Cmprehensive Diabetes Care fr Peple with Severe Mental Illness (based n HEDIS Cmprehensive Diabetes Care (nt NQF-endrsed) and Minnesta Cmmunity Measurement s Optimal Diabetes Care (NQF #0729)) Measure Dimensin Current Specificatin Denminatr Age Benefit Cntinuus Enrllment Denminatr Details 18 t 75 years f age. Medical N mre than ne gap in enrllment f up t 45 days during the measurement year. T determine cntinuus enrllment fr a Medicaid beneficiary fr whm enrllment is verified mnthly, the member may nt have mre than a 1-mnth gap in cverage (i.e., a member whse cverage lapses fr 2 mnths [60 days] is nt cnsidered cntinuusly enrlled). Step 1: In claims data, identify diagnsis f Biplar Disrder, Schizphrenia r Majr Depressin: Identify individuals with schizphrenia, biplar I disrder r majr depressin as thse wh met at least ne f the fllwing criteria during the measurement year: At least ne acute inpatient claim/encunter with any diagnsis f schizphrenia, biplar I disrder r majr depressin. At least tw visits in an utpatient, intensive utpatient, partial hspitalizatin, ED r nnacute inpatient setting, n different dates f service with any diagnsis f schizphrenia r biplar I disrder. Step 2: Of the patients identified in Step 1, identify individuals with diabetes: There are tw ways t identify individuals with diabetes: by pharmacy data and by claim/encunter data. The rganizatin must use bth methds t identify the eligible ppulatin, but an individual need nly be identified by ne t be included in the measure. Individuals may be identified as having diabetes during the measurement year r the year prir t the measurement year. Pharmacy data Individuals wh were dispensed insulin r ral hypglycemics/antihyperglycemics n an ambulatry basis. Numeratr Claim/encunter data. Individuals wh had a diagnsis f diabetes n claims fr either (a) tw face-t-face encunters in an utpatient setting r nnacute inpatient setting, n different dates f service; r (b) ne face-t-face encunter in an acute inpatient r ED setting. Ttal number f individuals wh had each f the fllwing during the measurement year: Hemglbin A1c (HbA1c) testing HbA1c pr cntrl (>9.0%) HbA1c cntrl (<8.0%) HbA1c cntrl (<7.0%) Eye exam LDL-C Screening LDL-C cntrl (<100 mg/dl) Medical attentin fr nephrpathy Bld Pressure Cntrl <140/90 mm Hg Page 1
Dimensin Numeratr Details Current Specificatin Current tbacc use status and cessatin cunseling r treatment ffered Fr individuals with a diagnsis f ischemic vascular disease, dcumentatin f daily aspirin use r dcumentatin f an accepted cntraindicatin HbA1c Testing: At a minimum, dcumentatin in the medical recrd must include a nte indicating the date when the HbA1c test was perfrmed and the result. Organizatins cunt ntatin f the fllwing in the medical recrd as HbA1c testing: A1c, Hemglbin A1c, HgbA1c, HbA1c, Glychemglbin A1c. HbA1c Pr Cntrl >9%: The member is numeratr cmpliant if the mst recent HbA1c level is >9.0%. The member is nt numeratr cmpliant if the result fr the mst recent HbA1c test during the measurement year is 9.0% r is missing a result, r if an HbA1c test was nt dne during the measurement year. HbA1c Cntrl <8%: The member is numeratr cmpliant if the mst recent HbA1c level is <8.0%. The member is nt numeratr cmpliant if the result fr the mst recent HbA1c test is 8.0% r is missing a result, r if an HbA1c test was nt dne during the measurement year. HbA1c cntrl <7.0%*: The member is numeratr cmpliant if the mst recent HbA1c level is <7.0%. The member is nt numeratr cmpliant if the result fr the mst recent HbA1c test is 7.0% r is missing a result, r if an HbA1c test was nt perfrmed during the measurement year. *Nte: Additinal exclusin criteria are required fr this indicatr that will result in a different eligible ppulatin frm all ther indicatrs. See exclusin sectin fr mre infrmatin. Eye Exam: At a minimum, dcumentatin in the medical recrd must include ne f the fllwing. A nte r letter prepared by an phthalmlgist, ptmetrist, PCP r ther health care prfessinal indicating that an pthalmscpic exam was cmpleted by an eye care prfessinal, the date when the prcedure was perfrmed and the results, r A chart r phtgraph f retinal abnrmalities indicating the date when the fundus phtgraphy was perfrmed and evidence that an eye care prfessinal reviewed the results. Alternatively, results may be read by a qualified reading center that perates under the directin f a medical directr wh is a retinal specialist. LDL-C Screening: At a minimum, dcumentatin in the medical recrd must include a nte indicating the date when the LDL-C test was perfrmed and the result. The rganizatin may use a calculated r direct LDL fr LDL-C screening. Lipid management: LDL-C cntrl <100 mg/dl: Dcumentatin in the medical recrd must include, at a minimum, a nte indicating the date when the LDL-C test was perfrmed and the result. The member is numeratr cmpliant if the mst recent LDL-C level is <100 mg/dl. If the result fr the mst recent LDL-C test during the measurement year is 100 mg/dl r is missing, r if an LDL-C test was nt perfrmed during the measurement year, the member is nt numeratr cmpliant. Page 2
