RULE SPECIFICATIONS

WellPoint P4P Physician Quality Measures Posting Book

VERSION:1.4 DATE: JANUARY 17, 2013 CLASS.:PROPRIETARY, FOR CLIENT USE AUTHORS:Y. CHIANG

Resolution Health, Inc. Proprietary Statement: This material constitutes proprietary and trade secret information of Resolution Health and shall not be disclosed to any third party, nor used by the recipient except under the terms and conditions prescribed by Resolution Health. This material is not to be copied or reproduced in any form, using any medium, without the prior written authorization of Resolution Health. Disclaimer of Currency: Resolution Health documentation reflects the state of products, software, reports, and procedures as of the publication date. All information is subject to change without notice. Additional changes to products and systems occur as needed, but may not be documented until a later date. Resolution Health, Inc. | 10490 Little Patuxent Parkway, Suite 610 | Columbia, MD 21044 | 877-225-4744 www.resolutionhealth.com

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TABLE OF CONTENTS

1

Introduction ................................................................................................................................... 1

2

Measures for P4P ........................................................................................................................... 2

2.1

Coronary Heart Disease ..................................................................................................... 2 Rule 7777: HEDIS CHD cholesterol management ...................................................... 2 Rule 7720: HEDIS MI hospitalization beta blocker 6 months .................................... 3

2.2

Hypertension ........................................................................................................................ 4 Rule 12091: HTN had creatinine test (NQF) ................................................................ 4 Rule 7670: New hypertension glucose test ................................................................... 5

2.3

Drug Safety Measures ........................................................................................................ 6 Rule 7716: HEDIS Digoxin annual potassium and creatinine ..................................... 6 Rule 7728: HEDIS Diuretics annual potassium and creatinine ................................... 7 Rule 7727: HEDIS Anticonvulsants annual drug level ................................................ 8

2.4

Endocrine Measures ........................................................................................................... 9 2.4.1

Diabetes ....................................................................................................................... 9 Rule 7718: HEDIS Diabetes annual hemoglobin A1c ................................................. 9 Rule 7717: HEDIS Diabetes annual LDL ................................................................... 10 Rule 7688: Diabetes hypertension nephropathy on ACE or ARB............................. 11 Rule 7719: HEDIS Diabetes annual nephropathy screening ..................................... 12

2.4.2

Dyslipidemia ............................................................................................................. 13 Rule 12093: Lipid Rx noncompliance (NQF)............................................................. 13

2.5

Preventive Health Measures ............................................................................................ 14 2.5.3

Women’s Health....................................................................................................... 14 Rule 7696: HEDIS Cervical cancer screening in past 3 years ................................... 14 Rule 7721: HEDIS Chlamydia annual screening........................................................ 15 Rule 7695: HEDIS Breast cancer screening in past 2 years ...................................... 16

2.5.4

Well Child Visits ...................................................................................................... 17 Rule 7813: Age 0-1 year old appropriate office visits................................................ 17 Rule 7814: Age 1-3 years old appropriate office visits .............................................. 18

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Rule 7860: Age 3-11 years old appropriate office visits ............................................ 19 Rule 7861: Age 12-18 years old appropriate office visits .......................................... 20 2.5.5

Pediatric Vaccinations ............................................................................................ 21 Rule 7764: HEDIS VZV vaccination .......................................................................... 21 Rule 7763: HEDIS MMR vaccination......................................................................... 22 Rule 7762: HEDIS _DTaP vaccination ....................................................................... 23 Rule 7760: HEDIS _IPV vaccination .......................................................................... 24 Rule 7761: HEDIS _HiB vaccination .......................................................................... 25 Rule 7759: HEDIS _Pneumococcal vaccination ........................................................ 26

2.6

Pulmonary Measures ........................................................................................................ 27 2.6.6

Asthma ....................................................................................................................... 27 Rule 7758: HEDIS Persistent asthma appropriate med .............................................. 27

