2015 HEDIS® measures

Updated August 2014

The tables below explain the HEDIS measures for two types of care: preventive health care (children and adolescents, women and adolescent girls, adults, and seniors) and condition-specific care.

New this year

Measure

Care, screening, or test

Non-Recommended PSA-Based Screening in Older Men (PSA)

Men 70 years and older who were screened for prostate cancer using prostate-specific antigen (PSA)-based testing (lower score is better).

 

Preventive health care

Children and adolescents

Measure

Care, screening, or test

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 or referral for nutrition or indication nutrition was addressed. Counseling or referral for physical activity or indication physical activity was addressed during an outpatient visit either by a claim or as a medical record entry during the measurement year (2014).

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 (none prior to 42 days of age)
  • 3 IPV (none prior to 42 days of age)
  • 1 MMR or documented history of illness or a seropositive test occurring prior to 2nd birthday
  • 3 HiB (none prior to 42 days of age)
  • 3 hepatitis B or documented history of illness or a seropositive test occurring prior to 2nd birthday
  • 1 hepatitis A or documented history of illness or a seropositive test occurring prior to 2nd birthday
  • 1 VZV, or documented history of illness or a seropositive test occurring prior to 2nd birthday4 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: anaphylactic reaction to the vaccine or its components on or before 13th birthday

Human Papillomavirus (HPV) for Female Adolescents

Three doses of HPV vaccine with different dates of service, on or between the 9th and 13th birthday.
Exclusions: anaphylactic reaction to the vaccine or its components on or before 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

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

Ages 21-64

PAP test within the measurement year or prior 2 years.
Or
PAP/HPV co-testing within the measurement year or prior 4 years.
Exclusions:

  • Women who have had a complete hysterectomy with no residual cervix.
Non-recommended cervical cancer screening in adolescent females Adolescent females 16-20 years or age who were screened unnecessarily for cervical cancer (lower score is better).

Breast cancer screening

Age 50-74
*****

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

  • Women who have had bilateral mastectomy or two unilateral mastectomies

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.

Adults

Measure

Care, screening, or test

Adults’ Access to Preventive/Ambulatory Health Services
Ages 20 and older
*****

Patients 20 years and older who had an ambulatory or preventive care visit.

Adult BMI assessment

Ages 18-74
*****

Patients 18-74 who had their body mass index (BMI) and weight documented during an outpatient visit either by a claim or as a medical record entry during the measurement year or year prior.

Avoidance of antibiotic treatment for adults with acute bronchitis

Ages 18-64

Adults diagnosed with acute bronchitis who did not receive an antibiotic Rx on or within 7 days of diagnosis.

Colorectal cancer screening

Ages 50-75
*****

One or more of the following screenings:

  • Fecal occult blood test yearly
  • Flexible sigmoidoscopy every five years
  • Colonoscopy every 10 years

Exclusions:

  • Colorectal cancer
  • Total colectomy

Annual monitoring for patients on persistent medications
Ages 18 and older

Patients 18 and older on persistent medications (at least 180 days) who received annual monitoring.

Medications examined

Annual monitoring

ACE inhibitors/ARBs
Diuretics

At least one serum potassium and one serum creatinine test

Digoxin At least one serum potassium, one serum creatinine (SCr) and one serum digoxin test

Exclusion:

  • Anyone with an acute or non-acute inpatient stay in the measurement year.

Plan All-Cause Readmissions
*****

Percentage of acute inpatient stays followed by an acute readmission for any cause within 30 days for 18 years and older.

Navicare

Measure

Care, screening, or test

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 assessment

Osteoporosis management in women who had a fracture
Age 67 - 85
*****

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 the six months after the fracture (NCQA removed Estrogen as a treatment option)

Exclusions:

  • Women who received a BMD screening in the two years prior to the fracture.
  • Women who received a prescription for a drug to treat or prevent osteoporosis 12 months prior to the fracture
  • Fractures of the finger, toe, face and skull are not included in this measure.

 

Condition-specific care

Alcohol and other drug dependence

Measure

Care, screening, or test

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

Ages 13 and older
13-17 years
18+ years
Total

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

Use of appropriate medications for people with asthma

Ages 5-64 years
Age stratifications:
5-11 years
12-18 years
19-50 years
51-64 years
Total rate

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

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.

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

Cardiac

Measure

Care, screening, or test

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

Controlling high blood pressure

Age 18-85
*****

Patients 18-85 with a diagnosis of hypertension whose most recent blood pressure reading was controlled.
Age 18-59 whose BP was <140/90
Age 60-85 with a diagnosis of diabetes whose BP was <140/90
Age 60-85 without a diagnosis of diabetes whose BP was <150/90

Exclusions:

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

Chronic obstructive pulmonary disease (COPD)

Measure

Care, screening, or test

Use of spirometry testing in the assessment and diagnosis of COPD

Ages 40 and older

Adults with a new (within the measurement year) diagnosis or newly active COPD who received spirometry testing to confirm the diagnosis.

  • Spirometry testing must occur 730 days prior to or 180 days after the diagnosing event.

Pharmacotherapy Management of COPD exacerbation
Adults 40 and older

Adults aged 40 or older who had an acute inpatient discharge or an ED encounter with a principal diagnosis of COPD who were dispensed both:

  • A systemic corticosteroid within 14 days of discharge
  • Bronchodilator within 30 days of discharge

NOTE: the eligible population for this measure is based on the discharges and visits, not the patient. It is possible for the denominator for this measure to include multiple events for the same patient.

Depression

Measure

Care, screening, or test

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

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 testing
  • LDL-C result
  • Retinal eye exam
  • Nephropathy screening test or evidence of nephropathy
  • Blood pressure collected as 2 measures
    < 140/90

Mental illness

Measure

Care, screening, or test

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

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 2014.

Tobacco users

Measure

Care, screening, or test

Medical assistance with smoking cessation

Tobacco users age 18 and older

Current smokers who were seen by a practitioner during the measurement year and:

  • Received advice to quit
  • Cessation medications were recommended and discussed
  • Cessation methods were recommended or discussed

Information is received via CAHPS®** survey methodology.

* HEDIS® is a registered trademark of NCQA.

** CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality.

***** Indicates Medicare 5 Star measures