Breast Cancer Screening
A HEDIS®-like measure

Description: The percentage of women 40-69 years of age (as of 12/31 of the measurement year) who had a mammogram to screen for breast cancer.

Administrative Specification
Denominator: The eligible population.
Numerator: One or more mammograms during the measurement year or the year prior to the measurement year.

Cervical Cancer Screening
A HEDIS®-like measure

Description: The percentage of women 21-64 years of age (as of 12/31 of the measurement year) who received one of more Pap tests to screen for cervical cancer.

Administrative Specification
Denominator: The eligible population
Numerator: One or more Pap tests during the measurement year or the two years prior to the measurement year.

Chlamydia Screening in Women
A HEDIS®-like measure

Description: The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year.
Event/Diagnosis: Sexually active. Two methods identify sexually active women: pharmacy data and claim/encounter data. The organization must use both methods to identify the eligible population; however, a member only needs to be identified in one method to be eligible for the measure.
Pharmacy data: Members who were dispensed prescription contraceptives during the measurement year.

Administrative Specification
Denominator: The eligible population.
Numerator: At least one Chlamydia test during the measurement year as documented through administrative data. A woman is counted as having had a test if she had a claim/encounter with a service data during the measurement year.

Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)
A HEDIS®-like measure

Description: The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge.

Definition:
Treatment days (covered days): The actual number of calendar days covered with prescriptions within the specified 180-day measurement interval (i.e. a prescription of 90 days supply dispensed on the 100th day will have 80 days counted in the 180-day interval)

Eligible Population:
Event/Diagnosis: Discharged alive from an acute inpatient settling with an AMI from July 1 of the year prior to the measurement year through June 30 of the measurement year.

If a member has more than one episode of AMI from July 1 of the year prior to the measurement year though June 30 of the measurement year, the organization should only include the first discharge.

Administrative Specification
Denominator: The eligible population.
Numerator: A 180-day course of treatment with beta-blockers.
Identify all members in the denominator population whose dispensed days supply is ≥135 days in the 180 days following discharge. Persistence of treatment for this measure is defined as at least 75 percent of the days supply filled.

To determine continuity of treatment during the 180-days period, sum the number of allowed gap days to the number of treatment days for a maximum of 180 days (i.e., 135 treatment days + 45 gap days = 180 days); identify all prescriptions filled with 180 days of the Discharge Date.

To account for members who are on beta-blockers prior to admission, the organization should factor those prescriptions into adherence rates if the actual treatment days fall within the 180 days following discharge.

Comprehensive Diabetes Care (CDC)
A HEDIS®-like measure

Description: The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following:

• Hemoglobin A1c (HbA1c) testing • LDL-C screening
• Eye exam (retinal) performed • Medical attention for nephropathy

Eligible Population:
Event/Diagnosis: Two methods identify members with diabetes: pharmacy data and claim/encounter data. The organization must use both to identify the eligible population, but a member only needs to be identified in one to be included in the measure. Members may be identified as having diabetes during the measurement year or the year prior to the measurement year.

Pharmacy Data: Members who were dispensed insulin or oral hypoglycemics/antihypercglycemics during the measurement year or year prior to the measurement year on an ambulatory basis

Administrative Specification
Denominator: A systematic sample drawn from the eligible population for each product line

Numerators:
HbA1c testing: An HbA1c test performed during the measurement years as identified by administrative data or medical record review.

Eye Exam: An eye screening for diabetic retinal disease as identified by administrative data or medical record review. This includes diabetics who had one of the following.

• A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year, or
• A negative retinal exam ( no evidence of retinopathy) by an eye care professional in the year prior to the measurement year

LDL-C Screening: An LDL-C test performed during the measurement year as identified by claim/encounter or automated laboratory data or medical record review.

Medical attention for nephropathy: A nephropathy screening test during the measurement year or evidence of nephropathy during the measurement year as documented through administrative data.