Dimensin Current Specificatin The rganizatin may calculate LDL-C levels frm ttal chlesterl, HDL-C and triglycerides using the Friedewald equatin if the triglycerides are less than r equal t 400 mg/dl. (LDL-C) = (ttal chlesterl) (HDL) (triglycerides/5) If lipprtein (a) is measured, use the fllwing calculatin. (LDL-C) = (ttal chlesterl) (HDL) (triglycerides/5) 0.3 [lipprtein (a)] These frmulae are used when all levels are expressed in mg/dl and cannt be used if triglycerides >400 mg/dl. The Friedewald equatin may nt be used if a direct r calculated result is present in the medical recrd fr the mst recent LDL-C test. Medical Attentin fr Nephrpathy: Nephrpathy screening test. At a minimum, dcumentatin must include a nte indicating the date when a urine micralbumin test was perfrmed, and the result. Any f the fllwing meet the criteria fr a urine micralbumin test: 24-hur urine fr micralbumin Timed urine fr micralbumin Spt urine fr micralbumin Urine fr micralbumin/creatinine rati 24-hur urine fr ttal prtein Randm urine fr prtein/creatinine rati Evidence f nephrpathy. Any f the fllwing meet the criteria fr evidence f nephrpathy. Dcumentatin f a visit t a nephrlgist. Dcumentatin f a renal transplant. Dcumentatin f medical attentin fr any f the fllwing (n restrictin n prvider type): Diabetic nephrpathy ESRD CRF Chrnic kidney disease (CKD) Renal insufficiency Prteinuria Albuminuria Renal dysfunctin Acute renal failure (ARF) Dialysis, hemdialysis r peritneal dialysis A psitive urine macralbumin test. At a minimum, dcumentatin in the medical recrd must include a nte indicating the date when the test was perfrmed, and a psitive result. Any f the fllwing meet the criteria fr a psitive urine macralbumin test: Psitive urinalysis (randm, spt r timed) fr prtein Psitive urine (randm, spt r timed) fr prtein Psitive urine dipstick fr prtein Page 3
Dimensin Current Specificatin Psitive tablet reagent fr urine prtein Psitive result fr albuminuria Psitive result fr macralbuminuria Psitive result fr prteinuria Psitive result fr grss prteinuria Nte: Trace urine macralbumin test results are nt cnsidered numeratr cmpliant. Evidence f ACE inhibitr/arb therapy. Dcumentatin in the medical recrd must include, at minimum, a nte indicating that the member received an ambulatry prescriptin fr ACE inhibitrs/arbs in the measurement year BP Cntrl <140/90 mm Hg: Organizatins shuld use the medical recrd frm which it abstracts data fr the ther CDC indicatrs. If the rganizatin des nt abstract fr ther indicatrs, it shuld use the medical recrd f the prvider that manages the member s diabetes. If that medical recrd des nt cntain a BP, the rganizatin may use the medical recrd f anther PCP r specialist frm whm the member receives care. T determine if BP is adequately cntrlled, the rganizatin must identify the representative BP fllwing the steps belw Step 1: Identify the mst recent BP reading nted during the measurement year. D nt include BP readings that meet the fllwing criteria: Taken during an acute inpatient stay r an ED visit Taken during an utpatient visit which was fr the sle purpse f having a diagnstic test r surgical prcedure perfrmed (e.g., sigmidscpy, remval f a mle) Obtained the same day as a majr diagnstic r surgical prcedure (e.g., stress test, administratin f IV cntrast fr a radilgy prcedure, endscpy) Reprted by r taken by the individual Step 2: Identify the lwest systlic and lwest diastlic BP reading frm the mst recent BP ntatin in the medical recrd. If there are multiple BPs recrded fr a single date, use the lwest systlic and lwest diastlic BP n that date as the representative BP. The systlic and diastlic results d nt need t be frm the same reading when multiple readings are recrded fr a single date. Minnesta Cmmunity Measurement Optimal Diabetes Care Indicatrs: Current Tbacc Use and Cessatin Cunseling r Treatment: Dcumentatin f current tbacc use (1 = tbacc user; 2 = nn-tbacc user; 3 = Nt knwn). If individual is identified as a current tbacc user, date f cessatin cunseling r treatment during the measurement year is dcumented. Aspirin Use: Dcumentatin in the medical recrd f daily aspirin use OR dcumentatin f an accepted cntraindicatin (any date) fr individuals diagnsed with ischemic vascular disease during the measurement year r year prir t the measurement year. The fllwing are accepted aspirin r anti-platelet medicatins: Aspirin Plavix (clpidgrel) Page 4
