2013 HEDIS^® measures

Measure

Care, screening, or test needed

Asthma Medication Ratio

Patients 5-64 years of age who are idenetified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during 2012.

Children and adolescents

Measure

Care, screening, or test needed

Weight assessment and counseling for nutrition and physical activity for children and adolescents.
Ages 3-17 years

Patients 3-17 who had evidence of body mass index (BMI) percentile including height and weight, counseling for nutrition and counseling for physical activity documented during an outpatient visit either by a claim or as a medical record entry during the measurement year.

Well-child exams

Ages 0-15 months

6 well-care visits (at least 2 weeks apart) with a PCP. Must show evidence of all of the following:

• Health and development history (physical and mental)
• Physical exam
• Health education/anticipatory guidance

Well-child exams

Ages 3-6 years

Annual well-care visit with a PCP each year. Must show evidence of all of the following:

• Health and development history (physical and mental)
• Physical exam
• Health education/anticipatory guidance

Well-child exams

Ages 12-21 years

Annual well-care visit with a PCP or OB/GYN. Must show evidence of all of the following:

• Health and development history (physical and mental)
• Physical exam
• Health education/anticipatory guidance

Childhood immunization

Series must be completed by the 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 hepatitis A
• 1 VZV, or documented chicken pox disease (or positive serology) occurring prior to 2nd birthday
• 4 pneumococcal conjugate (none prior to 42 days of age
• 2-3 rotavirus (none prior to 42 days of age)
• 2 influenza

Immunizations for Adolescents
13 year-olds

• 1 meningococcal vaccine on or between the member’s 11th or 13th birthday
• 1 Tdap or 1 Td on or between the member’s 10th or 13th birthday

Exclusions: contraindication to either vaccine

Human Papillomavirus (HPV) for Female Adolescents

Three doses of HPV vaccine with different dates of service, on or between the 9th and 13th birthday.

Lead screening in children (Medicaid only)

Children aged 2

Children who received at least one capillary or venous lead screening test on or before their second birthday.

Treatment of children with upper respiratory infections

Ages 3 months-
18 years

Children 3 months to 18 years who were given a diagnosis of upper respiratory infection (URI) and were NOT dispensed an antibiotic prescription within 3 days of the URI diagnosis.
Exclusions:

• Encounters with > 1 diagnosis
• Children with a history of antibiotic Rx within 30 days of encounter

Appropriate testing of children with pharyngitis

Ages 2-18 years

Children who had an outpatient visit or ED encounter with only a diagnosis of pharyngitis who were dispensed an antibiotic and also received a Group A streptococcus test 3 days before or 3 days after the prescription.
Exclusions:

• Encounters with > 1 diagnosis
• Children with a history of antibiotic Rx within 30 days of encounter

Follow-up care for children prescribed ADHD medication

Ages 6-12 years

Children who received an initial prescription for ADHD medication and:

• Received at least one follow-up visit with a prescriber within 30 days of initiation of medication
• Remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two more follow-up visits between four weeks and 9 months

Women and adolescent girls

Measure

Care, screening, or test needed

Chlamydia screening
Age 16-24 and sexually active

Women identified as presumed sexually active by pharmacy Rx data, or claims data indicating potential sexual activity

• Screening test for chlamydia yearly

Exclusions:

• Women who had a pregnancy test followed within 7 days by either a prescription for Accutane (isotretinoin) or an X-ray.

Cervical cancer screening

Age 21-64

PAP test within the measurement year or prior 2 years.
Exclusions:

• Women who have had a complete hysterectomy with no residual cervix.

Breast cancer screening

Age 40-69
*****

Mammogram in the measurement year or one year prior.
Exclusions:

• Women who have had bilateral mastectomy (may occur on the same or separate dates)

Prenatal/
postpartum care

Pregnant women

Prenatal visit within first trimester (or within 42 days of enrollment)

Postpartum visit between 21 and 56 days after delivery

Seniors

Measure

Care, screening, or test needed

Care for older adults
Age 65 years and older
*****

Adults aged 65 and older who had each of the following during the measurement year:

• Advance care planning
• Medication review
• Functional status assessment
• Pain screening

Glaucoma screening in older adults
Ages 65 and older

*****

Medicare members without a prior diagnosis of glaucoma or glaucoma suspect who received a glaucoma eye exam by an ophthalmologist or optometrist.

