Designing and Implementing Medicaid Disease and Care Management Programs

Exhibit 7.4. Core measures for asthma, diabetes, and congestive heart failure

 

Measure Description Data Source Measure aligns with interventions focused on: Most rapid timeframe in which change might occur Comments
Members Providers
Use of Appropriate Medications for People with Asthma (AQA and HEDIS Measure) Percentage of members with persistent asthma who received at least one prescription for an appropriate medication in the measurement year
  • Claims.
  • Case Data.*
6-12 mos This measure might be good to track in the short- to medium- term (6-18 mos).
Daily Preventive Medication Percentage of members with asthma who self-report the use of a controller medication
  • Case Data.
  • Patient Survey.
6 mos Patient self-report goals can be a good way to obtain information about an intervention's effects in a short timeframe (< 6 mos).
Written Action Plan Percentage of members with asthma who have a personal action plan for managing their asthma
  • Case Data.
  • Medical Record.
  • Patient Survey.
3-6 mos If an intervention uses action plans, this measure could be effective.
Self-Management Goal Percentage of members with asthma who have a self-management goal
  • Case Data.
  • Medical Record.
  • Patient Survey.
3-6 mos Patient self-report goals can be a good way to obtain information about an intervention's effects in a short timeframe.
Emergency Room (ER) Use Percentage of members who visited the ER for asthma in the past 12 mos
  • Claims.
  • Case Data.
  • Patient Survey.
12-18 mos Reducing ER visits can exert a significant impact on cost and quality of life.
Physician Followup Post-ER Visit or Post-Hospitalization Percentage of members who followed up with a physician after an ER visit or hospital admission
  • Claims.
  • Case Data.
  • Medical Record.
12-18 mos  
Influenza Vaccination Percentage of all members with asthma who received a influenza vaccination within the past 12 mos
  • Case Data.
  • Medical Record.
  • Patient Survey.
12-18 mos Influenza vaccination can exert a significant impact on health care expenditures in members with asthma, particularly in epidemic years. The effect will, of course, be seasonal.
HbA1c Screening (AQA and HEDIS Measure) Percentage of members who received one or more HbA1c screenings in the measurement year
  • Claims.
  • Case Data.
  • Medical Record.
  • Patient Survey.
12 mos Screening rates can be a good way to obtain information about an intervention's effects in a short timeframe.
HbA1c Control(AQA and HEDIS Measure) Percentage of members with diabetes with most recent LDL-C <130 mg/dl
  • Claims.
  • Case Data.
  • Medical Record.
  • Lab Results
12 mos  
Low Density Lipoprotein Cholesterol (LDL-C) Screening (AQA and HEDIS Measure) Percentage of members who received at least one LDL-C screening during the measurement year
  • Claims.
  • Case Data.
  • Medical Record.
  • Lab Results
12 mos Screening rates can be a good way to obtain information about an intervention's effects in a short timeframe.
LDL-C Level(<130mg/dl)(AQA Measure) Percentage of members with diabetes with most recent LDL-C <130 mg/dl
  • Claims.
  • Case Data.
  • Medical Record.
  • Lab Results.
12 mos Seeing a change in clinical outcomes, such as cholesterol levels, might take a year or more.
LDL-C Level (<100mg/dl) (AQA and HEDIS Measure) Percentage of members with diabetes with most recent LDL-C <100 mg/dl
  • Claims.
  • Case Data.
  • Medical Record.
  • Lab Results.
12 mos Seeing a change in clinical outcomes, such as cholesterol levels, might take a year or more.
Nephropathy Screening (HEDIS Measure) Percentage of members with diabetes with a nephropathy screening or evidence of nephropathy
  • Claims.
  • Case Data.
  • Medical Record.
12 mos Screening rates can be a good way to obtain information about an intervention's effects in a short timeframe.
Eye Examination (AQA and HEDIS Measure) Percentage of members who received one dilated retinal examination in the measurement year
  • Claims.
  • Case Data.
  • Medical Record.
  • Patient Survey.
12 mos Screening rates can be a good way to obtain information about an intervention's effects in a short timeframe.
