having documentation

All

Receipt of influenza vaccine annually

All

Receipt of influenza vaccination during the year under study

All

Monitoring of CD4+ cell counts and HIV HIV viral loads

All

Receipt of influenza vaccination

Patients with a CD4+ cell count of less than 50 cells/µL

Taking arithromycin, clarithromycin, or rifabutin in recommended doses for recommended duration

Patients with a CD4+ cell count of less than 50 cells/µL noted in chart or interview period in the previous 9 months

Receipt of any CDC/IDSA recommended form of prophylaxis against Mycobacterium avium complex infection

Patients whose current CD4+ cell count is <50/µL

Percent who have been offered chemoprophylaxis with clarithromycin or azithromycin within 2 months of determination that the CD4+ lymphocyte count is <50/µL

Patients with CD4+ cell count <50/µL

Receipt of at least one MAC drug class in prior 6 months

Mycobacterium avium complex (MAC)

RAND

Mycobacterium avium complex (MAC)

UHC

Pneumococcal pneumonia

FACCT

Pneumococcal pneumonia

HCSUS

Pneumococcal pneumonia

IHI

Pneumococcal pneumonia

RAND

Pneumococcal pneumonia

UHC

Pneumocystis carinii pneumonia (PCP)

FACCT

Pneumocystis carinii pneumonia (PCP)

HCSUS

Pneumocystis carinii pneumonia (PCP)

HIVQUAL (optional measure)

Pneumocystis carinii pneumonia (PCP)

IDSA

Pneumocystis carinii pneumonia (PCP)

IHI

Pneumocystis carinii pneumonia (PCP)

QUERI

Pneumocystis carinii pneumonia (PCP)

RAND

CD4+ cell count dropping below 50/µL

Offer of MAC prophylaxis within 1 month of drop in cell count below 50 CD4+ cells/µL

Most recent CD4+ cell count <50/µL

Receipt of MAC prophylaxis

All (optional if CD4+ cell count <200/µL

Receipt of Pneumovax­­® (pneumococcal vaccination) (once)

All

Receipt of Pneumovax­­® (pneumococcal vaccination) (ever)

All

Percent with documented Pneumovax­­® (pneumococcal vaccination) in last 5 years

Patients with lowest recorded CD4+ cell count > 200/µL

Documentation of Pneumovax­­® (pneumococcal vaccination) receipt

All

Receipt of Pneumovax­­® (pneumococcal vaccination)

CD4+ cell count 200/µL or CD4% <15%. Or oral thrush or fever for ≥2 weeks

Receipt of trimethoprim-sulfamethoxazole, Dapsone, or Aerosolized pentamidine in recommended doses for recommended duration

Patients with a CD4+ cell count of less than 200 cells/µL noted in chart or interview period in the previous 9 months

Receipt of any CDC/IDSA recommended form of prophylaxis against Pneumocystis carinii

Patients with CD4+ cell count <200/µL (patients with CD4+ cell count >200/ µL for less than 6 months are also eligible for review)

The number of patients prescribed PCP prophylactic therapy

Patients with CD4+ cell count currently <200/µL

Percent who were prescribed PCP prophylaxis within 2 months of determination of the CD4+ cell count to be <200/µL

Patients with CD4+ cell count <200 µL at last visit (within 3 months)

Percent with PCP prophylaxis (within last 3 months)

Patients with CD4+ cell count <200/µL

Receipt of at least one PCP drug class for 2 consecutive months in prior 6 months

CD4+ cell count less than 200 cells/µL, completion of active treatment of PCP, or CD4 below 15%.

Offer PCP prophylaxis within 1 month of these conditions

Pneumocystis carinii pneumonia (PCP)

UHC

Toxoplasmosis

FACCT

Toxoplasmosis

RAND

Tuberculosis

FACCT

Tuberculosis

RAND

Benefits advocacy

HCSUS

Emotional counseling

HCSUS

Most recent CD4-cell count <200/µL

Receipt of PCP prophylaxis

Positive antibody (IgG) to toxoplasma present and CD4+ <50 cells/µL

Receipt of trimethoprim-sulfamethoxazole, or Dapsone plus pyrimethamine, in recommended doses for recommended duration

Patients who do not have active toxoplasmosis and who meet either of the following conditions: Toxo IgG positive; or completion of therapy for active toxoplasmosis

Offered toxoplasmosis prophylaxis within 1 month of meeting all these conditions

Patients with tuberculin skin test >5ml or prior positive without treatment or contact with active case of tuberculosis

