Attached is updated information for HEDIS 2015 specifications relating to Respiratory Conditions:

Transcription

1 TO: Providers to FHCP Members FROM: FHCP Quality Management RE: Update on HEDIS Quality Measures for 2015 FHCP follows current clinical practice guidelines and we are monitored by HEDIS (Healthcare Effectiveness Data and Information Set). HEDIS is a widely used set of quality measures developed by the National Committee for Quality Assurance (NCQA), to ensure high healthcare standards. Attached is updated information for HEDIS 2015 specifications relating to Respiratory Conditions: ASM: Asthma (controller medications for persistent asthma) CWP: Pharyngitis (strep tests for children) URI: Upper Respiratory Infections (avoiding antibiotics in children) PCE: COPD Exacerbations (systemic corticosteroid w/in 14 days and bronchodilator w/in 30 days) AAB: Acute Bronchitis (avoiding antibiotics in adults) Also attached is information for a few additional measures where member compliance could improve: OMW: Osteoporosis (Bone Mineral Density test or osteoporosis drug within 6 months of fracture) LBP: Low Back Pain (avoid imaging for 28 days after coding a primary diagnosis for low back pain) PBH: Heart Attacks (Beta-blockers consistently in the first 6 months after a heart attack). Please help ensure optimal patient care by taking the time to read the summary of these 2015 HEDIS quality measures and using them in your treatment of FHCP patients. Thank you for all you do on behalf of FHCP members and their continued health and wellness! Clinical Practice Guidelines, the attached HEDIS updates, and CDC fact sheets are on our website at If you have questions, or to request copies of any materials, please call Quality , ext or QualityManagement@fhcp.com. cc: Joseph Zuckerman, M.D., Chief Medical Officer

2 Use of Appropriate Medications for People With Asthma (ASM) of the 2015 ASM measure: Members 5-64 years of age who were identified as having persistent asthma and who were prescribed appropriate controller medication during the current year. Patients with persistent asthma are identified as having met at least one (1) of the following criteria during both the current year and the year prior: At least one Emergency Department visit with asthma as the principal diagnosis. At least one acute Inpatient claim/encounter with asthma as the principal diagnosis. At least four (4) outpatient asthma visits on different dates of service, with asthma as one of the listed diagnoses and at least two asthma medication dispensing events. At least four asthma medication dispensing events. Generally, the majority of patients who fall onto the ASM Non-Compliant list have received 4 or more fast-acting rescue inhalers within each year, without the addition of an asthma controller medication. 1. If your patient has persistent asthma and is not on a controller medication, please review and consider initiation of this treatment as recommended in the Asthma Guidelines Summary for the diagnosis and management of asthma. Please see attached ASM-D: Asthma Controller Medications. 2. Be aware that the patient will state their symptoms are under control (per their perception) while using frequent rescue inhalers. Additional refills are requested, and use of a suppressant/controller medication is not addressed. Monitor the # of rescue inhalers the patient is refilling. 3. Explain to the patient that using an asthma controller medication should lessen asthma exacerbations and the need for rescue inhalers. 4. If your patient has been dispensed a sample controller medication, please fax a copy to Quality Management, Fax # (386) , Attn: ASM Measure. To view the Asthma Guidelines Summary, go to:

3 HEDIS Specifications ASM-D: Asthma Controller Medications RED indicates those available on FHCP formulary. Please refer to formulary for updates. Antiasthmatic combinations Dyphyllineguaifenesin (COPD, Dilor-G, Lufyllin-Gc) Prescriptions Guaifenesintheophylline (Bronkaid, Quibron, Quibron-300) Antibody inhibitor Omalizumab (Xolair)* *PA medication Inhaled steroid combinations Budesonideformoterol (Symbicort) Fluticasonesalmeterol (Advair) Mometasone-formoterol (Dulera) Inhaled corticosteroids Beclomethasone (Qvar) Flunisolide (Aerobid) Mometasone (Asmanex) Budesonide (Pulmicort Respules) (Peds only) Fluticasone CFC free (Flovent) Triamcinolone (Azmacort) Ciclesonide (Alvesco) Leukotriene modifiers Montelukast (Singulair) Zafirlukast (Accolate) Zileuton (Zyflo) Mast cell stabilizers Cromolyn (Intal) Methylxanthines Aminophylline (Phyllocontin, Truphylline) Theophylline (Theo-Dur, Respbid, Slo-Bid, Theo-24, Theolair) Dyphylline (Dilor, Dylix, Lufyllin)