Dimensin Current Specificatin Ticlid (ticlpidine) Pravigard (aspirin/pravastatin) Aggrenx (aspirin/dypyridamle) Lw dse enteric-cated 81 mg aspirin (Ectrin r Bayer) Accepted cntraindicatins: Anticagulant use, Lvenx (Enxaparin) r Cumadin (Warfarin) Any histry f gastrintestinal (GI)* r intracranial bleed (ICB) Allergy t ASA *Gastresphgeal reflux disease (GERD) is nt autmatically cnsidered a cntraindicatin but may be included if specifically dcumented as a cntraindicatin by the physician. Cntraindicatin cnsideratins: If ASA date field is cmpleted (individual is taking ASA), leave the ASA cntraindicatin date field blank. Fr patients taking Cumadin r Lvenx AND ASA, enter the aspirin use date and NOT the cntraindicatin date. Cntraindicatin date des nt need t be in the measurement perid. If nly the mnth and year is knwn, i.e., GI Bleeding-June 2007, enter a valid date t indicate the time, i.e., 6/01/2007. Lk back at least 3 r mre years fr cntraindicatin date. If individual is n anticagulant, enter the mst recent date. If the ASA has been discntinued prir t a surgical prcedure, d nt cunt this as a cntraindicatin. Dcument this individual as taking aspirin during the measurement perid. If there is n dcumentatin f aspirin use, anti-platelets, r a cntraindicatin, then bth date fields shuld be blank. Exclusins fr aspirin use: The fllwing may be exclusins if specifically dcumented by the physician: Use f nn-steridal anti-inflammatry agents Dcumented risk fr drug interactin Uncntrlled hypertensin defined as >180 mmhg systlic, >110 mmhg diastlic pressure Other prvider dcumented reasn fr nt being n ASA therapy Exclusins Required exclusins fr HbA1c Cntrl <7%: Exclude members wh meet any f the fllwing criteria. 65 years f age and lder as f December 31 f the measurement year. ABG r PCI. Dated dcumentatin f CABG r PCI in the measurement year r the year befre the measurement year. IVD. Dcumentatin f an IVD diagnsis. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year. Apprpriate diagnses include: IVD. Ischemic heart disease. Angina. Crnary athersclersis. Crnary artery cclusin. Cardivascular disease. Occlusin r stensis f precerebral arteries (including basilar, cartid and vertebral arteries). Athersclersis f renal artery. Athersclersis f native arteries f the extremities. Chrnic ttal cclusin f artery f the extremities. Page 5
Dimensin Arterial emblism and thrmbsis. Atheremblism. Current Specificatin Thracabdminal r thracic artic aneurysm. Dcumentatin f thracabdminal aneurysm r thracic artic aneurysm. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year. CHF. Dcumentatin f CHF r cardimypathy diagnsis. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year. Prir MI. Dcumentatin f prir MI. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year. CRF/ESRD. Dcumentatin f Stage 4 r 5 CRF r ESRD. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year. Dementia. Dcumentatin f dementia. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year. Blindness. Dcumentatin f blindness in ne r bth eyes. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year. Amputatin (lwer extremity). Dcumentatin f lwer extremity amputatin. Lk as far back as pssible in the member s histry thrugh December 31 f the measurement year Optinal Exclusins: Individuals with a diagnsis f plycystic varies wh did nt have a face-t-face encunter, in any setting, with a diagnsis f diabetes during the measurement year r the year prir t the measurement year. Diagnsis may ccur at any time in the individual s histry, but must have ccurred by December 31 f the measurement year. Individuals with gestatinal r sterid-induced diabetes wh did nt have a face-tface encunter, in any setting, with a diagnsis f diabetes during the measurement year r the year prir t the measurement year. Diagnsis may ccur during the measurement year r the year prir t the measurement year, but must have ccurred by December 31 f the measurement year. Nte: Organizatins that apply ptinal exclusins must exclude individuals frm the denminatr fr all indicatrs. Page 6