Table 3. Initial, recommended set of adult health care quality measures

Identifying Health Care Quality Measures for Medicaid-Eligible Adults

No.NQF IDa>Measure Owner>Measure Namep>ong> Denominator>NumeratorMUb

Prevention & Health Promotion

1

0039

NCQA

Flu Shots for Adults Ages 50-64

(Collected as part of HEDIS CAHPS Supplemental Survey)

The number of patients ages 50-64 years who responded "Yes" or "No" to the question "Have you had a flu shot since September 1, YYYY?"

The number of patients in the denominator who responded "Yes" to the question "Have you had a flu shot since September 1?"

 

2

0421

CMS

Preventive Care and Screening: Body Mass Index (BMI) Screening and Followup

All patients aged 18 years and older.

Patients with BMI calculated within the past 6 months or during the current visit and a followup plan documented if the BMI is outside parameters.

X

3

0031

NCQA

Breast Cancer Screening

Women ages 42-69 as of December 31 of the measurement year. (Note: Given the measurement look-back period, women 40-69 will be captured in this measure.)

One or more mammograms during the measurement year or the year prior to the measurement year.

X

4

0032

NCQA

Cervical Cancer Screening

Women 24-64 years of age as of December 31 of the measurement year.

(Note: Given the measurement look-back period, women 21-64 years will be captured in this measure.)

Women who received one or more Pap tests during the measurement year or the 2 years prior to the measurement year.

X

5

NA

RAND

Alcohol Misuse: Screening, Brief Intervention, Referral for Treatment

1. Alcohol Screening: Patients from the NEXUS Clinics cohort eligible for alcohol misuse screening

2. Alcohol Brief Intervention: Patients from the NEXUS Clinic Cohort screened for alcohol misuse with the AUDIT-C who exceed a threshold score of 5 and who were not seen in a substance use disorders addiction program in the prior 90 days.

1. Alcohol Screening: Patients screened annually for alcohol misuse with the 3-item AUDIT-C with item-wise recording of item responses, total score, and positive or negative result of the AUDIT-C in medical record.

2. Alcohol Brief Intervention: Patients screened for alcohol misuse with AUDIT-C who meet or exceed a threshold score who have brief alcohol counseling documented in the medical record within 14 days of the positive screen.

 

6

0027

NCQA

Medical Assistance With Smoking and Tobacco Use Cessation

Members 18 years and older as of December 31 of the measurement year who respond to the survey and indicate that they were current smokers or tobacco users.

The number of members in the denominator who indicated that they received advice to quit from a doctor or other health provider by answering the question as "Sometimes" or "Usually" or "Always."

X

7

0418

CMS

Screening for Clinical Depression and Followup Plan

All patients aged 18 years and older.

Patients screening for clinical depression using a standardized tool AND followup plan is documented.

 

8

NA

NCQA

Plan All-Cause Readmission

Count of Index Hospital Stays (IHS).

Count of 30-day readmissions.

 

9

0272

AHRQ

PQI 01: Diabetes, Short-Term Complica-Tions

Population in Metro Area or county, age 18 years and older.

All non-maternal/non-neonatal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for short-term complications (ketoacidosis, hyperosmolarity, coma).

 

10

0273

AHRQ

PQI 02: Perforated Appendicitis

Number of discharges with diagnosis code for appendicitis in any field in MSA or county.

Discharges with ICD-9-CM diagnosis code for perforations or abscesses of appendix in any field.

 

11

0274

AHRQ

PQI 03: Diabetes, Long-Term Complica-Tions

Population in Metro Area or county, age 18 years and older.

Discharges of age 18 years and older with ICD-9-CM principal diagnosis code for long-term complications (renal, eye, neurological, circulatory, or complications not otherwise specified).

 

12

0275

AHRQ

PQI 05: Chronic Obstructive Pulmonary Disease

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for COPD.

 

13

0276

AHRQ

PQI 07: Hypertension

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for hypertension.

 

14

0277

AHRQ

PQI 08: Congestive Heart Failure

Population in Metro Area or county, age 18 years and older.

All non-maternal/non-neonatal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for CHF.

 

15

0280

AHRQ

PQI 10: Dehydration

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for hypovolemia.