4 Appropriate Testing for Children With Pharyngitis (CWP) of the 2015 CWP measure: The percentage of children 2 18 years of age who were diagnosed with Pharyngitis, dispensed an antibiotic and received a Group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e. appropriate strep testing). To clarify, a strep test should be completed and documented for any patient receiving a diagnosis of Pharyngitis who is prescribed an antibiotic. What we have found for members on the CWP Non-Compliant list: A strep test was not performed for a diagnosis of Pharyngitis, or The code for the strep test was not included on the claim, or Additional diagnoses other than Pharyngitis which are present on office visit notes, have not been included on the actual claim. (Including additional diagnoses is important because more than 1 diagnosis on the claim, other than Pharyngitis, removes a member from the CWP Non- Compliant list). Pharyngitis Includes: ICD-9 Code Codes to Identify Group A Strep Tests Acute Pharyngitis 462 Acute Tonsillitis , 87071, 87081, 87430, 87650, 87651, 87652, Streptococcal Sore Throat If a member age 2 to 18 has Pharyngitis (which includes Acute Pharyngitis, Acute Tonsillitis, or Streptococcal Sore Throat), and you are prescribing an antibiotic: 1. Please complete a Strep Test. 2. Please include the CPT code for the Group A Strep Test. 3. Please include all diagnosis codes with the claim, if there are any other than Pharyngitis. You may go to to view Pediatric & Adult Treatment Guidelines for various Upper Respiratory Infections.

5 Appropriate Treatment for Children With Upper Respiratory Infection (URI) of the 2015 URI measure: The percentage of children 3 months - 18 years of age who were given a diagnosis of Upper Respiratory Infection (URI) and were not dispensed an antibiotic. For Upper Respiratory Infections, it is considered a mark of high quality care if these patients were not dispensed an antibiotic when they only have a diagnosis of a URI, which includes either: Acute Nasopharyngitis common cold (Code 460); or Upper Respiratory Infection (Code 465). As you are aware, Acute Nasopharyngitis (common cold), & Upper Respiratory Infections are usually viral illnesses that do not respond to antibiotics. We understand that many parents want an antibiotic for their sick child. It takes everyone in healthcare working together to diminish the use of antibiotics, and to avoid creating resistant strains of bacteria which are dangerous to all of us. 1. When an antibiotic is being prescribed for one of our members age 3 months to 18 years, with either Acute Nasopharyngitis (common cold Code 460), or Upper Respiratory Infection (Code 465), please evaluate the use of an additional diagnosis, if appropriate, such as: Otitis Media; Acute Sinusitis; Acute Pharyngitis; Acute Tonsillitis; Chronic Sinusitis; Infections of the Pharynx, Larynx, Tonsils or Adenoids; Bacterial infection unspecified; Pertussis; or Pneumonia. For a complete list of diagnosis codes where an antibiotic is considered appropriate, please see attached URI-C: Codes to Identify Competing Diagnoses. 2. If you are unable to add an additional diagnosis from URI-C, please consider not prescribing an antibiotic if using only the diagnoses of Acute Nasopharyngitis (Code 460) and/or Upper Respiratory Infection (Code 465). Per national standards of care as contained in HEDIS specifications, antibiotic use is not recommended for Acute Nasopharyngitis and/or Upper Respiratory Infection. You may go to to print education sheets (English/Spanish) to reinforce the decision to parents not to use an antibiotic.

6 URI-C: Codes to Identify Competing Diagnoses Intestinal infections ICD-9-CM Diagnosis Pertussis 033 Bacterial infection unspecified Lyme disease and other arthropod-borne diseases 088 Otitis media 382 Acute sinusitis 461 Acute pharyngitis 034.0, 462 Acute tonsillitis 463 Chronic sinusitis 473 Infections of the pharynx, larynx, tonsils, adenoids Prostatitis 601 Cellulitis, mastoiditis, other bone infections 383, 681, 682, 730 Acute lymphadenitis 683 Impetigo 684 Skin staph infections 686 Pneumonia , 474, , , , , Gonococcal infections and venereal diseases 098, 099, V01.6, V02.7, V02.8 Syphilis Chlamydia , , Inflammatory diseases (female reproductive organs) 131, Infections of the kidney 590 Cystitis or UTI 595, Acne 706.0, 706.1