Appropriate Treatment for Children with Upper Respiratory Infection (URI)
A HEDIS®-like measure

Description: The percentage of children 3 months -18 years of age who were given diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.
Calculation: The measure if reported as an inverted rate [1 – (numerator/eligible population)]. A higher rate indicates appropriate treatments of children with URI (i.e., the proportion for whom antibiotics were not prescribed).

Definitions:
Episode Date: The date of service for any outpatient or ED visit during the Intake period with only a diagnosis of URI. Excludes claims/encounters with more than one diagnosis.
IESD Index Episode Start Date: The earliest Episode Date during the Intake period that meets all of the following criteria.

• A 30-day Negative Medication History prior to the Episode Date
• A Negative Competing Diagnosis on or 3 days after the Episode Date
• The member was continuously enrolled 30 days prior to the Episode date through 3 days after the Episode Date

Negative Medication History: To qualify for Negative Medication History, the following criteria must be met.

• A period of 30 days prior to the Episode Date during which time the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug
• No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date

A prescription is considered active if the “days supply” indicated on the date when the member filled the prescription is the number of days or more between that date and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the Intake Period.

Negative Competing Diagnosis: The Episode date and three days following the Episode Date during which the member had no claims/encounters with any competing diagnosis.

Administrative Specification
Denominator: The eligible population.
Numerator: Dispensed prescription for antibiotic medication on or three days after the IESD.

Appropriate Testing for Children with Pharyngitis (CWP)
A HEDIS®-like measure

Description: 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 testing).

Definitions:
Episode Date: The date of service for any outpatient or ED visits during the Intake period with only a diagnosis of pharyngitis. Exclude claims/encounters with more than one diagnosis.

IESD Index Episode Start Date: The earliest Episode Date during the Intake period that meets all of the following criteria:

• Linked to a dispensed antibiotic prescription on or during the three days after the Episode Date.
• A 30-day Negative Medication History prior to the Episode Date
• The member was continuously enrolled 30 days prior to the Episode Date through 3 days after the Episode Date
Negative Medication History To qualify for Negative Medication History, the following criteria must be met.
• A period of 30 days prior to the Episode Date during which time the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug
• No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date

A prescription is considered active if the “days supply” indicated on the date when the member filled the prescription is the number of days or more between that date and the relevant service date. The 30-day look-back period for pharmacy data includes the 30 days prior to the Intake Period.

Administrative Specification
Denominator: The eligible population.
Numerator: A group A streptococcus test in the seven-day period from three days prior to the IESD through three days after the IESD.

Colorectal Cancer Screening
A HEDIS®-like measure

Description: The percentage of members 50-80 years of age (as of 12/31 of the measurement year), who had appropriate screening for colorectal cancer.

Administrative Specification
Denominator: The eligible population.
Numerators: One or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

• Fecal occult blood test (FOBT) during the measurement year. Regardless of FOBT type, guaiac (gFOBT) or immunochemical (iFOBT), assume that the required number of samples was returned.
• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.
• Double contrast barium enema (DCBE) or air contrast barium enema during the measurement year or the four years prior to the measurement year.

• Colonoscopy during the measurement year or the nine years prior to the measurement year.

Childhood Immunization Status
A HEDIS®-like measure

Description: The percentage of children two years of age who had four diphtheria, tetanus and acelluar pertussis (DTaP), three polio (IPV), one measles, mumps and rubella (MMR), two H influenza type B (Hib), three hepatitis B, one chicken pox (VZV) and four pneumococcal conjugate vaccines by their second birthday. The measure calculates a rate for each vaccine and two separate combination rates.

Administrative Specification
Denominator: The eligible population.
Numerators: For MMR, hepatitis B and VZV, count any of the following:

• Evidence of the antigen or combination vaccine, or
• Documented history of the illness, or
• A seropositive test result

For DTaP, IPV, Hib and pneumococcal conjugate, count only the following:

• Evidence of the antigen or the combination vaccine

For combination vaccinations that require more than one antigen (i.e., DTaP and MMR), the organization must find evidence of all the antigens.

DTaP-Four DTaP vaccinations, with different dates of service on or before the child’s second birthday. Do not count any vaccination administered prior to 42 days after birth.

