Attribute appropriate and inappropriate services to provider of initial visit
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1 Optimal Care for Acute Low Back Pain - Adults Primary Care Description The rate represents the percentage of members ages 18 and older with newly diagnosed acute low back pain who received optimal care for acute low back pain. Performance Measurement Period Methodology Optimal care for acute low back pain is defined as an initial office visit for low back pain and does NOT include any of the following services in the first six weeks of care: Imaging Injection therapy referral Narcotic prescription Surgical consultation January 1, 2012 through December 31, 2012 Administrative Ages Included 18 and older Products Commercial and Medicaid Continuous Enrollment Sample Size Full population Attribution Attribute appropriate and inappropriate services to provider of initial visit Sample Method Frequency Reported Provider groups with greater than 30 unique patients with a low back pain acute visit Measures Denominator Optimal Acute Care Rate % w/out Imaging within first 6 weeks % w/out Injection therapy within first 6 weeks % w/out Narcotics within first 6 weeks % w/out Surgical Consult within first 6 weeks Total number of members 18 and older on day of initial visit that meet initial low back pain visit criteria as described below: 1. Low Back Pain Diagnoses Diagnosis defined with ICD9 codes 720.1, 721.3, , 721.9, , , , 722.6, , , 724.2, 724.3, 724.4, 724.5, 724.6, , , , 738.4, 738.5, 739.3, 739.4, 846.0, 846.1,,846.2, 846.3, 846.8, 846.9, Primary Care Defined with one or more of the following: I. Physician Specialty of Family Medicine, Internal Medicine, Pediatrics, General Practice, Internal Medicine / Pediatrics, or Nurse Practitioner II. Facility Specialty of Family Medicine, Internal Medicine, or Pediatrics. 3. Office Visit (consider adding e-visits and phone visits) Defined with one or more of the following: I. CPT codes 99201, 99202, 99203, 99204, 99205, 99206, 99207, 99208, 99209, 99210, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99388, 99389, 99390, 99391, 99392, 99393, 99394, 99395, 99396, and II. Service Category Level Three Name of Office Visits Medical
2 4. Clean Period - No non-pharmacy low back pain claims (as defined by above diagnosis codes) at any facility in 180 days prior to visit Numerator The following Member Exclusions are applied: 1. Patient died prior to the end of the six week period 2. Patient resides in a nursing home 3. Patient was less than 18 on the initial visit 4. Patient was pregnant prior to the end of the six week period (identification with the maternity registry) 5. Patient had a diagnosis of one or more of the following prior to the end of the six week period: cancer, trauma, neurological impairment or IV drug abuse. (identification with the Low Back Pain analytical database/registry) 6. As indicated in ICSI guidelines, imaging non-compliance was reported only for patients < 50. Total number of members meeting initial low back pain visit criteria who did not have any of the following services within the first 6 weeks of the initial visit surgical referral, imaging, injection therapy or a narcotics prescription. This measure is reported as a percentage of guideline compliant adult acute low back pain cases compared to all adult acute low back pain cases. A higher rate indicates appropriate treatment of adults with acute low back pain care (per ICSI-guidelines) (i.e., the proportion for whom injection, surgical consult, imaging, or narcotic prescription were not done or prescribed within the first 6 weeks). A case refers to the aggregate of claims from the following: 1. A valid initial visit (see denominator section for definition) 2. The six week period following the initial visit for all other types of service and narcotic prescriptions Utilization of Selected Services outside ICSI-Guidelines for adult low back pain care includes: Pharmacy: Prescribed narcotics within the first 6 weeks of the initial visit. Non-pharmacy: 1. Cases receiving the following services: injections, imaging, and surgical referrals in the first six weeks of the initial visit. Non-Pharmacy Claim Inclusion Criteria: 1. Commercial and Medicaid Population 2. Primary Payer 3. Greater than $0 total reimbursement 4. Accepted claims Rate Calculations Pharmacy Claim Inclusion Criteria: 1. Commercial and Medicaid 2. Prescription filled between 1/1/2010 and 12/31/ Prescription for a drug with a GPI Drug Group Name includes Opioid and GPI Drug Code in (43xxxxxxxxxxxx, xxxxxx, 65xxxxxxxxxxxx) Numerator/Denominator Supporting Documents Technical Specification Primary Care
3 Low Back Pain - Optimal Care Health System-Red Wing Percent with Optimal Care within 6 weeks
4 Low Back Pain - Surgical Consult Health System-Red Wing Percent with No Surgical Consult within 6 weeks
5 Low Back Pain - Injections Health System-Red Wing Percent with No Injection within 6 weeks
6 Low Back Pain - Imaging Health System-Red Wing Percent with No Imaging within 6 weeks
7 Low Back Pain - Narcotics Use Health System-Red Wing Percent with No Narcotics within 6 weeks
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