Osteoporosis management in women who had a fracture
Age 67 and older

*****

Women who received the following within 6 months of suffering a fracture:

• Bone mineral density (BMD) test
• Prescription for a drug to treat or prevent osteoporosis in six months after the fracture

Exclusions:

• Women who received screening and/or treatment in the year prior to the fracture.
• Fractures of the finger, toe, face and skull are not included in this measure.

Care of older adults
Age 66 and older

*****

Adults aged who had the following in 2012:

• Advanced care planning
• Medication review, at least one
• Functional status assessment
• Comprehensive pain screening, at least one

Alcohol and other drug dependence

Measure

Care, screening, or test needed

Initiation and engagement of alcohol and other drug (AOD) dependence treatment

Ages 13 and older

Patients diagnosed with alcohol and other drug dependence who:

• initiate treatment within 14 days of diagnosis
• receive two additional AOD services within 30 days of initiation

Asthma

Measure

Care, screening, or test needed

Use of appropriate medications for people with asthma

Ages 5-56 years

Children and adults identified with asthma who received Rx for long term control of asthma (inhaled corticosteroids, cromolyn sodium, nedocromil, leokotriene modifiers, methylxanthines).
Exclusions:

• Patients with diagnosis of emphysema, COPD, cystic fibrosis, or acute respiratory failure

Note: Long-acting beta-2 agonists do not count by themselves. They are considered add-on therapy.

Medication Management
for People with Asthma

Ages 5-64

Age stratifications

5-11 years
12-18 years
19-50 years
51-64 years
Total rate

Exclusions:

Emphysema, COPD, cystic fibrosis, acute respiratory failure or no dispensed medications

The percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:

•The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period

•The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period

Cardiac

Measure

Care, screening, or test needed

Persistence of beta-blocker treatment after heart attack

Age 18 and older

Patients who were hospitalized and discharged alive after an acute MI who:

• Received treatment with beta-blockers for six months after discharge

Exclusions:

• Patients identified as having a contraindication to beta-blocker therapy
• Patients with a history of adverse reaction to beta-blocker therapy

Cholesterol management for patients with cardiovascular condition

Ages 18-75

*****

Patients who were discharged alive for any of the following:

• Acute myocardial infarction
• Coronary artery bypass graft
• Percutaneous coronary interventions

Or who had:

• Diagnosis of ischemic vascular disease

Patient should have each of the following during the measurement year:

• Calculated or direct LDL screening performed
• LDL level < 100

Controlling high blood pressure

Age 18-85
*****

Patients 18-85 with a diagnosis of hypertension whose most recent blood pressure reading was controlled (<140/90).
Exclusions:

• Patients with end stage renal disease (ESRD)
• Pregnant during the measurement year
• Admission to a non-acute inpatient setting during the measurement year

Depression

Measure

Care, screening, or test needed

Antidepressant medication management

Ages 18 years and older

Adults newly diagnosed with depression and treated with an antidepressant who received the following:

• Effective acute phase: filled sufficient number of Rx to allow for 84 days of continuous therapy.
• Effective continuation phase: filled sufficient number of Rx to allow for 180 days of continuous therapy.

To qualify as a new diagnosis, 2 criteria must be met:

• A 120-day (4 month) negative diagnosis history on or before the start date
• A 90-day (3 month) negative medication history on or before the start date

Diabetes

Measure

Care, screening, or test needed

Comprehensive diabetes care

Age 18-75

*****

Yearly screening of the following:

• HbA1c testing
• HbA1c result > 9.0 = poor control
• HbA1c result < 8.0 = good control
• LDL-C
• LDL-C result < 100
• Retinal eye exam
• Nephropathy screening test or evidence of nephropathy
• Blood pressure collected as 2 measures
  < 140/90
  < 140/80

Mental illness

Measure

Care, screening, or test needed

Follow-up after hospitalization for mental illness

Age 6 and over

Patients discharged from an inpatient mental health admission and receive:

• One follow-up encounter with a mental health provider within 7 days after discharge.
• One follow-up encounter with a mental health provider within 30 days after discharge.

Rheumatoid Arthritis

Measure

Care, screening, or test needed

Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
*****

Patients 18 years and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug during 2012.