Scott & White Health Plan

ALL ADULTS

Access to preventive/ ambulatory health services [A]

Ages 20-44. 45-64, and 65 and older

An ambulatory or preventive care visit during the last three years

Smoking and Tobacco Use Cessation [S]

Age 18 and older

Survey questions: current smoker or tobacco user

• Advised to quit in the last year
• Discussed or were recommended medications to quit in the last year
• Discussed or were provided cessation methods or strategies in the last year

Aspirin Use and Discussion [S]

Women: Age 55 to 79

Men: Age 45 to 79

Survey question:  Asked if currently taking aspirin

Women - with at least two risk factors for cardiovascular disease

Men age 45 to 64  - with at least one risk factor for cardiovascular disease

Men age 65 to 79  - regardless of risk factor

Colorectal cancer screening [H]

Age 50 - 75

One or more of the following appropriate colorectal cancer screenings: [fecal occult blood test (three-card specimen) (in the last year)], flexible sigmoidoscopy (in the last 5 years), or colonoscopy (in the last 10 years)

Flu shots for adults [S]

Age 50 to 64

Age 65 and older

Survey question: Did the member get a flu shot at any location during the previous flu season? (Between September 1st and the date the survey is completed)

Adult  BMI Assessment [H]

Age 18 to 74

An outpatient visit and had their body mass index (BMI) documented during the last two years. 

Medicare (HMO product SrCare) only

Osteoporosis Management in Women who had a fracture [A]

Age 67 and older

Women suffered a fracture, and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the date of the fracture.

Osteoporosis Testing in Older Women [S]

Age 65 and older

Survey question:  Women report if they ever received a bone density test to check for osteoporosis.

Glaucoma Screening in Older Adults [A]

Age 65 and older

Received a glaucoma eye exam by an eye care professional in the last two years. Exclude prior diagnosis of glaucoma or glaucoma suspect.

Physical Activity in Older Adults [S]

Age 65 and older

Had a doctor's office visit in the past 12 months

• Spoke with a doctor or other health provider about their level of exercise or physical activity
• Advised to start, increase or maintain their level of exercise or physical activity

Fall Risk Management [S]

Age 65 and older

Survey questions: Had a history of problems with balance, walking problems or a fall in the past 12 months

• Discussed falls, problems with balance or walking with their current practitioner
• Received fall risk intervention from their current practitioner

Urinary Incontinence in Older Adults [S]

Age 65 and older

Survey questions: Reported having a problem with urine leakage in the past six months

• Discussed their urine leakage problem with their current practitioner
• Received treatment for their current urine leakage problem

Pneumonia Vaccination Status  for Older Adults [S]

Age 65 and older

Survey question: Have you ever received a pneumococcal vaccine.

WOMEN & TEENAGE GIRLS

Breast cancer screening [A]

Age 40 - 69

At least one mammogram within the last two years. Excludes bilateral mastectomy.

Cervical cancer screening [A]

Age 21 - 64

At least one or more pap smears within three years. Excludes hysterectomy with no residual cervix.

Chlamydia screening in young women [A]

Sexually active women age 16-24

At least one screening test for Chlamydia within the past year

Prenatal / post-partum care [H]

Live birth from 11/6/08-11/5/09

• prenatal visit within first trimester (or 42 days of enrollment)
• post-partum visit between 21 and 56 days after delivery

CHILDREN & ADOLESCENTS

Childhood immunizations [H]

Age 0 - 2

4 DTap, 3 IPV, 1 MMR, 3 HIB, 3 Hep B, 1 VZV, 4 PCV, 2 Hep A, 2 or 3 RV and 2 flu by age two

DTap = Diphtheria - Tetanus - Pertussis / IPV = Polio  / MMR = Measles - Mumps - Rubella  / HIB = Haemophilus influenza type b /  HEP B = Hepatitis B /  VZV = Varicella (chickenpox)  / PCV = Pneumococcal / Hep A = Hepatitis A / RV = Rotovirus / flu = influenza vaccine

Adolescent immunizations [H]

Age 11-13

 Adolescents who received one meningococcal vaccine on or between the members 11^th and 13^th birthday and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the member's 10^th and 13^th birthdays.