 

16

0279

AHRQ

PQI 11: Bacterial Pneumonia

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for bacterial pneumonia.

 

17

0281

AHRQ

PQI 12: Urinary Tract Infection Admission Rate

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code of urinary infections.

 

18

0282

AHRQ

PQI 13: Angina Without Procedure

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for angina.

 

19

0638

AHRQ

PQI 14: Uncontrolled Diabetes Admission Rate

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for uncontrolled diabetes, without mention of a short-term or long-term complication.

 

20

0283

AHRQ

PQI 15: Adult Asthma

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code of asthma.

 

21

0285

AHRQ

PQI 16: Lower Extremity Amputations Among Patients With Diabetes

Population in Metro Area or county, age 18 years and older.

All non-maternal discharges of age 18 years and older with ICD-9-CM procedure code for lower-extremity amputation in any field and diagnosis code of diabetes in any field.

 

Management of Acute Conditions

22

0052

NCQA

Use of Imaging Studies for Low Back Pain

Members 18 years as of January 1 of the measurement year to 50 years as of December 31 of the measurement year.

Members who received an imaging study (plain x-ray, MRI, CT scan) conducted on the Index Episode Start Date or in the 28 days following the Index Episode Start Date.

X

23

0640

TJC

HBIPS-2 Hours of Physical Restraint Use

Number of psychiatric inpatient hours overall and stratified by age group: children (age 1 through 12 years), adolescents (age 13 through 17), adults (age 18 through 64), older adults (age > 65 years).

The number of hours that all psychiatric inpatients were maintained in physical restraint.

 

24

0576

NCQA

Followup After Hospitaliz-ation for Mental Illness

Members 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal mental health diagnosis on or between January 1 and December 1 of the measurement year. The denominator for this measure is based on discharges, not members. Include all discharges for members who have more than one discharge on or between January 1 and December 1 of the measurement year.

Rate 1: Members who had an outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 30 days after discharge. Include outpatient visits, intensive outpatient encounters, or partial hospitalizations that occur on the date of discharge.

Rate 2: Members who had an outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days after discharge. Include outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on the date of discharge.

 

25

0476

Providence St. Vincent Medical Center

Appropriate Use of Antenatal Steroids

Total number of mothers who delivered preterm infants (24-32 weeks with preterm premature rupture of membranes, or 24-34 weeks with intact membranes).

The number of mothers receiving antenatal steroids (corticosteroids administered IM) during pregnancy at any time prior to delivery of a preterm (24-32 weeks with preterm premature rupture of membranes, or 24-34 weeks with intact membranes) infant.

 

26

0469

Hospital Corpor-ation of America

Elective Delivery Prior to 39 Completed Weeks Gestation

All babies delivered at term (> or equal to 37 completed weeks gestation).

Any baby electively delivered prior to 39 completed weeks gestation.

 

27

0648

AMA-PCPI

Timely Transmission of Transition Record (Inpatient Discharges to Home/Self-Care or Any Other Site of Care)

All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self-care or any other site of care.

Patients for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for followup care within 24 hours of discharge.

 

28

0647

AMA-PCPI

Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self-Care or Any Other Site of Care)

(Inpatient Discharges to Home/Self-Care or Any Other Site of Care)

All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self-care or any other site of care.

Patients or their caregiver(s) who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the following elements:

Inpatient Care

  • Reason for inpatient admission, AND
  • Major procedures and tests performed during inpatient stay and summary of results, AND
  • Principal diagnosis at discharge

Post-Discharge/ Patient Self-Management

  • Current medication list, AND
  • Studies pending at discharge (e.g., laboratory, radiological), AND
  • Patient instructions

Advance Care Plan

  • Advance directives or surrogate decisionmaker documented OR
    Documented reason for not providing advance care plan

Contact Information/Plan for Follow-up Care

  • 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND
  • Contact information for obtaining results of studies pending at discharge, AND
  • Plan for followup care, AND
  • Primary physician, other health care professional, or site designated for followup care
 

Management of Chronic Conditions

29

0071

NCQA

Persistence of Beta-Blocker Treatment After a Heart Attack

Members 18 years of age and older as of December 31 of the measurement year who were discharged alive from an acute inpatient setting with an acute myocardial infarction (AMI) from July 1 of the year prior to the measurement year to June 30 of the measurement year.