2.6.7

Other Respiratory.................................................................................................... 28 Rule 7722: HEDIS Pharyngitis appropriate testing .................................................... 28 Rule 7723: HEDIS Upper respiratory infection appropriate med ............................. 29 Rule 7781: HEDIS Acute bronchitis avoid antibiotics............................................... 30

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1

Introduction

The quality measurement of physicians is based on identifying evidence-based care, using computer algorithms to identify patients who meet the requirements of each measure. This document describes each of the measures that Resolution Health, Inc. currently uses for its physician quality profiling (PQP) activities. For each quality of care measure, the following information is provided: Measure Title This title is used when reporting measure results for providers and plans. Measure Description The measure description provides the overall purpose of the measure. Numerator and Denominator The numerator is the number of measure-eligible patients whose care appears to be consistent with evidence-based guidelines, according to the available claims data. The denominator is the number of patients eligible for the measure (i.e., the patients who have the relevant condition, or take the relevant drug, or have the relevant age/gender demographic, etc.). Applicable Specialties Resolution Health maps applicable (relevant) clinical specialties to each measure, and attributes each patient’s care to the provider (1) who has a specialty mapped to the measure, and (2) who is considered a “primary specialist” for the patient. A patient’s primary specialist is the physician within a given specialty who provides the most ambulatory care services to the patient (as identified using the member’s prescription claims and medical claims for office visits during the most recent 18 months). Measure Citation The measure citation displays the organization (e.g., American Heart Association) that developed the clinical practice guideline upon which the quality measure is based, as well as citations to key publications related to the measure and a note as to whether the measure is programmed according to NCQA/HEDIS measure technical specifications.

For more information about these measures, please contact the Resolution Health Client Manager for the WellPoint Physician Quality Profile, Stephanie Parker: [email protected]

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2

Measures for P4P

2.1 Coronary Heart Disease Rule 7777: HEDIS CHD cholesterol management MEASURE DESCRIPTION

This measure identifies patients 18–75 years old discharged alive for acute myocardial infarction (AMI), coronary bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA) from January 1 to November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during or in the year prior to the measurement year, who had a LDL-C check during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had a lipid test within the measurement year. Denominator Patients with CHD diagnosed prior to the measurement year.

APPLICABLE SPECIALTIES MEASURE CITATION

Family Practice, General Practice, Internal Medicine, Cardiology National Committee for Quality Assurance. HEDIS 2012. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011. National Heart, Lung, and Blood Institute, National Institutes of Health, US Department of Health and Human Services. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda (MD): U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute; 2001. Antman EM, Anbe DT, et al. ACC-AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines on the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol. 2004;44:671–719.

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Rule 7720: HEDIS MI hospitalization beta blocker 6 months MEASURE DESCRIPTION

This measure identifies patients ages 18 or older who were hospitalized for AMI and discharged from the hospital between July 1 of the year prior to the measurement year and June 30 of the measurement year who have been taking a beta blocker consistently for at least 6 months post discharge.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have ≥135 days supply of a beta blocker medication in the 6 months post AMI discharge Denominator Patients hospitalized and discharged with an AMI between July 1 of the year prior to the measurement year and June 30 of the measurement year, who do not have a contraindication to beta blockers (contraindications include: history of asthma or use of asthma medications, hypotension, 2nd- or 3rd-degree heart block or sinus bradycardia with no history of pacemaker, or COPD).

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Cardiology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012 Measures. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011.

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2.2 Hypertension Rule 12091: HTN had creatinine test (NQF) MEASURE DESCRIPTION

This measure identifies patients with hypertension who had a serum creatinine test during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had a serum creatinine test during the measurement year (and 90 days after). Denominator Patients 18 years or older who have been diagnosed with hypertension between 1.5 to 3 years ago who do not have a diagnosis of end stage renal disease during the measurement year (this exclusion is only applied if the numerator is not met).