Receipt of isoniazid plus pyridoxine or rifampin in recommended doses for recommended duration

Patients who do not have active TB and who have not ever previously received TB prophylaxis with current PPD (skin test for TB) >5 mm; or provider noting that patient has had PPD (skin test for TB) >5 mm administered at anytime since HIV diagnosis

Offer of tuberculosis prophylaxis within one month of these conditions

Patients with a need for help in obtaining income assistance such as SSI, SSDI, AFDC, or health care benefits from Medicaid or the VA in the last 6 months as reported at interview

No unmet need

Patients with need for help in obtaining mental health or emotional care or counseling in the last 6 months as reported at interview

No unmet need

Home Health Services

HCSUS

Housing

HCSUS

Mental Health Assessment

HIVQUAL

Self-management goal setting

IHI

Substance abuse services

HCSUS

Substance abuse services

HIVQUAL

Substance abuse services

HIVQUAL

Substance abuse services

HIVQUAL

Support Service

IHI

OUTCOME MEASURES

CD4+ cell count

IHI

CD4+ cell count

IHI*

CD4+ cell count

IHI

Patients with need for help in obtaining home health care in the last 6 months as reported at interview

No unmet need

Patients with a need for help in finding a place to live in the last 6 months as reported at interview

No unmet need

All

The number of patients for whom a mental health assessment was performed during the past year. Assessment components include: cognitive function; screening for depression and anxiety; psychiatric history; psychiatric medication review; psychosocial assessment; sleeping and appetite assessment

All

Percent with self-management goal setting

Patients with need for help in obtaining drug or alcohol treatment in the last 6 months as reported at interview

No unmet need

All

The number of patients with whom substance use was discussed in the past year

Patients with current use (0–6 months from date of review) and not in treatment

Number for whom referrals are made for substance use treatment

Patients with past use (6–24 months from date of review)

Number with whom relapse prevention or ongoing treatment has been discussed and substance use within the last 12 months assessed.

All

Percent with Support Service Assessment

All patients with CD4+ cell count in last 3 months

Average of the last CD4+ cell count

Patients on HAART

Percent with CD4+ cell count >200/µL

All with at least two CD4+ cell count in last 6 months

Percent with CD4+ cell count rise of >50/µL in the past 6 months

CD4+ cell count

EQHIV

CD4+ cell count

EQHIV

Emergency room visits

UHC

Hospitalization

UHC

Hospitalization

IHI

HIV viral load

IHI*

HIV viral load

EQHIV

HIV viral load

EQHIV

HIV viral load

EQHIV

Patients with CD4+ cell count <200/µL

CD4+ cell count increased to >200/µL at the last visit

All

Last CD4+ cell count recorded were <200/µL

All

Non-injury-related emergency room visits per patient per year UHC categorized this measure under Resource Utilization

All

Non-injury-related hospitalizations per patient per year UHC categorized this measure under Resource Utilization

All

Percent with hospitalizations within the last month

Patients on HAART

Percent with undetectable HIV viral load

Patients on HAART (defined as three or more antiretroviral medications)

HIV viral load between 0 and 399 copies

Patients on HAART (defined as three or more antiretroviral medications)

HIV viral load between 400 and 19,999 copies

Patients on HAART (defined as three or more antiretroviral medications)

HIV viral load > 20,000 copies

PREVENTION

Counseling and testing (pregnant women)

Counseling on high-risk behaviors

Tobacco use assessment

SCREENING & MONITORING

CD4+ cell count

√

Cervical cancer and other pelvic disease

√

√

Complete blood count

√

Cytomegalovirus disease

√

Hepatitis A

Hepatitis B and/or C

√

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HIV specialists visit

Lipid screening

Oral health/dental exam

Outpatient visits

√

Syphilis

√

Toxoplasmosis

√

Tuberculosis

√

√

HIV viral load

√

ANTIRETROVIRAL TREATMENT (ART)

Appropriate management of patients on ART

Provision of adherence counseling and/or monitoring

Provision of indicated ART

√

√

Regimen change

PROPHYLACTIC TREATMENT

Hepatitis B

√

Influenza

√

√

Mycobacterium avium complex

√

Pneumococcal pneumonia

√

Pneumocystis carinii pneumonia

√

Toxoplasmosis

√

Tuberculosis

√

SOCIAL AND SUPPORT SERVICES

Benefits advocacy

Emotional counseling

Home health services

Housing

Mental health assessment

Self-management goal setting

Substance abuse services

Support services

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HEALTH OUTCOMES

CD4+ cell count

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Emergency room visits

Hospitalization

HIV viral load

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