Members with a 180-day course of treatment with beta-blockers.

 

30

0018

NCQA

Controlling High Blood Pressure

Members 18-85 years of age as of December 31 of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension during the first 6 months of the measurement year.

Members whose most recent blood pressure is adequately controlled during the measurement year. For a member's blood pressure to be controlled, both the systolic and diastolic blood pressure must be <140/90.

X

31

0074

AMA-PCPI

Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL Cholesterol

All patients aged 18 years and older with CAD.

Patients who were prescribed lipid-lowering therapy.

X

32

0075

NCQA

Compre-hensive Ischemic Vascular Disease Care: Complete Lipid Profile and LDL-C Control Rates

Patients 18 years of age or older as of December 31 of the measurement year who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) from January 1 to November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease during the measurement year and the year prior to the measurement year.

Complete Lipid Profile Rate (Numerator 1):
Patients with a complete lipid profile performed during the measurement year, as identified by claim/encounter or electronic laboratory data.

LDL-C Control Rate (Numerator 2):
Patients with an LDL-C value <100 mg/dL.

X

33

0063

NCQA

Diabetes: Lipid Profile

Patients 18-75 years of age as of December 31 of the measurement year who had a diagnosis of diabetes (type 1 or type 2). Patients with diabetes can be identified during the measurement year, or year prior to the measurement year through:

Pharmacy data: Patients who were prescribed insulin or oral hypoglycemics/ antihyperglycemics on an ambulatory basis. Prescriptions to identify patients with diabetes include insulin prescriptions (drug list is available) and oral hypoglycemics/ antihyperglycemics prescriptions (drug list is available).

A diagnosis of diabetes on the problem list or at least two visits with diabetes listed as a diagnosis.

An LDL-C test performed during the measurement year. Documentation in the medical record must include, at a minimum, a note indicating the date on which the LDL-C test was performed and the result.

 

34

0057

NCQA

Compre-hensive Diabetes Care:

  • Hemoglobin A1c testing

Members 18-75 years of age as of December 31 of the measurement year who had a diagnosis of diabetes (type 1 or type 2). Patients with diabetes can be identified during the measurement year, or year prior to the measurement year through:

Pharmacy data: Members who were dispensed insulin or oral hypoglycemics/ antihyperglycemics on an ambulatory basis.

Claim/encounter data: Members who had two face-to-face encounters, in an outpatient setting or nonacute inpatient setting, on different dates of service, with a diagnosis of diabetes, or one face-to-face encounter in an acute inpatient or emergency department setting during the measurement year or the year prior to the measurement year. The organization may count services that occur over both years.

An HbA1c test performed during the measurement year, as identified by claim/encounter or automated laboratory data or by documentation in the medical record. Documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result or finding. The organization may count notation of the following in the medical record: A1c, HbA1c, Hemoglobin A1c, Glycohemoglobin A1c; HgbA1c.

 

35

0036

NCQA

Use of Appropriate Medications for People With Asthma

Members 5-56 years of age by December 31 of the measurement year with persistent asthma, reported in two age stratifications (5-11, 12-50) and a total rate.

Members who were dispensed at least one prescription for a preferred therapy during the measurement year.

X

36

0403

NCQA

HIV/AIDS: Medical Visit

All patients, regardless of age, with a diagnosis of HIV/AIDS seen within a 12-month period.

Patients with at least one medical visit* in each 6-month period with a minimum of 60 days between each visit.

*Definition of "medical visit": any visit with a health care professional who provides routine primary care for the patient with HIV/AIDS (may be a primary care physician, ob/gyn, pediatrician, or infectious diseases specialist).

 

37

0105

NCQA

Antidepres-sant Medication Management

Members 18 years of age and older as of April 30 of the measurement year.

Effective Acute Phase Treatment: At least 84 days (12 weeks) of continuous treatment with antidepressant medication during the 114-day period following the Index Prescription Start Date (inclusive). The continuous treatment allows gaps in medication treatment up to a total of 30 days during the 114-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication. Regardless of the number of gaps, there may be no more than 30 gap days.