7 Pharmacotherapy Management of COPD Exacerbation (PCE) of the 2015 PCE measure: Members 40 years of age and older with a COPD exacerbation leading to an Emergency Department (ED) visit or acute Inpatient stay, who were dispensed appropriate medications upon discharge. To comply with the PCE standard and ensure the most optimal return to health, these members should fill both of the following medications within a specified time frame: Systemic corticosteroid within 14 days of the Episode Date. Bronchodilator within 30 days of the Episode Date. The Episode Dates are: ED - date of visit, and Inpatient - date of discharge. Most patients receive these prescriptions upon release from the hospital, but this is not always the case. 1. When your patient is discharged, please contact them to schedule a follow-up appointment no later than within 7 days, for re-evaluation and medication management. 2. For patients where COPD was coded as the principal diagnosis, ask if they filled a systemic corticosteroid and a bronchodilator prescription. Patients must actually fill the prescriptions for compliance with the measure. Please call Quality Management at (386) , Ext 7258 if you are unsure of the principal coded diagnosis for the hospital. 3. If the hospital staff did not prescribe both a systemic corticosteroid and a bronchodilator, it would be helpful if the Primary Care Provider could write the prescriptions, and encourage their patients to fill them within the allotted time of 14 or 30 days respectively. (If a patient had an active filled prescription at the time of admission, and it was still active upon discharge, then this meets compliance for the measure). You may go to to view the COPD Guidelines. Attached for your review are the medications listed in the HEDIS specifications for PCE: PCE-C: Systemic Corticosteroids PCE-D: Bronchodilators

8 HEDIS SPECIFICATIONS PCE-C: Systemic Corticosteroids RED indicates those available on FHCP formulary. Please refer to formulary for updates. Glucocorticoids Betamethasone Dexamethasone Hydrocortisone Methylprednisolone Prescription Prednisolone Prednisone Triamcinolone PCE-D: Bronchodilators RED indicates those available on FHCP formulary. Please refer to formulary for updates. Anticholinergic agents Albuterol-ipratropium (Combivent) Aclidinium-bromide (Tudorza) Ipratropium (Atrovent, Combivent, DuoNeb) Tiotropium (Spiriva) Beta 2-agonists Albuterol (Accuneb, ProAir HFA, Proventil, Proventil HFA, Ventolin HFA,Volmax, Vospire) Formoterol Indacaterol (Onbrez) Metaproterenol (Alupent, Metaprel) Pirbuterol (Maxair Autohaler) Arformoterol (Brovana) Levalbuterol (Xopenex) Salmeterol (Serevent Diskus) Budesonide-formoterol (Symbicort) Mometasoneformoterol (Dulera) Fluticasone-salmeterol (Advair Diskus) Methylxanthines Aminophylline Dyphylline Dyphylline-guaifenesin Theophylline (Theo-Dur, Respid, Slo-Bid, Theo-24, Theolair, Uniphyl, Slo-Phyllin) Guaifenesintheophylline

9 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) of the 2015 AAB measure: The percentage of adults years of age with a diagnosis of Acute Bronchitis (ICD Code 466), who were not dispensed an antibiotic. As you are aware, Acute Bronchitis is usually a viral illness that does not respond to antibiotics, and therefore antibiotic treatment is not recommended for this diagnosis. Overuse of antibiotics continues to be an ongoing problem in healthcare. Attached for your review from the HEDIS specifications for AAB: URI-C: Codes to Identify Competing Diagnoses AAB-C: Codes to Identify Comorbid Conditions 1. When an antibiotic is being prescribed for a patient with Code Acute Bronchitis, please evaluate the use of an additional diagnosis (URI-C), or evaluate the use of a comorbid condition (AAB-C), if appropriate to the patient. These are conditions where an antibiotic is appropriate. 2. If you are unable to add an appropriate additional diagnosis from URI-C, or an appropriate comorbid condition from AAB-C, please consider not prescribing an antibiotic for Acute Bronchitis. This is taken from the HEDIS specifications for national standards of care for these patients. Many times a patient believes an antibiotic is necessary to alleviate symptoms and may be persistent in this request. This is an opportunity to provide education on why antibiotics are not always necessary and can even be harmful. Symptom management can be stressed. You may go to to view information from the CDC on appropriate antibiotic use.

10 URI-C: Codes to Identify Competing Diagnoses ICD-9-CM Diagnosis Intestinal infections Pertussis 033 Bacterial infection unspecified Lyme disease and other arthropod-borne diseases 088 Otitis media 382 Acute sinusitis 461 Acute pharyngitis 034.0, 462 Acute tonsillitis 463 Chronic sinusitis 473 Infections of the pharynx, larynx, tonsils, adenoids , 474, , , , , Prostatitis 601 Cellulitis, mastoiditis, other bone infections 383, 681, 682, 730 Acute lymphadenitis 683 Impetigo 684 Skin staph infections 686 Pneumonia Gonococcal infections and venereal diseases 098, 099, V01.6, V02.7, V02.8 Syphilis Chlamydia , , Inflammatory diseases (female reproductive organs) 131, Infections of the kidney 590 Cystitis or UTI 595, Acne 706.0, AAB-C: Codes to Identify Comorbid Conditions ICD-9-CM Diagnosis HIV disease; asymptomatic HIV 042, V08 Cystic fibrosis Disorders of the immune system 279 Malignancy neoplasms Chronic bronchitis 491 Emphysema 492 Bronchiectasis 494 Extrinsic allergic alveolitis 495 Chronic airway obstruction, chronic obstructive asthma 493.2, 496 Pneumoconiosis and other lung disease due to external agents Other diseases of the respiratory system Tuberculosis

