TO MEET THIS MEASURE:

WE LOOK FOR THIS DESIRED CARE (the "measurement year" refers to prior year care):

Childhood Immunizations

Children with a completed series of the following vaccinations by 2nd birthday:

• 4 - DtaP/DT (none prior to 42 days of age)
• 3 -IPV (none prior to 42 days of age)
• 1 - MMR
• 3 - HiB (none prior to 42 days of age)
• 3 - Hepatitis B
• 1 - Varicella immunization or documented history of chickenpox disease having occurred prior to 2nd birthday
• 4 - Pneumococcal conjugate

Medical records may be reviewed if claims/encounter data not sufficient

Adolescent Immunizations

Adolescents with a completed series of the following vaccinations by 13th birthday:

• 1 - MMR (between 4th and 13th birthdays) or 2 - MMR (on or between the 1st and 4th birthdays)
• 3 - Hepatitis B vaccines (3 HepB by the 13th birthday or evidence of 2-dose regime having been completed)
• 1 - Varicella or documented history of chickenpox disease having occurred prior to the 13th birthday

Medical records may be reviewed if claims/encounter data not sufficient

Well-Child Exams (First 15 Months of Life)

Looks for 6 well-child exams (at least 2 weeks apart) having occurred by 15-month birthday; that must have evidence of all of the following components of care:

• A health and developmental history (physical and mental)
• A physical exam
• Health education/anticipatory guidance (problem focused guidance alone does not meet standard of care)

Medical records may be reviewed if claims/encounter data not sufficient

Well-Child Exams (Ages 3, 4, 5, and 6 years)

An annual well-child exam during the measurement year; that must have evidence of all of the following components of care:

• A health and developmental history (physical and mental)
• A physical exam
• Health education/anticipatory guidance (problem focused guidance alone does not meet standard of care)

Medical records may be reviewed if provider claims/encounter data not sufficient

TO MEET THIS MEASURE:

WE LOOK FOR THIS DESIRED CARE
(the "measurement year" refers to prior year care):

Adolescent Well-Care Exam
(Ages 12 through 21 years)

An annual well-child exam during the measurement year; that must have evidence of all of the following:

• A health and developmental history (physical and mental)
• A physical exam
• Health education/anticipatory guidance (problem focused guidance alone does not meet standard of care)

Medical records may be reviewed if provider claims/encounter data not sufficient

Follow-Up Care for Children Prescribed Attention-Deficit/ Hyperactivity Disorder (ADHD or ADD) Medication
(Ages 6 through 12 years)

Children who received an initial prescription dispensed for ADD/ADHD medication, and

• Who had one follow-up visit with practitioner with prescriptive authority during the 30-day after meds initiated (Initiation Phase); and
• Who remained on the medication for at least 210 days and had at least two additional follow-up visits with a practitioner within 9 months after the Initiation Phase ends. (This Continuous Medication Treatment phase spans a total of 9 months after the prescription start date.)

This is an administrative measure based on provider claim coding only

Appropriate Treatment for Children With Upper Respiratory Infection (URI)
(Ages 3 months to 18 years)

Children diagnosed with an upper respiratory infection (URI) that were not dispensed an antibiotic prescription on or three days after the Episode Date.

• EXCLUDES: members with history of antibiotic within last 30 days
• EXCLUDES: all encounters with more than one claim diagnosis

This is an administrative measure based on provider claim coding only

Appropriate Treatment for Children With Pharyngitis
(Ages 2 to 18 years)

Children diagnosed with pharyngitis, prescribed an antibiotic and who received a group A streptococcus (strep) test for the episode.

• EXCLUDES: members with a history of antibiotic Rx within last 30 days
• EXCLUDES: all encounters with more than one claim diagnosis

This is an administrative measure based on provider claim coding only

Inappropriate Antibiotic Treatment for Adults With Acute Bronchitis
(Ages 18 to 64 years)

Healthy adults with a diagnosis of acute bronchitis who were dispensed an antibiotic prescription on or within three days after the diagnosis date. (A history negative for: significant co-morbid conditions for 12 months prior to/on the "episode date," and, previous antibiotic Rx for 30 days prior, are both required for the individual to fall into the review population.) A lower rate represents better performance

This is an administrative measure based on provider claim coding only

Chlamydia Screening in Women
(Ages 16 to 25 years)

Women who are identified as presumed sexually active (by pharmacy, i.e. contraceptive Rx data, or claims data indicating potential sexual activity). Looks for evidence of annual Chlamydia testing.

• EXCLUDES: women who had a pregnancy test and within 7 days had a Rx for Acutane or an X-ray.

This is an administrative measure based on provider claim coding only

TO MEET THIS MEASURE:

WE LOOK FOR THIS DESIRED CARE (the "measurement year" refers to prior year care):

Cervical Cancer Screening

Looks at women 21 to 64 years of age as of the measurement year. Looks for evidence of a Pap test during the measurement year or within the prior 2 years.

• EXCLUDES: women who have had a complete hysterectomy with no residual cervix

Medical records may be reviewed if provider claims/encounter data not sufficient

NOTE: HEDIS 2007 – NCQA is considering change to increase lower age limit from 21 to 24.

Breast Cancer Screening

Looks at women 52 to 69 years of age. Looks for evidence of a mammogram in the measurement year or a year prior to the measurement year.