Effective Continuation Phase Treatment: At least 180 days (6 months) of continuous treatment with antidepressant medication during the 231-day period following the Index Prescription Start Date (inclusive). Continuous treatment allows gaps in medication treatment up to a total of 51 days during the 231-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication. Regardless of hte number of gaps, gap days may total no more than 51.

X

38

NA

RAND

Bipolar I Disorder 2: Annual Assessment of Weight or BMI, Glycemic Control, and Lipids

This indicator will be evaluated for the following populations: (1) Patients with bipolar disorder, (2) Patients with bipolar disorder who are taking a mood stabilizer or antipsychotic.

Patients from denominator who have had an assessment of weight/BMI, glycemic control, and lipids during the study period.

 

39

NA

RAND

Bipolar I Disorder C: Proportion of Patients with Bipolar I Disorder Treated With Mood Stabilizer Medications During the Course of Bipolar I Disorder Treatment.

All patients with bipolar I disorder.

Patients included in the denominator with evidence of (A) 12 months of any mood-stabilizing medication, (B) Any use of a mood-stabilizing agent during the study period, (C) No filled prescription for a mood stabilizer.

 

40

NA

RAND

Schizophrenia 2: Annual Assessment of Weight/BMI, Glycemic Control, Lipids

This indicator will be evaluated for the following populations: (1) Patients with schizophrenia diagnosis, (2) Patients with schizophrenia diagnosis who are taking antipsychotic medication.

All patients from the denominator with an assessment during the study period of (1) Weight or BMI, (2) Glycemic control, (3) lipids, (4) all the above, (5) at least one of the above.

 

41

NA

RAND

Schizophrenia B: Proportion of Schizophrenia Patients With Long-Term Utilization of Antipsychotic Medications

All patients with a schizophrenia diagnosis.

Those individuals who received an antipsychotic medication for the following periods of time: (A) Patients with 12 months supply of an antipsychotic medication during the study period, (B) Patients with at least one filled prescription of an antipsychotic during the study period, (C) Patients with no filled prescription for an antipsychotic during the study period.

 

42

NA

RAND

Schizophrenia C: Proportion of Selected Schizophrenia Patients with Antipsychotic polyPharmacy Utilization

All patients diagnosed with schizophrenia prescribed at least one antipsychotic agent during the study period.

Those patients in the denominator with simultaneous prescriptions for at least two oral antipsychotic agents for 90 or more days during the study period.

 

43

0021

NCQA

Annual Monitoring for Patients on Persistent Medications

Members 18 years of age and older as of December 31 of the measurement year who are on persistent medications, defined as members who received at least 180 treatment days of ambulatory medication in the measurement year .

Additional criteria for each rate:

Rate 1: Members who received at least 180 treatment days of ACE inhibitors or ARBs during the measurement year.
Rate 2: Members who received at least 180 treatment days of digoxin during the measurement year.
Rate 3: Members who received at least 180 treatment days of a diuretic during the measurement year.
Rate 4: Members who received at least 180 treatment days of anticonvulsant during the measurement year.

Rates 1-3: Members with at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. The member must meet one of the criteria to be compliant:

  • A code for a lab panel test during the measurement year.
  • A code for a serum potassium and a code for serum creatinine during the measurement year.
  • A code for serum potassium and a code for blood urea nitrogen during the measurement year.

Rate 4: Members who received at least one drug serum concentration level monitoring test for the prescribed drug in the measurement year. If the member received only one type of anticonvulsant, the drug serum concentration level test must be for the specific drug taken as a persistent medication. If a member persistently received multiple types of anticonvulsants, each anticonvulsant medication and drug monitoring test combination is counted as a unique event.

 

44

0541

PQA

Proportion of Days Covered(PDC): 5 Rates by Therapeutic Category

Patients who were dispensed at least two prescriptions in a specific therapeutic category on two unique dates of service during the measurement year.

The number of patients who met the PDC threshold during the measurement year for each therapeutic category separately. Follow the steps below for each patient to determine whether the patient meets the PDC threshold.

