Healthcare Effectiveness Data and Information Set (HEDIS ) Guide

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1 Healthcare Effectiveness Data and Information Set (HEDIS ) Guide Clinical ALL ADULTS Access to preventive/ ambulatory health services Smoking and Tobacco Use Cessation [S] Aspirin Use and Discussion [S] Ages and older Age 18 and older Women: Age 55 to 79 Men: Age 45 to 79 The percentage of members 20 years and older who had an ambulatory or preventive care visit (time frame depends on product line) Survey questions: current smoker or tobacco user Advised to quit in the last year Discussed or were recommended medications to quit in the last year Discussed or were provided cessation methods or strategies in the last year Survey question: Asked if currently taking aspirin Women - with at least two risk factors for cardiovascular disease Men age 45 to 64 - with at least one risk factor for cardiovascular disease Medicare only Colorectal cancer screening [H] Age Flu shots for adults [S] Age 50 to 64 Adult BMI Assessment [H] Osteoporosis Management in Women who had a fracture Osteoporosis Testing in Older Women [S] Glaucoma Screening in Older Adults Physical Activity in Older Adults [S] Age 18 to 74 Age 67 and older Men age 65 to 79 - regardless of risk factor One or more of the following appropriate colorectal cancer screenings: [fecal occult blood test (threecard specimen) (in the last year)], flexible sigmoidoscopy (in the last 5 years), or colonoscopy (in the last 10 years) Survey question: Did the member get a flu shot at any location during the previous flu season? (Between September 1st and the date the survey is completed) An outpatient visit and had their body mass index (BMI) documented during the last two years. Women suffered a fracture, and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the date of the fracture. Survey question: Women report if they ever received a bone density test to check for osteoporosis. Received a glaucoma eye exam by an eye care professional in the last two years. Excludes members with prior diagnosis of glaucoma or glaucoma suspect. Had a doctor's office visit in the past 12 months Spoke with a doctor or other health provider about their level of exercise or physical activity

2 Fall Risk Management [S] Advised to start, increase or maintain their level of exercise or physical activity Survey questions: Had a history of problems with balance, walking problems or a fall in the past 12 months Urinary Incontinence in Older Adults [S] Discussed falls, problems with balance or walking with their current practitioner Received fall risk intervention from their current practitioner Survey questions: Reported having a problem with urine leakage in the past six months Pneumonia Vaccination Status for Older Adults [S] Use of High-Risk Medications in the Elderly Discussed their urine leakage problem with their current practitioner Received treatment for their current urine leakage problem Survey question: Have you ever received a pneumococcal vaccine. 1. Received at least one high risk medication 2. Received at least two high risk medications Note: not all drugs in the categories below are included - there are specific medications for each category. Drug categories include: Antianxiety, antiemetics, analgesics, antihistamines, antipsychotic (typical), amphetamines, barbiturates, long-acting benzodiazepines, calcium channel blockers, gastrointestinal antispasmodics, Belladonna alkaloids, skeletal muscle relaxants, oral estrogens, oral hypoglycemics, narcotics, vasodilators, and others (androgens and anabolic steroids, thyroid drugs, and urinary anti-infectives). Potentially Harmful Drug-Disease Interactions in the Elderly Dispensed an ambulatory prescription for a contraindicated medication, concurrent with or after the diagnosis of one of the following: History of falls and prescription for tricycle antidepressants, antipsychotics or sleep agents Dementia and prescription for tricycle antidepressants or anticholinergic agents Chronic renal failure (CRF) and prescription for nonaspirin NSAIDs or Cox-2 Selective NSAIDs At least one mammogram within the last two years. Excludes members with a bilateral mastectomy. WOMEN & TEENAGE Breast cancer screening Age 40-69