APPLICABLE SPECIALTIES MEASURE CITATION

Family Practice, General Practice, Internal Medicine Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Hypertension Diagnosis and Treatment (Released October 2006). Accessed July 14, 2008. URL: http://www.icsi.org National High Blood Pressure Education Program. The seventh report of the Joint National Committee on Prevention and Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003;289:2560-72.

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Rule 7670: New hypertension glucose test MEASURE DESCRIPTION

This measure identifies patients with newly diagnosed hypertension during the measurement year with a lab claim for a serum glucose test at the time of diagnosis, if not done in the 6 months prior to diagnosis.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had a serum or plasma glucose test within 30 days after initial diagnosis of hypertension. Denominator Patients who meet criteria for newly diagnosed hypertension during the measurement year who do not have diabetes and who did not have a serum or plasma glucose test in the 6 months prior to diagnosis.

APPLICABLE SPECIALTIES MEASURE CITATION

Family Practice, General Practice, Internal Medicine, Cardiology Chobanian AV, et al. The Seventh Report of the Joint National Committee on prevention, detection, and evaluation and treatment of high blood pressure. NHLBI writing team. 2004. 28–32. NIH Publication No. 04-5230

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2.3 Drug Safety Measures Rule 7716: HEDIS Digoxin annual potassium and creatinine MEASURE DESCRIPTION

This measure identifies patients age 18 or older who had at least 180 days supply for digoxin during the measurement year who had at least 1 serum potassium and either a serum creatinine or a blood urea nitrogen (BUN) therapeutic monitoring test during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had at least 1 serum potassium and either a serum creatinine or a BUN test during the measurement year. Denominator Patients who had at least 180 days supply for digoxin during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Cardiology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Rule 7728: HEDIS Diuretics annual potassium and creatinine MEASURE DESCRIPTION

This measure identifies patients age 18 or older who had at least 180 days supply for diuretics during the measurement year who had at least 1 serum potassium and either a serum creatinine or a blood urea nitrogen (BUN) therapeutic monitoring test during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had at least 1 serum potassium and either a serum creatinine or a BUN therapeutic monitoring test during the measurement year. Denominator Patients who had at least 180 days supply for diuretics during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Cardiology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Rule 7727: HEDIS Anticonvulsants annual drug level MEASURE DESCRIPTION

This measure identifies patients age 18 or older who had at least 180 days supply for anticonvulsants during the measurement year who had at least 1 serum drug measurement (for the prescribed drug) during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had at least 1 serum drug measurement (for the prescribed drug) during the measurement year. Denominator Patients who had at least 180 days supply for anticonvulsants during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Neurology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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2.4 Endocrine Measures 2.4.1

Diabetes Rule 7718: HEDIS Diabetes annual hemoglobin A1c

MEASURE DESCRIPTION

This measure identifies patients between 18 and 75 years old who have diabetes and who had at least 1 HbA1c test during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had at least 1 serum HbA1c test during the measurement year. Denominator Patients with diabetes diagnosed during the measurement year or the year prior to the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Endocrinology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Rule 7717: HEDIS Diabetes annual LDL MEASURE DESCRIPTION

This measure identifies patients between 18 and 75 years old who have diabetes and who had an LDL-C level checked during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had an LDL-C level checked during the measurement year. Denominator Patients with diabetes diagnosed during the measurement year or the year prior to the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Endocrinology, Cardiology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Rule 7688: Diabetes hypertension nephropathy on ACE or ARB MEASURE DESCRIPTION

This measure identifies patients with diabetes plus hypertension or nephropathy who are taking an ACE inhibitor or ARB during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have ≥1 Rx claim for an ACE inhibitor or an ARB during the measurement year. Denominator Patients with past medical history of diabetes plus hypertension or nephropathy diagnosed prior to the measurement year.