Access to primary care physicians [A]

Ages 12-24 months, 25 months - 6 years, 7-11 and 12-19

A visit with a primary care physician (PCP) each year

Well-care visits within 1^st 15 months of life [A]

Age 0-15 months

At least six well-child visits with a PCP by age 15 months.

Well-care visits in the 3^rd, 4^th, 5^th and 6^th years of life [A]

Age 3-6

At least one well-child visit with a PCP within the past year.

Adolescent well-care visits [A]

Age 12-21

At least one well-care visit with a PCP or OB/GYN within the past year.

Weight Assessment Nutrition and Physical Activity [H]

Age 3-17

An outpatient visit with a primary care practitioner or OB/GYN and  evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity

CARDIAC CARE

Adults only

Persistence of Beta-Blocker Treatment after a Heart Attack [A]

Heart attack patients age 18 and older

Following a heart attack, member received a 135 - to 180-day course of treatment with a beta-blocker (Excludes history of asthma, hypotension, Heart Block greater than first degree, and sinus bradycardia)

Cholesterol Management for Patients with Selected Cardiovascular Conditions [H]

Selected cardiovascular diagnoses, age 18-75

• At least one LDL cholesterol test during the last year
• LDL Level less than 100 (must be the last test in the calendar year)

Includes acute myocardial infarction, coronary artery bypass, percutaneous coronary interventions and ischemic vascular disease.

Controlling High Blood Pressure (Hypertension) [H]

Age 18-85 with high blood pressure

Systolic blood pressure less than 140 mmHg AND diastolic blood pressure less than 90 mmHg (use the last outpatient blood pressure in the calendar year) Includes members with diagnosis of hypertension noted in the medical record prior to June 30 of measurement year.

DIABETICS

Adults only

Comprehensive Diabetes Care [H]

Members diagnosed with Type 1 or Type II diabetes, age 18-75

Each year, members with Type I or Type II diabetes should have:

• Hemoglobin A1c (HbA1c) tested
• HbA1c > 9 (lower is better, result must be the last test in the calendar year)
• HbA1c Control < 8 (result must be the last test in the calendar year)
• HbA1c Control < 7 for a selected population (result must be the last test in the calendar year)
• Dilated eye exam performed
• LDL cholesterol performed
• LDL cholesterol <100 ml/dL (result must be the last test in the calendar year)
• Screening for or monitoring of kidney disease (microalbumin or history of Diabetic Nephropathy)
• Blood pressure < 140/90 (use the last outpatient blood pressure in the calendar year)

RESPIRATORY

See also MEDICATION SECTION

Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive Pulmonary Disease (COPD) [A]

Age 40 and older.

New diagnosis of newly active COPD who received appropriate spirometry testing to confirm the diagnosis.

MEDICATION

Annual Monitoring for Patients on Persistent Medications [A]

Age 18 and older

1. Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)
2. Digoxin
3. Diuretics
4. Anticonvulsants

#1, 2, and 3: At least one serum potassium and either a serum creatinine or a blood urea nitrogen (BUN) test in the measurement year

#4. At least one serum concentration level test specific to drug taken (i.e. a member on both phenytoin and valproic acid with a 180-days supply of each drug must separately show evidence of receiving drug serum concentration tests for each drug.

Use of Appropriate Medications for People with Persistent Asthma [A]

Members with persistent asthma, age 5-50

Members with persistent asthma should receive a prescription medication acceptable as primary treatment for long-term control of asthma (persistent asthma = ANY of the following in the prior year - four prescriptions, one ER visit, one inpatient stay OR four outpatient visits for asthma treatment)

Appropriate treatment for children with upper respiratory infection (URI) [A]

Age 3 months - 18 years of age with diagnosis of URI

Did not receive an antibiotic prescription on or within 3 days after the diagnosis of an upper respiratory infection ( antibiotics are NOT an appropriate treatment for this diagnosis)

Appropriate testing for children with pharyngitis (sore throat) [A]

Age 2-18 with diagnosis of pharyngitis

Has been diagnosed with pharyngitis, received a prescription and received a group A streptococcus (strep) test within 3 days of the prescription

Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis [A]

Age 18 to 64 with diagnosis of Acute Bronchitis

Did not receive an antibiotic prescription

Pharmacotherapy Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbation [A]

Age 40 and older.

