The State of Health Care Quality Continuous Improvement and the Expansion of Quality Measurement www.ncqa.org
Phone 202.955.3500
Fax 202.955.3599
2011
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Suite 1000
Washington, DC 20005
Continuous Improvement
and the Expansion of
Quality Measurement
T h e S tat e o f H e a lt h C a r e Q u a l i t y 2 0 1 1
Continuous Improvement
and the Expansion of
Quality Measurement
T h e S tat e o f H e a lt h C a r e Q u a l i t y 2 0 1 1
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Unauthorized copying or use is prohibited.
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and Quality.
Portions of this report were prepared using select data provided by the Centers for Medicare & Medicaid Services
(CMS) pursuant to a data use agreement. The contents of the report represent the sole views of NCQA and have not
been approved, reviewed or endorsed by CMS or by any other federal agency.
© 2011 by the National Committee for Quality Assurance. All rights reserved.
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T h e S t a t e o f H e a l t h C a r e Q u a l i t y 2 0 1 1 • t a b l e o f c o n t e n ts
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President’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
HEDIS Measures of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Safety and Potential Waste
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Use of Imaging Studies for Lower Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Relative Resource Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Wellness and Prevention
Adult BMI Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Flu Shots for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Breast Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Cervical Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Medical Assistance With Smoking and Tobacco Use Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Chronic Disease Management
Persistence of Beta-Blocker Treatment After a Heart Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Comprehensive Diabetes Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Controlling High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Cholesterol Management for Patients With Cardiovascular Conditions . . . . . . . . . . . . . . . . . . . . . . . . 56
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . 58
Use of Appropriate Medications for People With Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Use of Spirometry Testing in the Assessment and Diagnosis of COPD . . . . . . . . . . . . . . . . . . . . . . . . . 62
Pharmacotherapy Management of COPD Exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Annual Monitoring for Patients on Persistent Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Antidepressant Medication Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment . . . . . . . . . . . . . . . . . . 70
Measures Targeted at Children and Adolescents
Appropriate Treatment for Children With Upper Respiratory Infection* . . . . . . . . . . . . . . . . . . . . . . . 72
Lead Screening in Children* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Ambulatory Care: Emergency Department Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Prenatal and Postpartum Care & Frequency of Ongoing Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . 77
Chlamydia Screening in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Follow-Up After Hospitalization for Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Appropriate Testing for Children With Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Well-Child Visits in the First 15 Months of Life and in the Third, Fourth, Fifth and Sixth Years of Life . . . 86
Adolescent Well-Care Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Children and Adolescents’ Access to Primary Care Practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Follow-Up Care for Children Prescribed ADHD Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Childhood Immunization Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Immunizations for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents . . . . 103
* As part of the Pediatric Quality Measures Program, states are working with AHRQ and CMS to report Children’s Initial Core Set measures at the
state level in order to assess the quality of Medicaid and CHIP. All measures in this section except the two noted are in the Children’s Initial Core Set.
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Measures Targeted at Older Adults
Fall Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Medication in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Management of Urinary Incontinence in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Physical Activity in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Glaucoma Screening in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Osteoporosis Testing in Older Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Osteoporosis Management in Women Who Had a Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Consumer and Patient Engagement and Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Methodology Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Appendices
HEDIS Effectiveness of Care Measures: 2010 National HMO Averages . . . . . . . . . . . . . . . . . . . . . . 130
HEDIS Effectiveness of Care Measures: 2010 National PPO Averages . . . . . . . . . . . . . . . . . . . . . . . 134
CAHPS Member Satisfaction Measures: 2010 National HMO Averages . . . . . . . . . . . . . . . . . . . . . 137
CAHPS Member Satisfaction Measures: 2010 National PPO Averages . . . . . . . . . . . . . . . . . . . . . . 138
Accredited vs. Nonaccredited Plans: 2010 Commercial HMO Averages . . . . . . . . . . . . . . . . . . . . . 139
Accredited vs. Nonaccredited Plans: 2010 Commercial PPO Averages . . . . . . . . . . . . . . . . . . . . . . 142
Accredited vs. Nonaccredited Plans: 2010 Medicaid HMO Averages . . . . . . . . . . . . . . . . . . . . . . . 145
Accredited vs. Nonaccredited Plans: 2010 Medicare HMO Averages . . . . . . . . . . . . . . . . . . . . . . . 148
Accredited vs. Nonaccredited Plans: 2010 Medicare PPO Averages . . . . . . . . . . . . . . . . . . . . . . . . 150
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial HMOs . . . . . . . . . . . . . . . . . 152
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial PPOs . . . . . . . . . . . . . . . . . . 155
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicaid HMOs . . . . . . . . . . . . . . . . . . . 158
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare HMOs . . . . . . . . . . . . . . . . . . . 161
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare PPOs . . . . . . . . . . . . . . . . . . . . 163
HMOs vs. PPOs, Commercial Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
HMOs vs. PPOs, Medicare Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
HMOs vs. PPOs, Commercial Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
HMOs vs. PPOs, Medicare Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial HMOs . . . . . 171
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial PPOs . . . . . . 174
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicaid HMOs . . . . . . . 177
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare HMOs . . . . . . . 180
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare PPOs . . . . . . . . 182
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
T he S tate o f H ea l th C are Q U A L I T Y 2 0 1 1 • P resident ’ s M essage
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President’s Message
Dear Colleague:
Every autumn, NCQA updates the nation on how consistently health plans deliver high-quality
care. This, our 15th State of Health Care Quality Report, is a snapshot of an industry that is
moving in the right direction, but has opportunities for further improvement.
We find encouraging signs of rising quality. Across diverse measures of care, performance
is improving, and insurers can be proud of what they have accomplished. We also note that
some insurers are not reporting and that for some measures, we have not seen the gains in
performance we would like.
Three features distinguish this year’s report. First, it is longer than in past years because it
includes, for the first time, comparisons between HMOs and PPOs across all measures.
That we are able to fill a report with PPO data tracked over time is a significant step in
quality’s story. Not long ago, few PPOs quantified or disclosed results. Now, measurement and
transparency are more common, though there is room to add more PPO reporting.
The rising tide of PPO reporting is a credit to PPOs that have worked hard to fashion themselves
into data-driven organizations that collect and report results. Their willingness to evaluate
themselves and be transparent is a boon to consumers, a third of whom are enrolled in PPOs.
A second distinct feature of this report is a focus on longer-term trends—a departure from our
usual concentration on one-year changes in performance.