APPLICABLE SPECIALTIES MEASURE CITATION

Family Practice, General Practice, Internal Medicine, Cardiology, Endocrinology American Diabetes Association. Standards of Medical Care in Diabetes--2009. Diabetes Care, Vol 32, Supp 1, Jan 2009:S13–61. Chobanian AV, et al. The Seventh Report of the Joint National Committee on prevention, detection, and evaluation and treatment of high blood pressure. NHLBI writing team. 2004. NIH Publication No. 04-5230

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Rule 7719: HEDIS Diabetes annual nephropathy screening MEASURE DESCRIPTION

This measure identifies patients between 18 and 75 years old who have diabetes and at least one nephropathy screening; or who had evidence of medical attention for existing nephropathy (diagnosis or treatment of nephropathy), who are taking ACE-I/ARBs, or who have had at least one visit with a nephrologist.

NUMERATOR/ DENOMINATOR

Numerator The number of patients from the denominator who during the measurement year had at least one test for nephropathy screening; or who had evidence of medical attention for existing nephropathy (diagnosis or treatment of nephropathy), who are taking ACEI/ARBs, or who have had at least one visit with a nephrologist. Denominator Patients with diabetes diagnosed during the measurement year or the year prior to the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Endocrinology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Dyslipidemia Rule 12093: Lipid Rx noncompliance (NQF)

MEASURE DESCRIPTION

This measure identifies patients on a lipid medication who have remained adherent to taking the medication regularly.

NUMERATOR/ DENOMINATOR

Numerator

APPLICABLE SPECIALTIES MEASURE CITATION

Patients in the denominator who have taken their lipid-lowering medication at least 80% of the time during the 6-month period after the initial prescription fill date. Denominator Patients at least 19 years old with a diagnosis of hyperlipidemia who filled a prescription for a lipid-lowering medication sometime between 6 and 18 months before the end of the measurement year, and who had at least 60 days of medication supply in the 6 months following the earliest prescription fill in this time period. Family Practice, General Practice, Internal Medicine, Cardiology, Endocrinology Miller, N.H., et al., The multilevel compliance challenge: recommendations for a call to action. A statement for healthcare professionals. Circulation, 1997. 95(4): p. 1085-90. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation, 2002. 106(25): p. 3143-421. ICSI. Health Care Guideline: Lipid Management in Adults. 2007 [cited January 9, 2008]; 10th edition:[Available from: http://www.icsi.org/lipid_management_3/lipid_management_in_adults_4.html.

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2.5 Preventive Health Measures 2.5.3

Women’s Health Rule 7696: HEDIS Cervical cancer screening in past 3 years

MEASURE DESCRIPTION

This measure identifies women age 21 to 64 who had at least 1 Pap test during the measurement year or during the 2 years prior to the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had 1 or more Pap tests during the measurement year or during the 2 years prior to the measurement year. Denominator Women who are 24-64 years of age as of the end of the measurement year who have a cervix (excludes women with a hysterectomy).

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Obstetrics & Gynecology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Rule 7721: HEDIS Chlamydia annual screening MEASURE DESCRIPTION

This measure identifies women age 16 to 24 identified as sexually active who had at least 1 Chlamydia test during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had 1 or more tests for Chlamydia during the measurement year. Denominator Females who are 16–24 years of age who were identified as sexually active (based on codes from claims during the measurement year that indicate pregnancy or abortion, as well as Rx claims for contraception).