Foot Examination Percentage of members with diabetes who received at least one foot examination from a health care provider
  • Claims.
  • Case Data.
  • Medical Record.
  • Patient Survey.
12 mos Screening rates can be a good way to obtain information about an intervention's effects in a short timeframe.
Blood Pressure (AQA and HEDIS Measure) Percentage of members with diabetes with most recent blood pressure <140/90 mm Hg
  • Claims.
  • Case Data.
  • Medical Record.
12 mos Seeing a change in clinical outcomes, such as blood pressure, might take a year or more.
ASA (aspirin)/Antiplatelet Therapy Percentage of members with diabetes who were prescribed ASA/antiplatelet therapy
  • Claims.
  • Case Data.
  • Medical Record.
6 mos  
Self-Management Goal Percentage of members with diabetes who have a self-management goal
  • Case Data.
  • Medical Record.
  • Patient Survey.
6 mos Self-management goals can be useful in gauging patient activation.
Influenza Vaccination Percentage of all members with diabetes who received a influenza vaccination within the past 12 mos
  • Case Data.
  • Medical Record.
  • Patient Survey.
12 mos  
LDL-C Intensification Percentage of members with diabetes with:
  • Most recent LDL-C <100 mg/dl or
  • LDL-C =100 mg/dl and on highest dose statin or
  • Statin started or statin increased within 6 mos of last value
  • Case Data.
  • Medical Record.
  • Lab Results.
12 mos This measure represents a more sensitive "hybrid" indicator of change in provider behavior and improved quality of care.
New York Heart Association (NYHA) Functional Classification Percentage of members who have documentation of NYHA classification
  • Case Data.
  • Medical Record.
  12 mos  
Blood Pressure Percentage of members with congestive heart failure (CHF) with most recent blood pressure <140/80 mm Hg
  • Claims.
  • Case Data.
  • Medical Record.
  • Lab Results.
12 mos Seeing a change in clinical outcomes, such as blood pressure, might take a year or more.
Beta Blocker Therapy after a Heart Attack (HEDIS) Percentage of members who were discharged from a hospital for AMI and received persistent beta-blocker treatment for 6 mos after discharge
  • Claims.
  • Case Data.
6-12 mos This measure could be good for tracking in the short- to medium-term (6-12 mos).
Cholesterol Management for Patients with a Cardiovascular Condition (HEDIS) Percentage of members who had a cholesterol screening in the measurement year after an AMI discharge
  • Claims.
  • Case Data.
  • Medical Record.
  • Lab Results.
  12-18 mos  
Left Ventricular Function (LVF) Assessment (AQA Measure) Percentage of members with CHF who have the results of an LVF assessment recorded
  • Claims.
  • Case Data.
  • Medical Record.
  12-18 mos  
ACE Inhibitor or Angiotensin Receptor (ARB) Therapy (AQA Measure) Percentage of members who have CHF and an LVSD who were prescribed ACEI or ARB
  • Claims.
  • Case Data.
  6-12 mos  
Emergency Room (ER) Use Percentage of CHF members with an ER visit for CHF in the past 12 mos
  • Claims.
  • Case Data.
12 mos Reducing ER visits can exert a significant impact on cost and quality of life.
Physician Followup Post-ER Visit or Post-Hospitalization Percentage of CHF members who followed up with a physician within 30 days after an ER visit or hospital admission
  • Claims.
  • Case Data.
  • Patient Survey.
12-18 mos  
Self-Management Goal Percentage of members with CHF who have a self-management goal
  • Case Data.
  • Medical Record.
  • Patient Survey.
6 mos Self-management goals can be useful in gauging patient activation.
Weight Self-Monitoring Percentage of CHF members who monitor their weight daily
  • Case Data.
  • Patient Survey.
6-12 mos This goal is useful in assessing patient activation.
Influenza Vaccination Percentage of all members with CHF who received a influenza vaccination within the last 12 mos
  • Case Data.
  • Medical Record.
  • Patient Survey.
12 mos  

*Case data is collected by care managers during the process of delivering care management (e.g., through assessments, telephonic care management).

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Page last reviewed October 2014
Internet Citation: Exhibit 7.4. Core measures for asthma, diabetes, and congestive heart failure. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/medicaidmgmt/exhibit7-4.html