In a fast-paced society where attention spans seem to grow ever shorter, it’s easy to overlook
the cumulative benefits of determined, incremental gains. Yet stepping back to look at the
long term confirms that the industry has come far. The data show that insurers’ commitment to
measurement, transparency and accountability has, over the years, improved care, saved lives
and reduced suffering.
Finally, this report looks ahead to consider how quality measurement can help address what is
arguably our country’s most ominous long-term threat—ballooning health care costs.
It is important to grasp that the most insidious cost problems are often problems of quality—
extra costs resulting from preventable medical errors, overtreatment and ineffective care. An
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increasingly common response to the cost crisis is to drop coverage or increase deductibles,
a reaction that can also be understood as a quality issue. After all, not having coverage is the
ultimate quality gap.
Reducing care as the main strategy for containing costs is a siren’s song: it might seem irresistible
or inevitable, but it is ultimately destructive. A more sustainable approach is to stretch our health
care dollars and get better results by emphasizing a value agenda.
This report identifies ways that health plans can be catalysts to transform health care from a
system that prizes volume to one that emphasizes value. In particular, we call on health plans to
redefine their roles to take advantage of existing tools that can spur and complement delivery
system reforms. These changes are important because value’s delicate intersection of cost and
quality is no longer just nice to have; it’s a necessity.
Thank you for your interest in these vital topics. And thank you for doing all you can to improve
the state of health care quality.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • intr o ducti o n
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Intr oducti o n
NCQA produces The State of Health Care Quality Report every year to call attention to key
quality issues the United States faces and to drive improvement in the delivery of evidence-based
medicine. This report documents performance trends over time, tracks variation in care and
recommends quality improvements.
Thousands of consumers, health insurance executives, benefits managers, policy makers,
academics, consultants and journalists read this report. More than 1,000 health plans voluntarily
disclose the clinical quality, customer experience and resource use data that are the report’s
foundation. All data are rigorously audited. Consumer experience information is independently
collected and verified.
We commend all the health plans that contributed data for this report, and for the commitment
to accountability and quality improvement that they show in opting to disclose their performance
results publicly.
Electronic copies of this report are available free of charge at NCQA’s Web site, www.ncqa.org.
Printed copies are available for purchase by calling 888-275-7585.
We appreciate your interest in these topics and welcome your feedback. You can reach us at
communications@ncqa.org.
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Executive Summary
The Healthcare Effectiveness Data and Information Set (HEDIS®) continually changes to capture
better information and new medical knowledge and to reflect purchaser and consumer needs.
HEDIS was developed by forward-thinking employers and quality experts in the late 1980s; since
the early 1990s, it has been the national standard for health plan performance reporting. NCQA’s
goal is for HEDIS measures to have strong evidence and be meaningful, valid and practical.
With the addition of preferred provider organization (PPO) performance results to HEDIS, we
can now compare PPOs with HMOs. We consider these comparisons—some surprising, many
encouraging—to be the key findings of this year’s State of Health Care Quality report.
PPOs on the Rise, Show They Improve by Measuring, Too
With some exceptions, commercial HMO performance is typically higher than PPO performance.
One reason may be that HMOs have traditionally had more tools to manage care: care
coordination processes, selective contracting and more bargaining power over providers.
Differences in information collection or populations could be factors, as could benefit design.
HMOs usually have lower cost sharing for services than PPOs, and higher PPO cost sharing
might reduce use of recommended services. That said, some PPOs offered by health plans that
also offer HMOs perform very well.
Differences between HMOs and PPOs in how they collect data for hybrid measures have
traditionally made it difficult to compare results. But there are indicators where PPOs perform
at virtually the same level as HMOs—for example, in the Use of Appropriate Medications for
Asthma measure. PPOs are catching up on other measures, as well, by making bigger year-toyear gains.
Interestingly, there are also performance differences between commercial HMOs and PPOs for
some patient experience measures. Many readers will recall that health plan members preferred
PPOs to HMOs because of fewer restrictions and larger networks. In 2005, PPO members were
more likely to give a high rating than HMO members were. But times have changed, and there
is a widening gap in performance: in 2010, HMO results were 6 percentage points higher than
PPO results.
The gap might be related to the rise in cost sharing—including deductibles—for PPOs.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • E x ecutive S ummar y
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One example where HMO results are higher than PPO results is in the share of members who
rated their health plan a 9 or 10 on a 10-point scale.
Figure 1. Percentage of Commercial HMO and PPO
Members Who Rate Their Plan 9 or 10, 2005–2010
100
90
80
70
60
50
40
30
20
10
0
2005
2006
2007
HMO
2008
2009
2010
PPO
Performance patterns between Medicare HMOs and PPOs are quite different. While HMOs
outperform PPOs on some measures, PPOs outperform HMOs on several others, notably
on measures related to drug therapy and monitoring. For example, on Pharmacological
Management of COPD—Systemic Corticosteroids, the average Medicare PPO rate is 69.6
percent and the average Medicare HMO rate is 66.6 percent.
Medicare has required HMOs and PPOs to report the same quality measures. The Medicare star
rating system that will send additional payments to high-performing plans is neutral to whether
a plan is a HMO or PPO. These policies may be driving higher PPO performance in Medicare.
Other reasons for higher PPO performance could be geographic differences or variations in the
nature of the participating PPOs.
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Comparisons across product line—Commercial, Medicaid and Medicare product measures
reflect varying policy and population differences, but we can compare performance on measures
reported by all product lines. On these measures, Medicaid performance tends to be worse than
commercial or Medicare performance. Exceptions are Chlamydia Screening for Women and
Persistence of Beta-Blocker Treatment After a Heart Attack. One reason for Medicaid’s lower
performance might be that its population faces challenging economic circumstances; for example,
transportation to doctor appointments may be an issue. Even though this pattern holds for the
overall population, we do see some Medicaid plans with very high performance, suggesting that
some of the challenges of caring for this population may be surmountable.
Medicare and commercial performance relative to each other varies by measure. Medicare
outperforms commercial plans on several intermediate outcome measures and process measures.
Comparison With Last Year’s Findings
Childhood immunizations—In last year’s State of Health Care Quality report, NCQA noted a
significant drop in childhood immunizations in commercial health plans. This drop also appeared
in the Centers for Disease Control and Prevention’s national data. Reasons for the drop include
widespread concern about the (disproven) potential for some immunizations to lead to autism;
other explanations were the rise in cost sharing and the economic downturn. The 2010 data do
not show a full recovery for commercial health plans. The Combination 2 Childhood Immunization
Rate for commercial HMOs had a slight uptick, but the numbers were not statistically significant.
Medicaid results held steady. There was a drop in the H influenza type B (HiB) immunization
rate, which might have been caused by a temporary shortage of vaccine, and a small gain in the
polio (IPV) immunization rate.