3 GIRLS Cervical cancer screening Chlamydia screening in young women Prenatal / post-partum care [H] Age Sexually active women age Live birth from 11/6/08-11/5/09 At least one or more pap smears within three years (annually for Medicaid). Excludes members who had a hysterectomy with no residual cervix. At least one screening test for Chlamydia within the past year Prenatal visit within first trimester (or 42 days of enrollment) CHILDREN & ADOLESCENTS Childhood immunizations [H] Post-partum visit between 21 and 56 days after delivery Age DTap, 3 IPV, 1 MMR, 3 HIB, 3 Hep B, 1 VZV, 4 PCV, 2 Hep A, 2 or 3 RV and 2 flu by age two CARDIAC CARE Adults only Adolescent immunizations [H] Human Papillomavirus Vaccine for Female Adolescents Access to primary care physicians Well-care visits within 1 st 15 months of life Well-care visits in the 3 rd, 4 th, 5 th and 6 th years of life Adolescent well-care visits Weight Assessment Nutrition and Physical Activity [H] Persistence of Beta- Blocker Treatment after a Heart Attack Cholesterol Management for Patients with Selected Age Age 13 Ages 12 months-19 years. DTap = Diphtheria - Tetanus - Pertussis / IPV = Polio / MMR = Measles - Mumps - Rubella / HIB = Haemophilus influenza type b / HEP B = Hepatitis B / VZV = Varicella (chickenpox) / PCV = Pneumococcal / Hep A = Hepatitis A / RV = Rotovirus / flu = influenza vaccine Adolescents who received one meningococcal vaccine on or between the members 11 th and 13 th birthday and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the member's 10 th and 13 th birthdays. Percentage of female adolescents 13 years of age who had three doeses of trhe human papillomavirus (HPV) vaccine by their 13 th birthday. A visit with a primary care physician (PCP) each year Age 0-15 months At least six well-child visits with a PCP by age 15 months. Age 3-6 Age Age 3-17 Heart attack patients age 18 and older Selected cardiovascular diagnoses, age 18- At least one well-child visit with a PCP within the past year. At least one well-care visit with a PCP or OB/GYN within the past year. An outpatient visit with a primary care practitioner or OB/GYN and evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity Following a heart attack, member received a to 180-day course of treatment with a beta-blocker (Excludes history of asthma, hypotension, Heart Block greater than first degree, and sinus bradycardia) 1. At least one LDL cholesterol test during the last year

4 DIABETICS Adults only RESPIRATORY See also MEDICATION SECTION Cardiovascular Conditions [H] Controlling High Blood Pressure (Hypertension) [H] Comprehensive Diabetes Care [H] Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive Pulmonary Disease (COPD) LDL Level less than 100 (must be the last test in the calendar year) Age with high blood pressure Members diagnosed with Type 1 or Type II diabetes, age Age 40 and older. Includes acute myocardial infarction, coronary artery bypass, percutaneous coronary interventions and ischemic vascular disease. Systolic blood pressure less than 140 mmhg AND diastolic blood pressure less than 90 mmhg (use the last outpatient blood pressure in the calendar year). Includes members with diagnosis of hypertension noted in the medical record prior to June 30 of measurement year. Each year, members with Type I or Type II diabetes should have: Hemoglobin A1c (HbA1c) tested HbA1c > 9 (lower is better, result must be the last test in the calendar year) HbA1c Control < 8 (result must be the last test in the calendar year) HbA1c Control < 7 for a selected population (result must be the last test in the calendar year) Dilated eye exam performed LDL cholesterol performed LDL cholesterol <100 ml/dl (result must be the last test in the calendar year) Screening for or monitoring of kidney disease (microalbumin or history of Diabetic Nephropathy) Blood pressure < 140/80 (use the last outpatient blood pressure in the calendar year) New diagnosis of newly active COPD who received appropriate spirometry testing to confirm the diagnosis. MEDICATION Annual Monitoring for Patients on Persistent Medications Age 18 and older 1. Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) 2. Digoxin 3. Diuretics 4. Anticonvulsants #1, 2, and 3: At least one serum potassium and

