Measure #411 (NQF 0711): Depression Remission at Six Months– National Quality Strategy Domain: Communication and Care Coordination 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY DESCRIPTION: Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment INSTRUCTIONS: This measure is to be reported once per reporting period for patients seen during the denominator identification measurement period with a diagnosis of depression and an initial PHQ-9 greater than nine. This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and an index date PHQ-9 Score greater than 9 documented during the denominator identification measurement period dates of 12/1/2014 to 11/30/2015. Measure Reporting via Registry: ICD-10-CM diagnosis codes, CPT or HCPCS codes, patient demographics, and PHQ-9 scores are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINATOR: Adult patients age 18 years and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine Definition: Index Date - The first instance (12/1/2014 to 11/30/2015) of elevated PHQ-9 greater than 9 and diagnosis of depression or dysthymia Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years AND Diagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.9, F34.1 AND Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439 AND Index date PHQ-Score greater than 9 documented during the twelve month denominator identification period: G9572 AND NOT Patients who died OR

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Patients who received hospice or palliative care service OR Patients who were permanent nursing home residents OR Patients with a diagnosis of bipolar disorder OR Patients with a diagnosis of personality disorder NUMERATOR: Adults who achieved remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five Definitions: Remission - a PHQ-9 score less than five. Six Months - the point in time from the index date extending out six months (+/- 30 days). The most recent PHQ-9 score within six months +/- 30 days (5 to 7 months after index) that is less than five is deemed as remission at 6 months. Scores obtained prior to or after this period are not counted as numerator compliant (remission). Numerator Options: Performance Met: OR

Performance Not Met:

Remission at six months as demonstrated by a six month (+/-30 days) PHQ-9 score of less than five (G9573) Remission at six months not demonstrated by a six month (+/-30 days) PHQ-9 score of less than five. Either PHQ-9 score was not assessed or is greater than or equal to five. (G9574)

RATIONALE The Patient Health Questionnaire (PHQ-9) tool is a widely accepted, standardized tool that is completed by the patient, ideally at each visit, and utilized by the provider to monitor treatment progress. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator. CLINICAL RECOMMENDATION STATEMENTS: Improvement in the symptoms of depression and an ongoing assessment of the current treatment plan is crucial to the reduction of symptoms and psychosocial well-being of patients with major depression. Most people treated for initial depression need to be on medication at least six to twelve months after adequate response to symptoms, patients with recurrent depression need to be treated for three years or more and response with psychotherapy can take eight to twelve weeks of regular and frequent therapy to show improvement. Remission is defined as a PHQ-9 score of less than five at twelve months. The Patient Health Questionnaire (PHQ-9) tool is a widely accepted, standardized tool [Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.] that is completed by the patient, ideally at each visit, and utilized by the provider to monitor treatment progress. This tool was selected for measuring outcomes for this population because it is 1) validated with a sensitivity of .080 and a specificity of 0.92 with substantial heterogeneity I2 = 82%, 2) widely accepted and utilized in Minnesota, 3) available for clinical use, 4) translated into many languages and 5) easy for the patient to complete and the provider to score. Available at www.phqscreeners.com. This nine question tool contains the following questions which are scored on a scale of 0 to 27 based on the scale of Not at All (0), Several Days (1), More Than Half the Days (2), or Nearly Every Day (3) for responses to the questions over the last 2 weeks. • Little interest or pleasure in doing things Version 10.0 11/17/2015

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• Feeling down, depressed, or hopeless • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself - or that you are a failure or have let yourself or your family down • Trouble concentrating on things, such as reading the newspaper or watching television • Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual • Thoughts that you would be better off dead or of hurting yourself in some way Source: ICSI Guideline for Major Depression in Adults in Primary Care 16th edition September 2013 https://www.icsi.org/_asset/fnhdm3/Depr.pdf Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect major depression in only one-third to one-half of their patients with major depression (Williams Jr, 2002; Schonfeld, 1997). Usual care for depression in the primary care setting has resulted in only about half of depressed adults getting treated (Kessler, 2005) and only 20-40% showing substantial improvement over 12 months (Unützer, 2002; Katon, 1999). Antidepressant medications and/or referral for psychotherapy are recommended as treatment for major depression. For medication treatment, patients may show improvement at two weeks but need a longer length of time to really see response (25-50% decrease in PHQ-9 score) and remission (PHQ-9 < 5). Most people treated for initial depression need to be on medication at least 6 – 12 months after adequate response to symptoms. For psychotherapy treatment, 8 – 10 weeks of regular and frequent therapy may be required to show improvement. Acute therapy is the treatment phase focused on treating the patient to remission. Acute therapy typically lasts 6 – 12 weeks but technically lasts until remission is reached. Full remission is defined as a two-month period devoid of major depressive signs and symptoms. Continuation therapy is the 4 – 9 month period beyond the acute treatment phase during which the patient is continuing therapy. Relapse is common within the first 6 months following remission from an acute depressive episode; as many as 20 – 85% of patients may relapse. Adult Depression in Primary Care- Guideline Aims    

Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder Increase the percentage of patients with major depression or persistent depressive disorder who have a follow-up to assess of response to treatment. Improve the communication between the primary care and behavioral health providers, have a common tool to document response. Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed).

Reliability/ Validity of the PROM- PHQ-9: As PHQ-9 depression severity increased, there was a substantial decrease in functional status of all 6 SF-20 subscales in addition to an increase in symptom-related difficulty, sick days and health care utilization. Construct validity, using mental health professional re-interview as the criterion standard, has demonstrated a PHQ-9 score > 10 has a sensitivity of 88% and a specificity of 88% for major depression. Additionally, a score