Overall pattern 2009 to 2010—Although several measures showed important gains—including
Colorectal Cancer Screening, Use of Spirometry Testing in the Assessment and Diagnosis of COPD
and Pharmacotherapy Management of COPD—many measures showed little meaningful change.
Commercial and Medicare PPOs displayed significant performance improvement and showed
progress in closing the performance gap with HMOs.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • E x ecutive S ummar y
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HEDIS: Responding to Evidence and to Purchaser Needs
Early quality measures were developed specifically for HMOs, and focused on use of recommended
services. Today, measures are reported by other types of health plans, as well as some fee-for-service
(FFS) programs like Medicaid. Public payers (Medicare, Medicaid and the Federal Employees Health
Benefit [FEHB] program) and private payers (including those in the Evalu8 tool) use HEDIS measures.
Figure 2. Eye Exams for Diabetics–Medicare
80
70
Screening Rate
60
50
40
30
20
10
0
2001
2002
2003
2004
2005
HMO
2006
2007
2008
2009
2010
PPO
NCQA now specifies HEDIS measures for individual clinician and clinician groups, using
both conventional data sources and electronic health records (EHR). HEDIS—the most widely
used measures for ambulatory care—includes measures of outcome; measures of overuse and
resource use; and measures of care coordination.
Outcome measures—NCQA measures of outcome include “intermediate outcome measures” that
reflect test results, as well as patient experience. They capture cholesterol control, blood pressure
control and blood sugar (HbA1c) control in diabetics. Patient experience of care—measured
through the Consumer Assessment of Healthcare Providers and Systems (CAHPS®)—is another
important measure of outcome.
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Top 10 and Bottom 10 States
“Location, location, location” is not only the mantra of the real estate industry—it’s relevant to health
care, too.
Past editions of the State of Health Care Quality Report showed that quality varies by Census Bureau
region. This year’s analysis of top 10 and bottom 10 states is more specific: it shows that some states
are outliers within their own regions.
Cohort calculations of top 10, bottom 10 and middle 32 states include Puerto Rico and Washington,
D.C. The calculations are based on mean rates of four measures: Comprehensive Diabetes Care
(nine indicators), Controlling High Blood Pressure (one indicator), Persistence of Beta-Blocker
Treatment After a Heart Attack and Cholesterol Management for Patients With Cardiovascular
Conditions (two indicators).
Top 10 cohort
Rose to 2010 cohort from 2009
Fell to 2010 cohort from 2009
d
Middle 32 cohort
Bottom 10 cohort
d
No state went from the top cohort to the bottom cohort (or vice versa) from 2009 to 2010.
d
d
d
d
d
d
d
d
d
d
d
d
d
d
d
!
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • E x ecutive S ummar y
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Quality Measurement and the Million Hearts Initiative
Gains in HEDIS measures relevant to heart disease provide momentum for CDC’s Million Hearts initiative.
Millions Hearts launched in September 2011 and aims to prevent 1 million heart attacks in five years.
Performance on six heart-related measures improved in the four years the measures held their
current specifications—five improved by almost three percentage points. These steady gains
confirm that what gets measured gets improved, especially when measurement becomes a habit
that insurers sustain.
Improvement in Measures Related
to Heart Disease—Commercial HMOs
90
80
Mean Rate
70
60
50
40
30
20
10
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Cholesterol Management for Patients With Cardiovascular Conditions—LDL Cholesterol Screening
Medical Assistance With Smoking and Tobacco Use Cessation—Advising Smokers and
Tobacco Users to Quit
Persistence of Beta-Blocker Treatment After a Heart Attack
Controlling High Blood Pressure*
Cholesterol Management for Patients With Cardiovascular Conditions—LDL Control
(<100 mg/dL)
Physical Activity in Older Adults—Advice (MEDICARE HMOs)
* Measure respecification in 2005 accounts for some of the 2005-2006 performance change.
Overuse and resource use—HEDIS emerged during an era when consumers were concerned
that HMOs would deny needed care. Initial HEDIS measures focused on transparency around the
use of proven therapies and preventive care.
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As health care spending skyrocketed and recognition of wasteful spending caught the nation’s
attention, NCQA invested in measures to prevent overuse. Examples of these measures are
Imaging Studies for Low Back Pain and Avoidance of Antibiotic Treatments in Adults With Acute
Bronchitis. NCQA’s Relative Resource Use measures help purchasers determine which plans
provide the highest quality of care with the lowest use of resources.
Care coordination—Many experts point to duplicate procedures and poor transitions between
providers and settings as examples of wasteful spending and poor quality. Several HEDIS
measures capture the results of care coordination and chronic disease management: Annual
Monitoring of Patients on Persistent Medications and Follow-Up After Hospitalization for Mental
Illness are two of them.
NCQA is also developing measures, standards and programs to assess and recognize care
coordination and case management. NCQA’s Patient-Centered Medical Home (PCMH) program
and new Accountable Care Organization (ACO) program aim to improve care coordination.
They target the clinical practices and delivery system levels.
Responding to the evidence—NCQA works with clinical experts to develop and revise HEDIS
measures based on evidence. Measures start with guidelines grounded in robust findings. When
the evidence base changes, so do the measures.
HEDIS measures for clinicians—In response to requests for measures below the health plan
level, NCQA collaborated with the American Medical Association to develop HEDIS physician
measures that assess clinical performance of ambulatory practices. These measures are widely
used in the Medicare Physician Quality Reporting System, the Meaningful Use programs and
NCQA’s Clinical Practice Recognition programs. The NCQA Diabetes Recognition program is
supported by private sector initiatives, including the New York State Diabetes Campaign, led by
the New York State Health Foundation.
EHR measures—NCQA is working closely with the Office of the National Coordinator for Health
Information Technology, the Centers for Medicare & Medicaid Services (CMS) and the National
Quality Forum (NQF) to translate HEDIS measures into electronic formats. EHRs will simplify
reporting of quality measures. They have the potential to apply clinical logic, based on quality
measures, to improve care in different settings. They also create opportunities for developing
measures that were previously set aside because of the burden of data collection.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • E x ecutive S ummar y
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Figure 3. Trends in Colorectal Cancer Screening
for Commercial HMOs, 2004–2010
100
90
80
70
60
50
40
30
20
10
0
2004
2005
2006
2007
2008
2009
2010
The Importance of Public Reporting in Improving Health Plan Performance
Many health plans have stepped up to the challenge of collecting, reporting performance data
and being held accountable. Plans’ disclosure of quality information using reliable, audited,
standardized measures helps purchasers and consumers learn which plans and clinicians have
the best results. NCQA credits public reporting and plans’ commitment to improving for the
progress we have seen overall.