IPV-At least three IPV vaccinations, with different dates of service on or before the child’s second birthday. IPV administered prior to 42 days after birth cannot be counted.

MMR-At least one MMR vaccination, with a date of service falling on or before the child’s second birthday.

Hib-At least two Hib vaccinations, with different dates of service on or before the child’s second birthday. Hib administered prior to 42 days after birth cannot be counted.

Hepatitis B-Three hepatitis B vaccinations, with different date of service on or before the child’s second birthday.

VZV-At least one VZV vaccination, with a date of service falling on or before the child’s second birthday.

Pneumococcal Conjugate-At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday.

Combination 2 (DTaP, IPV, MMR, Hib, hepatitis B, VZV)-Children who received four DTap; three IPV; one MMR; two Hib; three hepatitis B; and one VZV vaccination on or before the child’s second birthday.

Combination 3 (DTaP, IPV, MMR, Hib, hepatitis B, VZV, pneumococcal conjugate)-Children who received all antigens listed in Combination 2 and four pneumococcal conjugate vaccinations on or before the child’s second birthday.

Lead Screening in Children (LSC)
A HEDIS®-like measure

Description: The percentage of children two years of age who had one of more capillary or venous lead blood tests for lead poisoning by their second birthday.

Administrative Specification
Denominator: The eligible population
Numerator: At least one capillary or venous blood test on or before the child’s second birthday.

Use of Appropriate Medications for People with Asthma (ASM)
A HEDIS®-like measure

Description: The percentage of members 5-56 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.

Definitions:
Dispensing event: A dispensing event is one prescription of an amount lasting 30 days or less. To calculate dispensing events for prescriptions longer than 30 days, divide the days supply by 30 and round down to convert. For example, a 100-day prescription if equal to three dispensing events (100/30 = 3.33, rounded down to 3). The organization should allocate the dispensing events to the appropriate year based on the date on which the prescription is filled.

Inhaler Dispensing Event: Inhalers count as one dispensing event; for example, an inhaler with a 90-day supply is considered one dispensing event. In addition, multiple inhalers of the same medication (as identified by Drug ID in the NDC list) filled on the same date of service should be counted as one dispensing event; for example a member may obtain two inhalers on the same day (one for home and one for work), but intend to use both during the same 30-day period. The organization should allocate the dispensing events to the appropriate year based on the date on which the prescription is filled.

Eligible Population
Event/Diagnosis
Step 1
Follow the steps below to identify the eligible population for the measure.
Identify members as having persistent asthma who met at least one of the following criteria during the measurement year and the year prior to the measurement year. Criteria need not be the same across both years.

• At least one ED visit with asthma as the principal diagnosis
• At least one acute inpatient discharge with asthma as the principal diagnosis
• At least four outpatient asthma visits with asthma as one of the listed diagnoses and at least two asthma medication dispensing events
• At least four asthma medication dispensing events

Step 2
A member identified as having persistent asthma because of at least four asthma medication dispensing events, where leukotriene modifiers were the sole asthma medication dispensing in that year, must also meet the following criterion.

• Have at least one diagnosis of asthma, in any setting, in the same year as the leukotriene modifier (i.e., measurement year or year prior to the measurement year).

Administrative Specification
Denominator: The eligible population.
Numerator: Dispensed at least one prescription for a preferred therapy during the measurement year.

Antidepressant Medication Management
A HEDIS®-like measure

Description: The percentage of members 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported.

• Effective Acute Phase Treatment. The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks).
• Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months).

Definitions:
IESD Index Episode Start Date: The earliest encounter during the Intake Period with any diagnosis of major depression (Table AMM-A) that meets the following criteria:

• A 120-day Negative Diagnosis History
• A 90-day Negative Medication History

For an inpatient (acute or nonacute) claim/encounter, the IESD is the date of discharge.

For a transfer, the IESD is the discharge date from the facility to which the member was transferred.

Negative Diagnosis History: A period of 120 days (4 months) prior to the IESD, during which time the member had no claims/encounters with any diagnosis of major depression or prior episodes of depression

IPSD Index Prescription Start Date: The earliest prescription dispensing date for an antidepressant medication during the period of 30 days prior to the IESD (inclusive) through 14 days after the IESD (inclusive).