An acute inpatient discharge or emergency department (ED) encounter for COPD exacerbation between January 1 and December 1 and where dispensed appropriate medications.

Two rates are reported:

1. Dispensed a systemic corticosteroid within 14 days of the event
2. Dispensed a bronchodilator within 30 days of the even

Use of High-Risk Medications in the Elderly [A]

Age 65 and older

(Medicare only)

1. received at least one high risk medication
2. who received at least two high risk medications

Note: not all drugs in the categories below are included - there are specific medications for each category.  Drug categories include:  Antianxiety, antiemetics, analgesics, antihistamines, antipsychotic (typical), amphetamines, barbiturates, long-acting benzodiazepines, calcium channel blockers, gastrointestinal antispasmodics, Belladonna alkaloids, skeletal muscle relaxants, oral estrogens, oral hypoglycemics, narcotics, vasodilators, and others (androgens and anabolic steroids, thyroid drugs, and urinary anti-infectives).

Potentially Harmful Drug-Disease Interactions in the Elderly [A]

Age 65 and older (Medicare only)

Dispensed an ambulatory prescription for a contraindicated medication, concurrent with or after the diagnosis of one of the following:

• History of falls and prescription for tricycle antidepressants, antipsychotics or sleep agents
• Dementia and prescription for tricycle antidepressants or anticholinergic agents
• Chronic renal failure (CRF) and prescription for nonaspirin NSAIDs or Cox-2 Selective NSAIDs

Rheumatoid Arthritis - Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis [A]

Age 18 and older

Dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD) 5-Aminosalicylates, Alkylating agents, Aminoquinolines, Anti-rheumatics, Immunomodulators, Immunosuppressive agents or Tetracyclines.

RADIOLOGY

Use of Imaging Studies for Low Back Pain [A]

Age 18 to 50 (Commercial only)

Did not receive an imaging study within 28 days of a primary diagnosis of low back pain (plain x-ray, MRI or CT scan)   Exclude cancer, trauma, IV drug abuse or neurologic impairment.

BEHAVIORAL HEALTH CARE

Antidepressant Medication Management [A]

Adults, age 18 and older, diagnosed with a new episode of depression & treated with an antidepressant drug

• Effective acute-phase treatment = remained on an antidepressant medication during the 12 weeks following diagnosis
• Effective continuation-phase treatment = remained on an antidepressant medication for at least 6 months following diagnosis

Follow-up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication [A]

Age 6 to 12, dispensed ADHD medication

• Initiation Phase = ambulatory prescription dispensed for ADHD medication, had one follow-up visit with practitioner with prescribing authority during the 30-day initiation phase.
• Continuation and Maintenance (C&M) Phase - remained on the medication for at least 210 days and in addition to the visit in the initiation phase also had two follow-up visits with a practitioner within 270 days (9 months) after the initiation phase ended.

Follow-up visit after hospitalization for mental illness[A]

Members, age 6 and older, discharged from an inpatient mental health hospitalization

After hospitalization a outpatient visit  is needed by a mental health practitioner

• One follow-up visit within 7 days of hospital discharge
• One follow-up visit within 30 days of hospital discharge

Note a Primary Care Physician visit does not count towards compliance. Mental health practitioner includes:  A psychiatrist, psychologist,  Master's degree in social work, RN certified as a psychiatric nurse or mental health clinical nurse specialist, Master's degree or doctoral degree in counseling, marital and family therapy.

Initiation of alcohol and other drug (AOD) dependence treatment [A]

Members aged 13 and older diagnosed with AOD dependence

Initiation of  treatment - AOD dependence who initiate treatment within 14 days of diagnosis through either:

• inpatient admission
• outpatient visit
• intensive outpatient encounter
• partial hospitalization

Engagement of alcohol and other drug (AOD) dependence treatment [A]

Members aged 13 and older diagnosed with AOD dependence

An intermediate step between initially accessing care (initiation treatment) and completing a full course of treatment.  This measure is designed to assess the degree to which members engage in treatment with two or more additional AOD services within 30 days after completing the Initiation treatment with any AOD diagnosis:

• inpatient admissions
• outpatient visits
• intensive outpatient encounters
• partial hospitalizations