The next section highlights significant gains in performance over time. Our discussion focuses on
commercial HMOs, for which we have the longest series of data. We compare trends across plan
types and product lines.
Of the 32 HEDIS Effectiveness of Care measures, 23 show clear trends of improvement. While
year-to-year gains are often quite small, they are steady over time. Only one measure showed
unmistakable signs of worsening—Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis.
One example of progress is Colorectal Cancer Screening, with an almost 2 percentage point
increase (to 62.6 percent) between 2009 and 2010 for commercial HMOs. Introduced in 2004,
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this measure has shown steady gains. Similar gains have transpired for Medicare HMOs,
although they have not reached the same level overall.
Figure 4. Trends in HbA1c Screening for People With
Diabetes for Commercial HMOs, 1999–2010
100
90
80
70
60
50
40
30
20
10
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
HbA1c Screening for People With Diabetes, introduced with a suite of diabetes measures in
1999, is another example of growth. The screening rate has risen steadily over the past 11 years,
progressing from 75 percent in 1999 to almost 90 percent in 2010 for commercial HMOs. We
have seen similar gains across HMOs, PPOs and product lines, with Medicare performing best.
Performance on Medical Attention for Nephropathy has more than doubled for commercial
HMOs. From 36 percent in the first year, it rose to almost 84 percent in 2010. (The 2005
addition of ACE/ARB therapy to the measure’s qualifying criteria accounts for some of the
performance gain.) Like the HbA1c screening measure, all plan types, in all product lines, have
experienced gains. Medicare HMOs had the strongest performance of all groups (89.2 percent)
in 2010.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • E x ecutive S ummar y
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Figure 5. Trends in Medical Attention for Nephropathy for
People With Diabetes for Commercial HMOs, 1999–2010
100
90
80
70
60
50
40
30
20
10
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Health plans have shown steady increases on most consumer experience measures, which are based
on a rating scale of 0–10. Of seven CAHPS indicators, six showed consistent, gradual improvement.
Health plans that report quality publicly and have earned NCQA Accreditation based on their
performance should be applauded for achieving these gains. Public and private purchasers,
including Medicare, have contributed to this effort by offering incentives for plans and providers
to report and improve quality.
Complementary policies can create even stronger improvement incentives. NCQA incorporates
HEDIS results into accreditation levels and health plan rankings. Differentiating among health
plans gives credit to the work of excellent performers—and signals the results to consumers and
purchasers.
Even stronger incentives can flow from pay-for-performance programs, which are used by many
Medicaid agencies and the Medicare Advantage (MA) program. Health plans with the best
performance on quality might win additional payments; Medicaid plans might be assigned more
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members. Purchasers that want to expedite performance gains may want to create incentives
around measures where there has been little progress.
Public reporting alone might not be a strong enough incentive to lead to change. The record on overuse
measures is disappointing, and suggests other factors are at play. For example, we have seen virtually
no change during the six-year history of Use of Imaging Studies for Low Back Pain. And although
overuse of antibiotics leads to development of antibiotic-resistant strains of bacteria, performance on
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis has worsened, falling from almost
29 percent (successful avoidance) to 22.5 percent for commercial HMOs in 2010. One reason for this
might be that providers have difficulty resisting patients’ demand for a pill to address symptoms.
Implications: A Vision of High-Value Health Plans
In the 1990s, many policy makers thought health plans were the vehicle to better quality of care
and lower costs. The notion of “managed competition” underpinned the Clinton health reform
proposals. Proponents envisioned that health plans would compete on cost, and drive consumer
choice through transparency. HMOs would combine their insurance function with active
management of patient care. Advocates saw opportunities to avoid emergency room use and
hospital care by improving benefit design, networks and other programs.
What happened instead was “managed care backlash”: members rebelled against limited
provider networks and utilization review.1 And the rise of self-insured employers led to increased
contracting with PPO networks, rather than with full-risk-bearing HMOs.
One big difference between earlier ideas about health reform and the 2010 Patient Protection
and Affordable Care Act (PPACA) is an expectation that change should happen in the health
care delivery system. The locus is the clinician’s office—and, to a lesser extent, the hospital.
Programs like PCMH and the Meaningful Use of Health Information Technology (HIT) initiative
push small practices to track patients’ care over time and across settings and to report and
benchmark their performance against quality measures derived from medical evidence.
The ACO program reflects this vision on a larger scale. The model involves a collection of
clinician practices (and possibly hospitals) taking collective responsibility for improving patient
care and lowering costs.
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Changes to payment incentives will allow organizations to share savings for reducing
unnecessary care. Proponents hope ACOs will invest in strategies and technologies to help
patients manage chronic disease. The goal is to avoid emergency room and hospital care.
Some might ask, if the delivery system embraces better coordination, patient management and
integration, why do we need health plans? How do health plans add value if physicians and
hospitals deliver better care?
What can health plans do?
It is worth noting that health plans will continue to be the entities holding insurance risk.
Organizations committed to delivery system innovations will likely be wary of holding full
insurance risk and managing population health. Thus, health plans will continue to serve this
important purpose for some payers.
Health plans have experience managing insurance risk and are regulated by states to ensure
stability and financial soundness. They hold reserves and have processes to account for claims
that have been incurred but not recorded; they can pool risk and access commercial reinsurance
policies. They have data that enable analysis of services and use predictive modeling to target
interventions—like case management—to high-risk populations.
Health plans offering coverage in Medicaid, Medicare and Exchanges (2014) will have to bear
financial risk. They also will have roles in benefit and coverage design, as well as collecting and
reporting quality results.
The following section describes a value agenda for health plans and suggests a vision for highvalue health plans. NCQA sees a strong role for health plans to nurture and promote changes at
the delivery-system level.
Fostering delivery-system reforms—Health plans can lead or partner with other payers
(employers, Medicaid, Medicare) to sponsor PCMH and ACO projects. They can change payment
methods to encourage these programs, set participation standards and offer technical support.
Health plans can also work with hospitals to implement safety initiatives and reduce readmissions.
Health plans can provide data to practices to help them manage and coordinate care. They can
offer incentives to invest in and use HIT, can explain the benefits of these innovations to members
and can identify participating providers.
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Designing benefits and coverage—Most recent changes in benefit design have involved setting
coverage limits and increasing cost sharing through higher deductibles. However, health plans
and purchasers can collaborate to develop benefits that encourage members to select care that
improves their health and deter members from using services that are dangerous or ineffective.
