Proposed Changes to Existing Measure for HEDIS : Controlling High Blood Pressure (CBP)
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1 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Proposed Changes to Existing Measure for HEDIS : Controlling High Blood Pressure (CBP) NCQA seeks comments on proposed modifications to the Controlling High Blood Pressure measure. The measure would continue to assess the number of members 18 years of age and older who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled during the measurement year. In December 2013, the eighth Joint National Committee (JNC 8) released updated guidance for treatment of hypertension. The new guidelines: Set the BP treatment goal for patients 60 and older to <150/90 mm Hg. Keep the BP treatment goal for patients at <140/90 mm Hg. The proposed measure aligns with the JNC 8 guidelines. The measure will be based on one sample for a total rate reflecting age related BP thresholds. The total rate will be used for reporting and comparison across organizations. Supporting documents for the proposed measure include the draft measure specification and performance data. Specific Comment Request The latest JNC 8 guidelines also recommends treating all adults ages 18 and older with diabetes to a BP goal of <140/90 mm Hg. No age stratification or upper limits on age are recommended for this population. Should CBP also assess members 18 and older with diabetes whose most recent BP reading was < 140/90 mm Hg? This proposal would allow the CBP measure to continue as a comprehensive measure of blood pressure control and keep the measure aligned with other measurement programs. NCQA acknowledges the contributions of the Cardiovascular Measurement Advisory Panel. 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
2 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Controlling High Blood Pressure (CBP) SUMMARY OF CHANGES TO HEDIS 2015 Revised the measure description to members 18 years of age and older. Added (<150/90 mm Hg) to BP was adequately controlled. Revised the definition of Adequate control to include age stratification and systolic BP <150 mm Hg. Revised the ages in the eligible population. Revised the Hybrid Specification to include age stratification and BP <150/90 mm Hg. Description The percentage of members years of age and older who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year using the following criteria: Members years of age whose BP was <140/90 mm Hg. Members 60 years of age and older whose BP was <150/90 mm Hg. Use the Hybrid Method for this measure. Definitions Adequate control Representative BP Both a representative systolic BP <140 mm Hg (18 59 years) or BP <150 mm Hg (60 and older) and a representative diastolic BP<90 mm Hg (BP in the normal or high-normal range). The most recent BP reading during the measurement year (as long as it occurred after the diagnosis of hypertension was made). If multiple BP measurements occur on the same date, or are noted in the chart on the same date, the lowest systolic and lowest diastolic BP reading should be used. If no BP is recorded during the measurement year, assume that the member is not controlled. Eligible Population Product lines Ages Continuous enrollment Allowable gap Anchor date Benefit Commercial, Medicaid, Medicare (report each product line separately) years and older as of December 31 of the measurement year. The measurement year. No more than one gap in continuous enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1- month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled). December 31 of the measurement year. Medical.
3 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Event/ diagnosis Members are identified as hypertensive if there is at least one outpatient visit (Outpatient CPT Value Set) with a diagnosis of hypertension (Hypertension Value Set) during the first six months of the measurement year. Note: In order to increase the specificity of the eligible population, only CPT 1 codes are used to identify outpatient visits. Hybrid Specification Denominator A systematic sample drawn from the eligible population for each product line whose diagnosis of hypertension is confirmed by chart review. The organization may reduce the sample size using the prior years audited, product line-specific rate. Organizations may reduce the sample size using the current year s administrative rate. Refer to the Guidelines for Calculations and Sampling for information on reducing the sample size. To confirm the diagnosis of hypertension, the organization must find notation of one of the following in the medical record on or before June 30 of the measurement year: Hypertension HTN. High BP (HBP). Elevated BP (BP). Borderline HTN. Intermittent HTN. History of HTN. Hypertensive vascular disease (HVD). Hyperpiesia. Hyperpiesis. The notation of hypertension may appear on or before June 30 of the measurement year, including prior to the measurement year. It does not matter if hypertension was treated or is currently being treated. The notation indicating a diagnosis of hypertension may be recorded in any of the following documents: Problem list (this may include a diagnosis prior to June 30 of the measurement year or an undated diagnosis; see Note at the end of this section). Office note. Subjective, Objective, Assessment, Plan (SOAP) note. Encounter form. Diagnostic report. Hospital discharge summary. Statements such as rule out HTN, possible HTN, white-coat HTN, questionable HTN and consistent with HTN are not sufficient to confirm the diagnosis if such statements are the only notations of hypertension in the medical record. Identifying the medical record Use one medical record for both the confirmation of the diagnosis of hypertension and the representative BP. All eligible BP measurements recorded in the record must be considered. If an organization cannot find the medical record, the member remains in the measure denominator and is considered noncompliant for the numerator. Use the following steps to find the appropriate medical record to review. 1 CPT codes copyright 2014 American Medical Association. All rights reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