APPLICABLE SPECIALTIES MEASURE CITATION

Family Practice, General Practice, Internal Medicine, Obstetrics & Gynecology, Pediatrics National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: 2008. Agency for Healthcare Research and Quality. (2007 Orig Release Date)

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Rule 7695: HEDIS Breast cancer screening in past 2 years MEASURE DESCRIPTION

This measure identifies women age 42 to 69 as of Dec 31st of the measurement year who had a mammogram during the measurement year or during the year prior to the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had a mammogram during the measurement year or during year prior to the measurement year. Denominator Women who are 42-69 years of age by Dec 31st of the measurement year without evidence of history of breast cancer or a bilateral mastectomy.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Obstetrics & Gynecology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Well Child Visits Rule 7813: Age 0-1 year old appropriate office visits

MEASURE DESCRIPTION

This measure identifies infants who have had at least 5 office visits with a pediatrician, family practitioner, or general practitioner during the first year of life.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥5 office visits with a pediatrician, family practitioner, or general practitioner. Denominator Children who turn 1 year old during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

American Academy of Pediatrics and Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008, American Academy of Pediatrics.

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Rule 7814: Age 1-3 years old appropriate office visits MEASURE DESCRIPTION

This measure identifies children who turned 3 years old during the measurement year and had ≥5 office visits with a pediatrician, family practitioner, or general practitioner between the ages of 1 and 3.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥5 office visits with a pediatrician, family practitioner, or general practitioner between the ages of 1 and 3. Denominator Children who turn 3 years old during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

American Academy of Pediatrics and Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008, American Academy of Pediatrics.

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Rule 7860: Age 3-11 years old appropriate office visits MEASURE DESCRIPTION

This measure identifies children whose 4th to 11th birthdays occur during the measurement year who have ≥office visit with a pediatrician, family practitioner, or general practitioner during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥1 office visit with a pediatrician, family practitioner, or general practitioner during the measurement year. Denominator Children who are at least 3 years old and less than 11 years old at the start of the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

American Academy of Pediatrics and Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008, American Academy of Pediatrics.

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Rule 7861: Age 12-18 years old appropriate office visits MEASURE DESCRIPTION

This measure identifies children whose 12th to 18th birthdays occur during the measurement year who have ≥1 office visit with a pediatrician, family practitioner, or general practitioner during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥1 office visit with a pediatrician, family practitioner, or general practitioner during the measurement year. Denominator Children who are at least 11 years old and less than 18 years old at the start of the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

American Academy of Pediatrics and Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008, American Academy of Pediatrics.

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Pediatric Vaccinations Rule 7764: HEDIS VZV vaccination

MEASURE DESCRIPTION

This measure identifies the percentage of children 2 years of age who had one chicken pox (VZV) vaccination on or before their second birthday.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had at least one VZV vaccination on or before the child’s second birthday. Denominator Enrolled children who turn 2 years of age during the measurement year, excluding children with history of anaphylactic reaction to immunizations, lymphoreticular cancer, HIV, other immunodeficiencies, leukemia, or multiple myeloma.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012 Measures. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011.

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Rule 7763: HEDIS MMR vaccination MEASURE DESCRIPTION

This measure identifies the percentage of children 2 years of age who had one measles, mumps, and rubella (MMR) vaccination on or before their second birthday.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had at least one MMR vaccination on or before the child’s second birthday. Denominator Enrolled children who turn 2 years of age during the measurement year, excluding children with history of anaphylactic reaction to immunizations, lymphoreticular cancer, HIV, other immunodeficiencies, leukemia, or multiple myeloma.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012 Measures. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011.

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Rule 7762: HEDIS _DTaP vaccination MEASURE DESCRIPTION

This measure identifies the percentage of children 2 years of age who had ≥4 diphtheria, tetanus, and acellular pertussis (DTaP) vaccinations on or before their second birthday .

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥4 DTaP vaccinations on or before the child’s second birthday. Denominator Enrolled children who turn 2 years of age during the measurement year, excluding children with history of encephalopathy.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012 Measures. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011.

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Rule 7760: HEDIS _IPV vaccination MEASURE DESCRIPTION

This measure identifies the percentage of children 2 years of age who had ≥3 injectable poliovirus (IPV) vaccinations on or before their second birthday.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥3 IPV vaccinations on or before the child’s second birthday. Denominator Enrolled children who turn 2 years of age during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012 Measures. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011.