An application of this idea is value-based insurance design. It reduces cost sharing for services
with the greatest value; for example, proven preventive care and maintenance therapies for chronic
conditions. Another example is reference pricing, which steers physicians and patients to the most
effective treatments by tying reimbursement for an item or service to the price of the most effective
treatment. Less effective treatments are still covered by the plan, but members pay more for them.
Collecting data from claims, enrollment, patients and medical records—Health plans’ ability to
aggregate data creates opportunities to report on care for their populations and for practices.
Because of their size and experience, health plans can manage a diverse group of patients
across sites of care.2 George Isham, medical director of Health Partners in Minnesota, identified
key areas where health plans contribute:
• Paying, collecting and aggregating bills. Billing records describe patients’ conditions and the
care they received. Combined with enrollment information from pharmacies and laboratories,
and extracts from medical records, these records form the basis of quality measurement.
• Collecting data and using it to inform the three-part aim in the National Quality Strategy
(better care, healthy people/healthy communities and affordable care). Plans know how to
turn information into quality measures.
• Cultivating transparency and displaying information for the public. Hospitals and nursing homes
are becoming accustomed to transparency, but it is still rare among physicians and in outpatient
settings. Small numbers and a lack of specialty care measures have hindered progress.
Physicians and their representatives have not embraced public performance reporting.
• Developing quality improvement projects. Health plans have significant experience helping
providers improve care.
• Collaborating to develop innovations in performance measurement and data analysis. Health
plans have had success identifying high-risk patients and deploying inventive case management.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • E x ecutive S ummar y
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Putting the network together—ACOs may eventually become health plans. Short of that, they
may serve as the provider network for an employer- or provider-sponsored Medicare Advantage
or Medicaid plan. But many purchasers need to offer coverage across a state—or even across
the country—and health plans must assemble entire networks to meet this need.
Health plans can use cost sharing to guide patients to high-value hospitals and providers. They
can identify hospitals that are “Centers of Excellence” for treating high-cost or high-risk conditions.
Then, they can make them preferred providers with the lowest cost sharing for patients. This
approach could also reward hospitals or other providers that have strong patient safety records.
The high-value plan of the future should rely heavily on value metrics to select its network.
Ensuring that members have access to physicians with good credentials is an important part of
consumer protection—and of NCQA Health Plan Accreditation. But excellent health plans must
also measure the performance of providers. They must use that information to build networks and
report the information to consumers.
Activating patients—Because health plans will continue to hold risk and enroll members, they
are uniquely situated to connect with patients and make them active partners in their health and
wellness. Plans could pursue the following strategies to engage patients.
• Conduct wellness and health promotion through health appraisals and other strategies. Use
financial incentives to encourage participation in programs designed to improve health.
Smoking cessation and weight loss are two examples.
• Incorporate benefit design incentives that promote the best care and providers.
• Publicly report provider performance and involvement in delivery system reforms.
• Provide members with incentives to use decision aids to choose therapies.
• Cover palliative and end-of-life care and implement strategies to ensure that providers know
and follow patient preferences and decisions.
• Survey enrollees about their experiences and how they rate providers. Then, use this
information to provide feedback to physicians and construct networks.
• Make other options available to patients who opt out of ACOs.
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Health plans serving low-income patients and those with multiple chronic conditions also can invest
in care management, which concentrates the focus on providing or connecting patients to health
care and other service providers. While some of this work is moving to the delivery system, small
clinical practices may not have the resources to invest in dedicated staff to do this work; health
plans can either provide it or make available care coordination to share across multiple practices.
How do we get health plans to high value?
NCQA’s experience has demonstrated that “what gets measured gets improved.” Many of our
expectations for health plans could be turned into performance measures or standards, allowing
health plans to review programs and policies against clear, detailed program elements.
We have developed several programs that let high-performing health plans earn NCQA
Recognition or NCQA Distinction. Most recently we created a distinction program for plans
committed to improving multicultural care.
Pay for performance might be successful in furthering the value agenda by awarding higher
payments to plans that demonstrate high value. Many state Medicaid agencies have such
programs; the Medicare Advantage program will soon, as well. Measures of health plan value
could be added to that program or used to give health plans extra credit.
Additionally, the Exchanges created by the PPACA could direct participants into plans that offer
value. High-value plans could be visibly rewarded on the Exchanges’ report cards—or listed
prominently on the national Web portal.
Information about high-value plans could be presented when consumers are first comparing
plans. However, Exchanges must be mindful of “choice fatigue,” which can result from
consumers’ having too much information and too many options. Exchanges can be architects
of choice that guide people toward better value and quality, but the success of health reform
depends on galvanizing consumers, not overwhelming them.
Regardless of the specific approach, policy makers and purchasers should seize opportunities to
work with health plans. Collaboration can improve health care and markets.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • E x ecutive S ummar y
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Conclusion
The Dartmouth Group has shown that cost and quality do not have to be a trade-off, but how do
we get to affordable, quality health care?
We must focus on buying value in health care, but the politics are challenging. Our current marketplace
is fractured; providers have different approaches for working with each sector. Patients are confused
and vulnerable, and appeals to their fears have succeeded. It is challenging in this environment to
implement strong, synchronized strategies to improve coordination and delivery of care.
Health plans can be drivers of improvements to cost and quality in health care markets. As
“market makers,” they should pursue strategies to activate and engage members.
Leading-edge health plans devote significant resources to keeping their members healthy. Health
plans need to construct “value choices” at the provider level so patients do not overpay and are
not over-treated or victims of medical errors. NCQA’s objective in seeking a value agenda is
to advance the triple aim—improving the individual’s experience of care and the population’s
health, and reducing the overall cost of care.
Ultimately, consumers hold the power to reshape insurance markets. The concept of a new insurance
marketplace, facilitated by Exchanges, flows from the premise that consumers will be motivated to
compare health plans. Measures based on CAHPS and HEDIS are a logical place to start.
Endnotes
1. Draper, D.A., R.E. Hurley, C.S. Lesser, B.C. Strunk. 202. The Changing Face Of Managed Care. Health Affairs, Jan-Feb;21(1):11–23.
2. Enthoven, A. 1993. The History and Principles of Managed Competition. Health Affairs, Vol 12, Supplement 1, 24–48.
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HEDIS Measures of Care
About HEDIS
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by most HMOs and
PPOs plans to measure performance on important dimensions of care and service. By providing
objective, clinical performance data measures against a detailed set of measurement criteria,
HEDIS helps purchasers and consumers compare health plans’ performance.