Step 1: Count the total days supply (covered days) within the measurement year for the specific therapeutic medication dispensed during the measurement year.
Step 2: Count the total number of days from the first day of the first fill of the relevant medication in the therapeutic category in the measurement year to the last day of the measurement year.
Step 3: Divide the total days supply (covered days) of the medication dispensed within the measurement year (Step 1) over the total number of days from the first fill of the medication in the measurement year to the last day of the measurement year (Step 2).
Step 4: Count the number of patients who met a PDC threshold of 80% or higher (as calculated in Step 3).

 

Family Experiences of Care

45

0006

AHRQ

CAHPS® Health Plan Survey v 4.0 - Adult Question-naire

Adults.

https://cahps.ahrq.gov

 

46

0007

NCQA

CAHPS Health Plan Survey v 4.0H - NCQA Supplemen-tal Items for CAHPS® 4.0 Adult Question-naire

Adults.

https://cahps.ahrq.gov

 

Availability

47

NA

NCQA

Ambulatory Care: Outpatient and Emergency Department Visits

Count of member months for the measurement year.

Outpatient Visits: Count of outpatient visits, including office or other outpatient visits, home visits, nursing facility care, domiciliary or rest home care, visits for preventive medicine, visits for newborn care, ophthalmology and optometry visits.

Emergency Department Visits: Count of emergency department visits.

 

48

NA

NCQA

Inpatient Utilization: General Hospital/ Acute Care

Count of member months for the measurement year.

Count of discharges for the following categories:

  • Total inpatient
  • Medicine
  • Surgery
  • Maternity
 

49

0004

NCQA

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Members 13 years of age and older as of December 31 of the measurement year with a new episode of alcohol or other drug during the intake period, reported in two age stratifications (13-17 years, 18+ years) and a total rate. The total rate is the sum of the two numerators divided by the sum of the two denominators.

Initiation of Alcohol and other Drug (AOD) Dependence Treatment: Members with initiation of AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of diagnosis.

Engagement of AOD Treatment: Initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days after the date of the Initiation encounter (inclusive). Multiple engagement visits may occur on the same day, but they must be with different providers in order to be counted.

X

50

NA

NCQA

Mental Health Utilization

Count of member months for the measurement year.

Count of mental health services received during the measurement year.

Inpatient: Include inpatient care at either a hospital or a treatment facility with mental health as the principal diagnosis.

Intensive outpatient and partial hospitalization: Report intensive outpatient and partial hospitalization claims/encounters in conjunction with a principal mental health diagnosis.

Outpatient or Emergency Department: Report outpatient and emergency department claims/encounters in conjunction with a principal mental health diagnosis. Count services provided by physicians and nonphysicians.

 

51

NA

NCQA

Prenatal and Postpartum Care: Postpartum Care Rate

Deliveries of live births on or between November 6 of the year prior to the measurement year and November 5 of the measurement year.

Multiple births: Women who had two separate deliveries (different dates of service) between November 6 of the year prior to the measurement year and November 5 of the measurement year should be counted twice. Women who had multiple live births during one pregnancy should be counted once in the measure.

Postpartum Care Rate:

Administrative method: A postpartum visit to an OB/GYN practitioner or midwife, family practitioner or other primary care provider for a pelvic exam or postpartum care on or between 21 and 56 days of delivery as identified by claims data.

Medical record method: A postpartum visit to an OB/GYN practitioner or midwife, family practitioner or other primary care provider on or between 21 and 56 days of delivery. Documentation in the medical record must include a note indicating the date when a postpartum visit occurred and one of the following:

  • Pelvic exam, or
  • Evaluation of weight, blood pressure, breasts, and abdomen, or notation of postpartum care, including but not limited to notation of "postpartum care," "PP care," "PP check," "6-week check," a preprinted "Postpartum Care" form in which information was documented during the visit
 

a NQF ID National Quality Forum identification numbers are used for measures that are NQF-endorsed; otherwise, NA is used.
b MU Measures with an "X" are designated Meaningful Use. Electronic medical record specifications for these measures are available from the CMS Web site at http://www.cms.gov/QualityMeasures/03_ElectronicSpecifications.asp#TopOfPage.

Return to Document

Page last reviewed December 2010
Internet Citation: Table 3. Initial, recommended set of adult health care quality measures: Identifying Health Care Quality Measures for Medicaid-Eligible Adults. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/nac/reports/nacqm11/table3.html