National Academies Press: OpenBook

Performance Measurement: Accelerating Improvement (2006)

Chapter: Appendix G Starter Set of Measures

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Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
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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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

 

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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.

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

  • 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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
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  • 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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

 

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.

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix G Starter Set of Measures." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
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Next: Appendix H Commissioned Paper: Efficiency/Value-Based Measures for Services, Defined Populations, Acute Episodes, and Chronic Conditions--Kyle L. Grazier »
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Performance Measurement is the first in a new series of an ongoing effort by the Institute of Medicine (IOM) to improve health care quality. Performance Measurement offers a comprehensive review of available measures and introduces a new framework to examine these measures against the six aims of the health care system: health care should be safe, effective, patient-centered, timely, efficient, and equitable. This new book also addresses the gaps in performance measurement and introduces the need for measures that are longitudinal, comprehensive, population-based, and patient-centered. This book is directed toward all concerned with improving the quality and performance of the nation’s health care system in its multiple dimensions and in both the public and private sectors.

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