• EXCLUDES: women who have had bilateral (occurring on same or separate dates) mastectomy

This is an administrative measure based on provider claim coding only

NOTE: HEDIS 2007 – NCQA is considering change to decrease lower age limit from 52 to 40 and increase upper age limit from 69 to 74.

Prenatal and Postpartum Care (by event)

Women who delivered a live birth between November 6 of the previous year and November 5 of the measurement year. Looks for evidence of:

• Timeliness of Prenatal Care - Prenatal care in the first trimester or within 42 days of enrollment in HNE
• Postpartum Care - Postpartum visit occurring on or between 21 and 56 days after delivery

Medical records may be reviewed if provider claims/encounter data not sufficient

Frequency of Ongoing Prenatal Care (by event)

Women who delivered a live birth between November 6 of the previous year and November 5 of the measurement year. The percentages of the expected number of prenatal care visits (based on ACOG guidelines) are compared to the number of received visits adjusted for the month of pregnancy at time of enrollment and gestational age.

Medical records may be reviewed if provider claims/encounter data not sufficient

Antidepressant Medication Management
(Ages 18 years and older)

A new diagnosis of major depression (no claims with depression diagnosis for past 120 days). Seeking to identify the following care for these identified members:

• Optimal practitioner contacts - Member had at least 3 follow-up visits within 12 weeks
• An effective acute phase to see whether member filled a sufficient number of Rx(s) for antidepressant medication to allow for 84 days of continuous therapy (up to 30 days of allowable gaps permitted)
• An effective continuation phase of 180-day treatment of antidepressant medication (a total of 51 days of allowable gaps are permitted)

This is an administrative measure based on provider claim coding

TO MEET THIS MEASURE:

WE LOOK FOR THIS DESIRED CARE (the "measurement year" refers to prior year care):

Use of Appropriate Medications for People With Asthma
(Ages 5 to 56 years)

Children and adults who are identified as having persistent asthma, who were appropriately prescribed inhaled corticosteroids, cromolyn sodium, nedocromil, leukotriene modifiers, methylxanthines.

Note: long acting beta-2 antagonists do not count by themselves, they are viewed as an add-on therapy

• EXCLUDES: individuals with diagnosis of emphysema or COPD

This is an administrative measure based on provider claim coding only

Use of Spirometry Testing in the Assessment and Diagnosis of COPD
(Age 40 years and older)

Adults with a new (within the measurement year) diagnosis or newly active chronic obstructive pulmonary disease (COPD) and who received appropriate spirometry testing to confirm the diagnosis; (at least one claim/encounter for spirometry in the 720 days before or 180 days after the diagnosis event.)

This is an administrative measure based on provider claim coding only

Controlling High Blood Pressure

Adults 46 to 85 years of age as of the measurement year with a diagnosis of hypertension (HTN) on or before June 30 of the measurement year. Medical records are reviewed for diagnosis of hypertension (HTN) and for the presence of control:

• Review the most recent office visit blood pressure (BP) at PCP office
• Controlled if systolic BP is <140 and diastolic BP is <90

EXCLUDES:

• readings done same day as major diagnostic or surgical procedure, or an emergency room visit
• readings self-reported by the patient to the provider
• adults with End Stage Renal Disease (ESRD)
• (may) exclude members who had admission to a non-acute inpatient setting during the year

Medical records must be reviewed unless measure rotated

NOTE: HEDIS 2007 – NCQA is considering change to decrease lower age limit from 46 to 18. AND Change adequately controlled blood pressure from < 140/90 to <140/90

TO MEET THIS MEASURE:

WE LOOK FOR THIS DESIRED CARE
(the "measurement year" refers to prior year care):

Comprehensive Diabetes Care
(Ages 18 to 75 years)

Adults with diagnosis of diabetes (Type I or II) who demonstrate annual care during the measurement year:

• A1c screening lab
• Last A1c of the measurement year >9.0 (seeking evidence of poor control)
• LDL screening lab - with last LDL of the measurement year <100 (also measures rate for <130)
• Documented results of a diabetic retinal eye exam by an eye care specialist
• Documented evidence of monitoring for nephropathy (or treatment of nephropathy) by any of the following methods:
  • Testing for urine microalbuminuria (24hr urine/timed urine/spot urine/microalbumin/creatine ratio)
  • Documented treatment for nephropathy, end stage renal disease, chronic renal insufficiency, acute renal failure dialysis, or visit with nephrologist
  • A positive urine macroalbumin test in the measurement year (macro must be beyond trace)

Medical records may be reviewed

NOTE: HEDIS 2007 – NCQA is considering change to add A1c control measure of  <7.0  AND  add blood pressure control measure of 135/85

Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
(Ages 18 years and older)

Adults with a diagnosis of rheumatoid arthritis and who had at least one ambulatory prescription dispensed for a disease modifying antirheumatic drug (DMARD) during the measurement year. See table:

This is an administrative measure based on provider claim coding only

Annual Monitoring for Patients on Persistent Medications
(Ages 18 years and older)

Adults on any of the following medications for at least 180 days and for whom for at least one therapeutic monitoring event for the specific medication(s) occurred in the measurement year. The intent is to prevent potential harm associated with persistent use of these drugs.

• angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)
• digoxin
• diuretics
• anticonvulsants (phenytoin, phenobarbital, valproic acid, carbamazepine)
• statins

EXCLUDES: anyone with a hospitalization in the measurement year

This is an administrative measure based on provider claim coding only