Negative Medication Diagnosis: A period of 90 days (3 months) prior to the IPSD, during which time the member had no pharmacy claims for either new or refill prescriptions for an antidepressant medication

Treatment Days: The actual number of calendar days covered with prescriptions within the specified 180-day measurement interval. For Effective Continuation Phase Treatment, a prescription of 90 days supply dispensed on the 100th day will have 80 days counted in the 190-day interval.

Eligible Population:
Event/Diagnosis:
The organization should follow the steps below to identify the eligible population, which should be used for both rates.

Step 1
Identify all members who met at least one of the following criteria during the Intake Period.
• At least one principal diagnosis or major depression in any setting or
• At least two visits in an outpatient, ED, intensive outpatient or partial hospitalization setting on different dates of service with any diagnosis of major depression or
• At least one acute or nonacute inpatient discharge with any diagnosis of major depression

Step 2
Determine the IESD. For each member identified in step 1, identify the date of the earliest encounter during the Intake Period with any diagnosis of major depression. If the member had more than one encounter during the Intake Period, include only the first encounter.

Step 3
Test for Negative Diagnosis History. Exclude members who had a claim/encounter for any diagnosis of major depression or prior episodes of depression during the 120 days prior to the IESD.

Step 4
Identify the IPSD. The IPSD is the date of the earliest dispensing event for an antidepressant medication during the period of 30 days prior to the IESD (inclusive) through 14 days after the IESD (inclusive). Exclude members who did not fill a prescription for an antidepressant medication during this period.

Step 5
Test for Negative Medication History. Exclude members who filled a prescription for an antidepressant medication from 90 days (3 months) prior to and including the IPSD.

Step 6
Calculate continuous enrollment. Members must be continuously enrolled for 120 days prior to the IESD to 245 days after the IESD.

Administrative Specification
Denominator: The eligible population
Numerator: At least 84 days (12-weeks) of continuous treatment with antidepressant medication during the 114-day period following the IPSD (inclusive). The continuous treatment allows gaps in medication treatment up to a total of 30 days during the 114-day period.

Allowable medication changes or gaps include the following:

• Washout period gaps to change medication
• Treatment gaps to refill the same medication

Regardless of the number of gaps, there may be no more than 30 gap days. The organization may count any combination of gaps (e.g., two washout gaps, each 15 days, or two washout gaps of 10 days each and one treatment gap of 10 days).

Prenatal and Postpartum Care
A HEDIS®-like measure

Description: The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care:

• Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.
• Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

Cholesterol Management for Patients with Cardiovascular Conditions
A HEDIS®-like measure

Description: The percentage of members 18-75 years of age who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1- November 1 of the year prior to the measurement year, or who had a diagnosis of ischematic vascular disease (IVD) during the measurement year and the year prior to measurement year, who had an LDL-C screening during the measurement year.

Eligible Population:

Event/Diagnosis: Members are identified for the eligible population in two ways: event or diagnosis.
The organization must use both to identify the eligible population, but a member only needs to be identified in one to be included in the measure.

Event: Discharged alive for AMI, CABG or PTCA on or between January 1 and November 1 of the year prior to the measurement year.

Diagnosis: Identify members as having IVD who met at least one of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years.

• At least one outpatient visit with any IVD diagnosis or
• At least one acute inpatient visit with any IVD diagnosis

Administrative Specification
Denominator: The eligible population.
Numerator: An LDL-C test performed anytime during the measurement year, as identified by the claim/encounter or automated laboratory data.

Heart Failure- ACE Inhibitor or ARB Therapy
An AMA measure

Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure and left ventricular systolic dysfunction (LVSD) who were prescribed ACE Inhibitor or ARB therapy.

Administrative Specification
Denominator: Heart failure patients aged 18 years and older with LVEF < 40% or with moderately or severely depressed left ventricular systolic function.
Numerator: Patient who were prescribed ACE inhibitor or ARB therapy.