HEDIS measures address a broad range of important health issues:
• Antibiotic use
• Diabetes
• Asthma
• High blood pressure
• Breast, cervical and colorectal cancers
• Medication management
• Care for older adults
• Mental illness
• Childhood immunizations
• Smoking
• Cholesterol management
• Prenatal and postpartum care
HEDIS includes the Consumer Assessment of Healthcare Providers and Systems (CAHPS) 4.0
Survey. The CAHPS survey measures members’ experiences with their health care in areas such
as claims processing and getting needed care quickly, and asks them to rate their health plan on
a scale of 0–10.
HEDIS 2011 data collected for this report generally reflect services delivered during calendar
year 2010. To ensure validity of HEDIS results, certified analysts rigorously audit all data, using
a process NCQA designed. See the appendices for more details about national averages and
performance trends.
HOS Measures
Medicare Health Outcomes Survey (HOS) measures evaluate the physical and mental health
of seniors enrolled in Medicare and are the first patient-based self-report of health status as a
measure of quality of care in elderly populations. Including HOS in HEDIS measurement creates
a broader scope of measures to evaluate the quality of care provided by health plans for the
Medicare population. Included in this report are four HOS measures:
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
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• Fall Risk Management
• Management of Urinary Incontinence in Older Adults
• Osteoporosis Testing in Older Adults
• Physical Activity in Older Adults.
Terms
NA: Measure rates have no available data. In some instances, data are not collected for a
measure in a product line.
Rate: The statistical mean for reported data. Each measure is described by an average rate for
each applicable product line.
A Note on Medicare Survey Data
Medicare CAHPS survey data of consumer experience and HEDIS measures collected through
the survey (such as Flu Shots for Adults and Medical Assistance With Smoking and Tobacco
Use Cessation) are not available when NCQA prints the State of Health Care Quality Report
in September. NCQA will issue an updated version of this report that includes those data in
November.
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S a f et y and P o tentia l W aste
Avoidance of Antibiotic Treatment
in Adults With Acute Br onchitis
Acute bronchitis clinically presents as a cough lasting more than five days (typically, from
one to three weeks). About 90 percent of cases are caused by a virus.1,2 The Avoidance of
Antibiotic Treatment in Adults With Acute Bronchitis measure evaluates whether adults were
treated appropriately by not receiving antibiotics, which are not indicated and may contribute to
antibiotic resistance.
• Acute bronchitis affects approximately
• Diminished effectiveness of antibiotics
5 percent of U.S. adults annually and
against bacterial infections, particularly
continues to rank among the top 10
for use in patients who may need them
conditions for which patients seek treatment
to fight future, life-threatening bacterial
in clinical settings.1
infections, poses a significant public health
• Antibiotics are prescribed in more than 60
percent of bronchitis cases; of those, 80
percent were unnecessary, according to the
Centers for Disease Control and Prevention
(CDC) guidelines.1,2 Antibiotic treatment
is not usually appropriate for acute
bronchitis, with the exception of comorbid
diseases requiring antibiotics.3
The Case for Improvement
• More than $1.1 billion is spent annually
on unnecessary antibiotics for respiratory
infections in adults.4
• Treating drug-resistant pathogens poses
a significant burden on the system
through repeated health care visits and
greater risk of disease complications and
hospitalizations—which lead to increased
health care costs.5,6
concern. When resistance makes widelyused antibiotics ineffective, an alternative
treatment may not be available,7 or
physicians may use more potent antibiotics,
which are often more toxic and more
expensive. This can result in longer hospital
stays, more serious side effects and
increased financial burden on the system
and on patients.8
HEDIS Measure Definition
This measure assesses the percentage of
adults 18–64 years of age with a diagnosis of
acute bronchitis who were not dispensed an
antibiotic prescription on or three days after
an episode. A higher rate indicates better
performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Treatment Rate
Antibiotic treatment is only infrequently
appropriate for acute bronchitis. Misuse
Commercial
Medicare
Medicaid
or overuse can be avoided by prescribing
Year
HMO
PPO
HMO
PPO
HMO
treatment when necessary, as well as
2010
22.5
21.3
NA
NA
23.5
2009
24.0
22.6
NA
NA
25.6
2008
24.6
26.8
NA
NA
25.8
2007
25.4
29.3
NA
NA
25.9
2006
28.7
29.7
NA
NA
28.0
informing patients and clinicians regarding
the appropriate use of antibiotics.
S a f et y and P o tentia l W aste
Results
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S a f et y and P o tentia l W aste
Use of Imaging Studies for L ower Back Pain
Back pain is one of America’s most common medical problems. An estimated 75 percent–85
percent of Americans will experience back pain at some point,1 and approximately 25 percent
of Americans will experience at least one day of back pain during any three-month period.2
Although imaging is used to diagnose the cause of low back pain, it is costly and ineffective. Less
than 1 percent of radiographs identify a specific cause of low back pain.3 The Use of Imaging
Studies for Low Back Pain measure assesses the number of patients with lower back pain who did
not get an X-ray, MRI or CT scan as part of their treatment.
• Although a variety of minor injuries and
conditions can lead to back pain, most
The Case for Improvement
• On average, patients with low back pain
acute low back pain is benign and self-
have higher overall medical costs. Patients
limiting. Imaging studies are not required
with back pain spend an average of
for diagnosis.
$7,211, while comparable patients without
8
• Studies have shown that patients treated
without imaging experience no difference
in health outcomes.4,5 Abnormalities
discovered through imaging were as
back pain spend an average of $2,400
over a two-year period. Patients with low
back pain who opt for surgery incur an
average of $34,000 in direct medical costs.8
common in individuals without back pain
• According to the Agency for Healthcare
as they were in individuals with low back
Research and Quality (AHRQ), almost
pain.
18,000 Americans sought medical attention
4
• Imaging for early, acute low back pain
can lead to surgery. Complications from
unnecessary surgery can prolong back
pain or lead to permanent disability.
5
for low back pain in 2008. Additionally,
medical care for these individuals cost
approximately $35 billion dollars, with
imaging driving much of the cost.6,7
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Imaging Studies for
Low Back Pain
The percentage of adults with a primary
diagnosis of low back pain who did not have
an imaging study (plain X-ray, MRI or CT
scan) within 28 days of the diagnosis.
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
74.2
73.3
NA
NA
75.5
Results
2009
73.9
72.7
NA
NA
76.1
With the use of costly imaging studies failing
2008
73.1
72.3
NA
NA
75.7
2007
74.6
73.3
NA
NA
77.3
2006
73.9
72.1
NA
NA
78.3
2005
75.4
72.6
NA
NA
79.0
to produce positive health outcomes for
patients with low back pain, X-ray, MRI and
CT scans should primarily be used for patients
with neurologic deficits or other serious
underlying conditions.