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Rule 7761: HEDIS _HiB vaccination MEASURE DESCRIPTION

This measure identifies the percentage of children 2 years of age who had ≥3 haemophilus influenza type B (HiB) vaccinations on or before their second birthday .

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥2 HiB vaccinations on or before the child’s second birthday. Denominator Enrolled children who turn 2 years of age during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012 Measures. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011.

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Rule 7759: HEDIS _Pneumococcal vaccination MEASURE DESCRIPTION

This measure identifies the percentage of children 2 years of age who had ≥4 pneumococcal conjugate vaccinations on or before their second birthday

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have had ≥4 pneumococcal conjugate vaccinations on or before the child’s second birthday. Denominator Enrolled children who turn 2 years of age during the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012 Measures. Vol 2. Washington, DC: National Committee for Quality Assurance; 2011.

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2.6 Pulmonary Measures 2.6.6

Asthma Rule 7758: HEDIS Persistent asthma appropriate med

MEASURE DESCRIPTION

This measure identifies patients age 5 to 56 during the measurement year who have persistent asthma and who were appropriately prescribed medication during the measurement year.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who have at least 1 claim for an asthma controller medication. Denominator Patients who meet HEDIS criteria for persistent asthma during or prior to the measurement year with pharmacy benefits during the measurement year. Excludes members with any history of emphysema, COPD, cystic fibrosis, and acute respiratory failure.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Internal Medicine, Pediatrics, Pediatric Allergy, Pediatric Pulmonology, Pulmonary Medicine, Allergy & Immunology

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2008. Available from: http://www.ginasthma.org.

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Other Respiratory Rule 7722: HEDIS Pharyngitis appropriate testing

MEASURE DESCRIPTION

This measure identifies children 2–18 years of age who were diagnosed with pharyngitis prior to or during the measurement year, dispensed an antibiotic, and had a test for group A streptococcus for the episode.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who had a test for group A streptococcus (strep) for the episode of pharyngitis. Denominator Children age 2 to 18 who were diagnosed with pharyngitis and dispensed an antibiotic within 6 months prior to the measurement year or during the first 6 months of the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

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Rule 7723: HEDIS Upper respiratory infection appropriate med MEASURE DESCRIPTION

This measure identifies children age 3 months to 18 years who were diagnosed with an upper respiratory infection (URI) who did not receive an antibiotic prescription within 3 days after diagnosis.

NUMERATOR/ DENOMINATOR

Numerator Patients in the denominator who did not receive an antibiotic prescription within 3 days after the diagnosis. Denominator Children age 3 months old as of 18 months prior to the end of the measurement year to 18 years old 6 months prior to the end of the measurement year who were diagnosed with URI between 545 and 180 days prior to the end of the measurement year.

APPLICABLE SPECIALTIES

Family Practice, General Practice, Pediatrics

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

Proprietary: For Client Use

v1.7

WellPoint P4P Physician Quality Measures Posting Book

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Rule 7781: HEDIS Acute bronchitis avoid antibiotics MEASURE DESCRIPTION

This measure identifies adults age 18 to 64 years with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or within 3 days after the Index Episode Start Date.

NUMERATOR/ DENOMINATOR

Numerator Patients from the denominator who were not dispensed a prescription for antibiotic medication on or within 3 days after the Index Episode Start Date. Denominator Patients ≥18 years of age at the start of the year prior to the measurement year to ≤64 years of age by the end of the measurement year, with a Negative Medication History, a Negative Comorbid Condition History and a Negative Competing Diagnosis, who had an outpatient or emergency department (ED) visit with any diagnosis of acute bronchitis during the Intake Period.

APPLICABLE SPECIALTIES

Family Practice, Internal Medicine, Pulmonology, General Practice

MEASURE CITATION

National Committee for Quality Assurance. HEDIS 2012. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2011.

Proprietary: For Client Use

v1.7