11 Osteoporosis Management in Women Who Had a Fracture (OMW) of the 2015 OMW measure: Evaluates the percentage of women years of age with a fracture (excluding finger, toe, face and skull), and who had a bone mineral density (BMD) test or filled a prescription for a drug to treat osteoporosis, in the 6 months after the fracture. (If the member had a BMD within 24 months prior to the fracture, or an osteoporosis drug within 12 months prior to the fracture, they are considered compliant). For women in this age group with a fracture, please consider prescribing an osteoporosis medication, based on your evaluation and any previous BMD test scores. (Please see attached Table OMW-C). If the need for treatment is unclear, please obtain a follow-up BMD test, given the recent fracture. (This may not apply if your patient has an end-stage condition such as dementia, or is on hospice or some similar condition). The National Osteoporosis Foundation recommends that postmenopausal women over 50 should be considered for pharmacologic therapy, when presenting with the following: 1 A hip or vertebral fracture. In these patients, the T-score is not as important as the fracture itself in predicting future fracture risk and efficacy from treatment. Research shows that patients with spine and hip fractures will have reduced fracture risk if treated with pharmacologic therapy. This applies to fracture patients with BMD in both the low bone mass and osteoporosis range. T-score at the femoral neck, total hip or lumbar spine (osteoporosis). Low bone mass (osteopenia : T-score between -1.0 and -2.5 at the femoral neck or lumbar spine) and a U.S.-adapted WHO 10-year probability of a hip fracture 3% or 10-year probability of any major osteoporosis-related fracture 20%. Please fax any medication samples given to patient to us at FAX #: , ATTN: OMW. 1 Clinician's Guide to Prevention and Treatment of Osteoporosis, National Osteoporosis Foundation, 2014 Issue, Version 1, Release Date: April 1,

12 Osteoporosis Management in Women Who Had a Fracture (OMW) Table OMW-C: Osteoporosis Therapies Biphosphonates Alendronate Alendronate-cholecalciferol Calcium carbonate-risedronate Prescription Ibandronate Risedronate Zoledronic acid Other agents Calcitonin Denosumab Raloxifene Teriparatide Please note that for HEDIS 2015, estrogens were removed from the list of osteoporosis therapies. Spring 2015 Quality Management

13 Use of Imaging Studies for Low Back Pain (LBP) of the 2015 LBP measure: Members 18 to 50 with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the coded diagnosis. Current guidelines indicate that providers should not routinely order imaging or other diagnostic tests in patients with nonspecific low back pain in the absence of red-flag signs and symptoms. In general, diagnostic imaging and testing for these patients should be ordered only when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination. HEDIS Table LBP-C: If any of the following diagnosis codes accompany a low back pain diagnosis, then evaluation by imaging is appropriate within the first 28 days: Cancer , , V10 ICD-9-CM Diagnosis Trauma , , , , , , 929, 952, IV drug abuse , 304.4, Neurologic impairment , If the history and physical examination does not reveal any of the above diagnoses or other red-flag signs and symptoms, but the member still wants an imaging study right away: 1. Explain that most people with lower-back pain feel better in about a month, whether or not they have an imaging test. 2. Suggest simple steps such as over-the-counter pain medicine, walking and other ways of staying active, using heat, avoid sleeping on the stomach, massage, etc. 3. Warn that X-rays and CT scans use radiation, and exposure to unnecessary radiation should be avoided. The amount of gonadal radiation from a single plain radiograph (2 views) of the lumbar spine equals being exposed to a daily chest radiograph for more than 1 year. Chou, R., Qaseem, A., & Snow, V., et al. (2007). Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. American College of Physicians, Annals of Internal Medicine, 147(7),

14 Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) of the 2015 PBH measure: The percentage of adult members who were hospitalized and discharged with a diagnosis of Acute Myocardial Infarction (AMI) and who received persistent betablocker treatment for 6 months after discharge. Table PBH-B: Beta-Blocker Medications Noncardioselective beta-blockers Carteolol Carvedilol Labetalol Nadolol Penbutolol Pindolol Prescription Propranolol Timolol Sotalol Cardioselective betablockers Acebutolol Atenolol Betaxolol Bisoprolol Metoprolol Nebivolol Antihypertensive combinations Atenolol-chlorthalidone Bendroflumethiazide-nadolol Bisoprolol-hydrochlorothiazide Hydrochlorothiazide-metoprolol Hydrochlorothiazide-propranolol Please ensure that your patient consistently fills a beta-blocker medication each month for the 6 months following a discharge from the hospital after an AMI.