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HEDIS Measure Definition
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S a f et y and P o tentia l W aste
Re lative Reso urce Use
NCQA’s Relative Resource Use (RRU) measures indicate how intensively health plans use heath
care resources (e.g., doctor visits, hospital stays, surgery, drugs) compared with other plans
in the same region, adjusted for the population of members they serve. When combined with
NCQA HEDIS quality measures, RRU measures reveal value.
RRU measures help health care purchasers identify health plans that deliver high-quality care while
managing associated costs. The table below is a hypothetical example of RRU results for plans in
one region for patients with diabetes. Scores above 1.0 indicate higher-than-average use, while
scores below 1.0 indicate lower-than-average use. In this example, Plan D is highlighted because
it offers an appealing combination of above-average quality and below-average resource use.
Hypothetical Diabetes RRU in a Single Region
Diabetes Medical Resource Use
Plan
Quality
Score
Combined
Medical
Inpatient
Hospital
Evaluation &
Management
Surgery &
Procedures
Rx Drugs
Plan A
1.06
1.14
1.32
1.00
0.89
1.14
Plan B
1.10
0.85
0.96
0.74
0.73
1.12
Plan C
1.10
0.80
0.84
0.79
0.71
1.16
Plan D
1.14
0.74
0.77
0.85
0.56
1.13
Plan E
0.97
0.73
0.79
0.76
0.54
1.19
NCQA collects RRU data for five conditions that account for more than 60 percent of all health
spending: asthma, cardiovascular disease, COPD, diabetes and hypertension. Overall, RRU measures
reveal that the amount of services used to treat people often has little correlation to the quality of care.
To allow fair comparison of plans, RRU measures feature risk adjustment and price
standardization of services. The goal of risk adjustment is to eliminate sources of variation that
neither health plans nor providers can control. Factors used in risk adjustment include age,
gender and presence of other serious health conditions. Standardized prices are assigned to
each unit of service delivered to health plan members and reported by service category (e.g.,
inpatient hospital care, evaluation and management, surgery and other procedures, diagnostic
lab and imaging, prescription drugs) for each of the five conditions.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
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plans that are high in quality and low in resource use. As depicted in the following scatterplots,
scores that place health plans in the upper left quadrant are generally considered most desirable
(above-average quality, below-average resource use). Health plans in the lower right quadrant
are less desirable (below-average quality, above-average resource use).
This report focuses on the three RRU measures where discrepancies between plans’
resource use and resulting quality are most pronounced: hypertension, diabetes and certain
cardiovascular conditions. We do not show commercial RRU scatterplots because they have
changed little since last year’s State of Health Care Quality Report and are available in NCQA’s
Quality Compass product. Conversely, we show Medicare and Medicaid results because we
did not do so in last year’s report, and because the data are not available in Quality Compass.
Upcoming Refinements to RRU
• Updated Risk Adjustment Approach: NCQA moved to an improved risk adjustment
approach that was adapted from the Center for Medicare & Medicaid Service’s (CMS)
Hierarchical Condition Category (HCC) case-mix adjustment approach. The revised risk
adjustment considers disease severity and number of comorbidities, in addition to other
factors that inform the cost of care delivered to health plan members.
• Measure Enhancement: NCQA expanded its measurement of specific procedures,
particularly for diabetes and cardiovascular care, to provide plans with actionable
information about the frequently performed services that significantly contribute to resource
use. Examples of these procedures include cardiac catheterization; carotid artery stenosis
diagnostic tests; electron beam computed tomography and nuclear imaging stress tests
for coronary artery disease; and cardiac computed tomography screening. Reporting risk
adjusted utilization of these services, alongside cost information, is expected to increase
meaning and actionability of measure results.
• Pharmacy Prescription Utilization: To provide more detail for the prescription drugs service
category, NCQA added generic and name-brand utilization rates to the five measures.
Compared with the previous format, the data now capture how well a plan manages its
pharmacy costs with respect to generic, brand-name and multisource drugs.
S a f et y and P o tentia l W aste
Looking at quality and resource use scores together, purchasers should be most interested in
nati o na l c o mmittee f o r qua l it y assurance
Medicare HMOs: Diabetes
Quality (Indexed Ratio)
1.5
1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
Medicare PPOs: Diabetes
1.5
Quality (Indexed Ratio)
S a f et y and P o tentia l W aste
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1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Quality (Indexed Ratio)
1.5
1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
Medicare PPOs: Cardiovascular Conditions
Quality (Indexed Ratio)
1.5
1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
S a f et y and P o tentia l W aste
Medicare HMOs: Cardiovascular Conditions
33
nati o na l c o mmittee f o r qua l it y assurance
Medicare HMOs: Hypertension
Quality (Indexed Ratio)
1.5
1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
Medicare PPOs: Hypertension
1.5
Quality (Indexed Ratio)
S a f et y and P o tentia l W aste
34
1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Quality (Indexed Ratio)
1.5
1
0.5
0.5
1
1.5
RRU (Indexed Ratio)
Medicaid HMOs: Cardiovascular Conditions
Quality (Indexed Ratio)
1.5
1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
Medicaid HMOs: Hypertension
Quality (Indexed Ratio)
1.5
1
0.5
0.5
1
RRU (Indexed Ratio)
1.5
S a f et y and P o tentia l W aste
Medicaid HMOs: Diabetes
35
36
nati o na l c o mmittee f o r qua l it y assurance
W e l l ness and P reventi o n
Adult BMI Assessment
Obesity is responsible for more deaths in the U.S. than AIDS, all cancers and all accidents
combined.1 Individuals are identified as being overweight or obese if their weight range is greater
than is generally considered healthy for their height.2 Obesity is measured by body mass index
(BMI), which estimates body fat and gauges risk for high body-fat diseases.3 The Adult Body
Mass Index Assessment measure evaluates the percentage of adults who have their BMI measured
regularly to assess their risk for overweight or obesity, and/or risk for related health complications.