5 either a serum creatinine or a blood urea nitrogen (BUN) test in the measurement year #4. At least one serum concentration level test specific to drug taken (i.e. a member on both phenytoin and valproic acid with a 180-days supply of each drug must separately show evidence of receiving drug serum concentration tests for each drug. Use of Appropriate Medications for People with Persistent Asthma Medication Management for People with Asthma Asthma Medication Ratio Appropriate treatment for children with upper respiratory infection (URI) Appropriate testing for children with pharyngitis (sore throat) Age 5-64, with persistent asthma (1-ER visit, 1-inpatient asthma stay, 4 outpatient asthma vsts, or 4 asthma Rx events). Age 5-64, with persistent asthma (1-ER visit, 1-inpatient asthma stay, 4 outpatient asthma vsts, or 4 asthma Rx events). Age 5-64, with persistent asthma (1-ER visit, 1-inpatient asthma stay, 4 outpatient asthma vsts, or 4 asthma Rx events). Age 3 months - 18 years of age with diagnosis of URI Age 2-18 with diagnosis of pharyngitis Avoidance of Antibiotic Age 18 to 64 with Treatment in Adults With diagnosis of Acute Acute Bronchitis Bronchitis Pharmacotherapy Management of Chronic Obstructive Pulmonary Disease (COPD) Age 40 and older. Members with persistent asthma should receive a prescription medication acceptable as primary treatment for long-term control of asthma. 1. Percentage of members who remained on an asthma controller medications for at least 50% of their treatment period. 2. Percentage of members who remained on an asthma controller medications for at least 75% of their treatment period. Percentage of Members who had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. Percentage of Members who did not receive an antibiotic prescription on or within 3 days after the diagnosis of an upper respiratory infection (antibiotics are NOT an appropriate treatment for this diagnosis; therefore a lower rate is better) Members who were diagnosed with pharyngitis, received a prescription and received a group A streptococcus (strep) test within 3 days of the prescription Percentage of Members who did not receive an antibiotic prescription on or within 7 days after the diagnosis of acute bronchitis (antibiotics are NOT an appropriate treatment for this diagnosis; therefore a lower rate is better) An acute inpatient discharge or emergency department (ED) encounter for COPD exacerbation between January 1 and December 1 and where

6 Exacerbation dispensed appropriate medications. Two rates are reported: RADIOLOGY BEHAVIORAL HEALTH CARE Rheumatoid Arthritis - Disease-Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis Use of Imaging Studies for Low Back Pain Antidepressant Medication Management Follow-up Care for Children Prescribed Attention- Deficit/Hyperactivity Disorder (ADHD) Medication Follow-up visit after hospitalization for mental illness Age 18 and older Age 18 to 50 (Commercial only) Adults, age 18 and older, diagnosed with a new episode of depression & treated with an antidepressant drug Age 6 to 12, dispensed ADHD medication Members, age 6 and older, discharged from an inpatient mental health hospitalization 1. Dispensed a systemic corticosteroid within 14 days of the event 2. Dispensed a bronchodilator within 30 days of the even Dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD) 5-Aminosalicylates, Alkylating agents, Aminoquinolines, Anti-rheumatics, Immunomodulators, Immunosuppressive agents or Tetracyclines. Percentage of members who did not receive an imaging study within 28 days of a primary diagnosis of low back pain (plain x-ray, MRI or CT scan). Exclude members with cancer, trauma, IV drug abuse or neurologic impairment. Effective acute-phase treatment = remained on an antidepressant medication during the 12 weeks following diagnosis Effective continuation-phase treatment = remained on an antidepressant medication for at least 6 months following diagnosis Initiation Phase = ambulatory prescription dispensed for ADHD medication, had one followup visit with practitioner with prescribing authority during the 30-day initiation phase. Continuation and Maintenance (C&M) Phase - remained on the medication for at least 210 days and in addition to the visit in the initiation phase also had two follow-up visits with a practitioner within 270 days (9 months) after the initiation phase ended. After hospitalization a outpatient visit is needed by a mental health practitioner One follow-up visit within 7 days of hospital discharge One follow-up visit within 30 days of hospital discharge Note a Primary Care Physician visit does not count towards compliance. Mental health practitioner includes: A psychiatrist, psychologist, Master's degree in social work, RN certified as a psychiatric nurse or mental health clinical nurse specialist, Master's degree or doctoral degree in counseling,

7 Initiation of alcohol and other drug (AOD) dependence treatment Engagement of alcohol and other drug (AOD) dependence treatment Members aged 13 and older diagnosed with AOD dependence Members aged 13 and older diagnosed with AOD dependence marital and family therapy. Initiation of treatment - AOD dependence who initiate treatment within 14 days of diagnosis through either: inpatient admission outpatient visit intensive outpatient encounter partial hospitalization 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 or more additional AOD services within 30 days after completing the Initiation treatment with any AOD diagnosis: inpatient admissions outpatient visits intensive outpatient encounters partial hospitalizations Source: HEDIS 2013 Technical Specifications Volume Two National Committee for Quality Assurance (NCQA) HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). "Reproduced with permission from the HEDIS 2013 Volume 2 Technical Specifications by the National Committee for Quality Assurance (NCQA). To purchase copies of this publication, contact NCQA Customer Support at or HEDIS is a registered trademark of NCQA. NCQA has not reviewed and does not endorse this reproduction."

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