4 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Step 1 Identify the member s PCP. If the member had more than one PCP for the time period, identify the PCP who most recently provided care to the member. If the member did not visit a PCP for the time period or does not have a PCP, identify the practitioner who most recently provided care to the member. If a practitioner other than the member s PCP manages the hypertension, the organization may use the medical record of that practitioner. Step 2 Use one medical record to both confirm the diagnosis for the denominator and identify the representative BP level for the numerator. There are circumstances in which the organization may need to go to a second medical record to either confirm the diagnosis or obtain the BP reading, as in the following two examples. If a member sees one PCP during the denominator confirmation period (on or before June 30 of the measurement year) and another PCP after June 30, the diagnosis of hypertension and the BP reading may be identified through two different medical records. If a member has the same PCP for the entire measurement year, but it is clear from claims or medical record data that a specialist (e.g., cardiologist) manages the member s hypertension after June 30, the organization may use the PCP s chart to confirm the diagnosis and use the specialist s chart to obtain the BP reading. For example, if all recent claims coded with 401 came from the specialist, the organization may use this chart for the most recent BP reading. If the member did not have any visit with the specialist prior to June 30 of the measurement year, the organization must go to another medical record to confirm the diagnosis. Numerator Administrative Medical record Step 1 The number of members in the denominator whose most recent BP was adequately controlled during the measurement year. For a member s BP to be controlled, both the systolic and diastolic BP must be <140/90 for members years of age and <150/90 for members 60 years of age and older. To determine if the member s BP is adequately controlled, the representative BP must be identified. None. Follow the steps below to determine representative BP and determine compliance with the measure. Identify the number of members years of age as of December 31 of the measurement year whose most recent BP reading is <140/90 mm Hg during the measurement year. For a member s BP to be controlled, both the systolic and diastolic BP must be <140/90. The reading must occur after the date when the diagnosis of hypertension was confirmed. Do not include BP readings: Taken during an acute inpatient stay or an ED visit. Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole). Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy). Reported by or taken by the member. Use the lowest systolic and lowest diastolic BP reading from the most recent BP notation in the medical record. If multiple readings were recorded for a single date, use
5 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, the lowest systolic and lowest diastolic BP on that date as the representative BP. The systolic and diastolic results do not need to be from the same reading. The member is not compliant if the BP reading is 140/90 mm Hg or is missing, or if there is no BP reading during the measurement year or if the reading is incomplete (e.g., the systolic or diastolic level is missing). Step 2 Step 3 Identify the number of members 60 years of age and older as of December 31 of the measurement year whose most recent BP reading is <150/90 mm Hg during the measurement year. The reading must occur after the date when the diagnosis of hypertension was confirmed. Do not include BP readings: Taken during an acute inpatient stay or an ED visit. Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole). Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy). Reported by or taken by the member. Use the lowest systolic and lowest diastolic BP reading from the most recent BP notation in the medical record. If multiple readings were recorded for a single date, use the lowest systolic and lowest diastolic BP on that date as the representative BP. The systolic and diastolic results do not need to be from the same reading. The member is not compliant if the BP reading is 150/90 mm Hg or is missing, or if there is no BP reading during the measurement year or if the reading is incomplete (e.g., the systolic or diastolic level is missing). Sum the events from steps 1 2 to obtain the rate. Exclusions (optional) Exclude from the eligible population all members with evidence of end-stage renal disease (ESRD) (ESRD Value Set; ESRD Obsolete Value Set) or kidney transplant (Kidney Transplant Value Set) on or prior to December 31 of the measurement year. Documentation in the medical record must include a dated note indicating evidence of ESRD, kidney transplant or dialysis. Exclude from the eligible population all members with a diagnosis of pregnancy (Pregnancy Value Set) during the measurement year. Exclude from the eligible population all members who had a nonacute inpatient encounter (Nonacute Care Value Set) during the measurement year. Note Organizations may use an undated notation of hypertension on problem lists. Problem lists generally indicate established conditions; to discount undated entries might hinder confirmation of the denominator. Organizations generally require an oversample of 10 percent 15 percent to meet the MRSS for confirmed cases of hypertension. Data Elements for Reporting
6 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, Data Elements for Reporting Organizations that submit HEDIS data to NCQA must provide the following data elements. Table CBP-1/2/3: Data Elements for Controlling High Blood Pressure Measurement year Data collection methodology (Hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year s administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of records excluded because of false-positive diagnoses Number of administrative data records excluded Number of medical record data records excluded Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Hybrid
7 Draft Document for HEDIS 2015 Public Comment Obsolete After March 19, CBP COMMERCIAL Report Type HMO PPO CBP MEDICARE Report Type HMO PPO Controlling High Blood Pressure (CBP) Performance Data Number of Standard 10th 25th 50th 75th 90th Year Plans Average Deviation Number of Standard 10th 25th 50th 75th 90th Year Plans Average Deviation CBP MEDICAID Report Type HMO Year Number of Plans Average Standard Deviation 10th 25th 50th 75th 90th
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