• According to the Centers for Disease
Control and Prevention (CDC), more than
The Case for Improvement
• According to a 2009 study by the
two-thirds of U.S. adults are overweight
CDC and RTI International, a research
or obese and more than one-third are
organization,6 the direct and indirect
considered obese.4
cost of obesity is more than $147 billion
• Overweight and obesity occur from
consuming too many calories and not
engaging in enough physical activity to
compensate. This can be the result of a
number of factors, including behavior,
environment, culture and socioeconomic
status. Genes and metabolism can also
affect weight.5
• As few as 31 percent of U.S. adults report
that they participate in regular leisuretime physical activity: three sessions per
week of vigorous physical activity lasting
20 minutes or more, or five sessions per
week of light-to-moderate physical activity
lasting 30 minutes or more. Approximately
40 percent report no leisure-time physical
activity.4
annually. Obese patients spend 42 percent
more for their medical care than those in a
healthy weight range—an average $1,429
more per year. The study found that
Medicare, Medicaid and private insurers
increased spending due to obesity from 6.5
percent in 1998 to 9.1 percent in 2006.
This amounts to a $40 billion increase in
medical sending through 2006, including a
$7 billion increase in Medicare prescription
drug costs.7
• Obesity can cause a number of serious
medical conditions, including type 2
diabetes, heart disease and high blood
pressure, and increases the risk of strokes
and certain types of cancers.8
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Assessment Rate
cancer of the colon, rectum or prostate;
obese women are more likely to develop
Commercial
Medicare
Medicaid
cancer of the gallbladder, uterus, cervix or
Year
HMO
PPO
HMO
PPO
HMO
ovaries.
2010
40.7
11.6
50.4
36.6
42.2
2009
41.3
15.7
38.8
24.1
34.6
8
HEDIS Measure Definition
The percentage of adults 18–74 years of age
who had an outpatient visit and who had their
BMI documented during the measurement year
or the year prior to the measurement year.
Results
Weight loss and physical activity are
recommended for people who are overweight
or obese. Losing 5 percent–10 percent of
body weight will help lower an obese person’s
risk of developing diseases associated with
obesity.4
W e l l ness and P reventi o n
• Obese men are more likely to develop
37
38
nati o na l c o mmittee f o r qua l it y assurance
W e l l ness and P reventi o n
Flu Shots for Adu lts
Each year, 5 percent–20 percent of Americans contract influenza (flu). More than 200,000
people are hospitalized from flu-related complications, which include pneumonia, dehydration
and deterioration of chronic health conditions, such as heart failure, diabetes and asthma.1
The Flu Shots for Adults Ages 50–64 measure assesses whether adults received an influenza
vaccination (flu shot).
• Flu especially affects the health of people
• A single flu epidemic can result in more
50–64 years of age. One third of all
than $3 billion in direct hospitalization
Americans 50–64 have one or more
costs alone.8
2
chronic medical conditions that puts
• Flu shots have been shown to be highly
them at increased risk for serious flu
cost-effective for adults 50–64.9 The
complications.3
vaccination is estimated to cost just $16.70
• Flu shots are the most effective way to
per person vaccinated, including direct and
prevent severe illness or death resulting
indirect medical costs and costs associated
from influenza and its complications.
with potential side-effects.10
4
• Influenza vaccines may prevent 50
percent–60 percent of hospitalizations
and 68 percent of deaths from flu-related
complications for this age group.5
The Case for Improvement
• In 2008, only 67 percent of adults between
50 and 64 reported receiving an influenza
vaccination.6 Over the course of an
average flu season, more than 15,000 lives
could be saved if 90 percent vaccination
coverage was achieved annually.7
HEDIS Measure Definition
A rolling average represents the percentage of
commercial members 50–64 years of age who
received an influenza vaccination between
September 1 of the measurement year and
the date when the CAHPS 4.0H survey was
completed.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Vaccination Rate
Flu shots for adults ages 50–64 could save
thousands of lives and result in dramatic cost
savings for the health care system.
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
52.5
51.6
NA
NA
NA
2009
51.3
50.5
64.5
65.1
NA
2008
49.8
49.2
65.8
66.7
NA
2007
48.6
48.1
68.6
68.9
NA
2006
45.6
44.5
67.8
68.2
NA
2005
36.2
37.1
70.3
69.9
NA
2004
38.9
NA
74.8
NA
NA
2003
47.9
NA
74.4
NA
NA
2002
44.0
NA
72.5
NA
NA
2001
30.3
NA
71.2
NA
NA
W e l l ness and P reventi o n
Results
39
40
nati o na l c o mmittee f o r qua l it y assurance
W e l l ness and P reventi o n
Breast Cancer Screening
Breast cancer is one of the most common types of cancers, and accounts for a quarter of all new
cancer diagnoses among women in the U.S.1 The Breast Cancer Screening measure assesses whether
women between 40 and 69 years of age received a mammogram screening for breast cancer.
• Breast cancer is the second cause of cancer
deaths in women (after lung cancer).2
• Breast cancer deaths have decreased over
the years, thanks to early detection using
mammography. Screening every two years
decreases the risk of mortality by more
than 16 percent in women between 50 and
69, compared with no screening.
3
• About 70 percent–80 percent of breast
cancers occur in women who have no
family history of breast cancer. These
cancers occur because of genetic
abnormalities that happen as a result of
the aging process,4 and there is a clear
The Case for Improvement
• Breast cancer treatment costs in the U.S.
total nearly $7 billion a year, including $2
billion spent on late-stage treatment.5 Lowincome women are less likely to have had
a mammogram within the past two years,
increasing their risk of late-stage diagnosis
and decreasing their chance of survival.7
• Early detection of breast cancer by
mammography may lead to greater
range of treatment options that include
less-aggressive surgery and less-invasive
therapy.7
• The five-year survival rate for women
connection between age and developing
who are diagnosed early is 98 percent,
breast cancer.5,6
compared with the late-diagnosed breast
• Mammogram screening has demonstrated
reductions in breast cancer mortality
and there is a clear connection between
developing breast cancer and age.5,6
cancer survival rate of only 23 percent.2
HEDIS Measure Definition
The percentage of women 40–69 years of age
who had at least one mammogram to screen
for breast cancer in the past two years.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Screening Rate
Early detection and better treatment have
resulted in increased survival rates for
Commercial
Medicare
Medicaid
women with breast cancer. If breast cancer
Year
HMO
PPO
HMO
PPO
HMO
is diagnosed when it is in its earliest stages,
2010
70.8
67.0
68.5
65.8
51.3
2009
71.3
67.1
69.3
65.5
52.4
2008
70.2
66.0
68.0
65.2
50.8
2007
69.1
64.6
67.3
64.5
49.8
2006
68.9
63.5
69.5
68.6
49.1
2005
72.0
63.9
71.6
69.0
53.9
2004
73.4
NA
74.0
NA
54.1
2003
75.3
NA
74.0
NA
55.9
2002
74.9
NA
74.5
NA
56.0
2001
75.5
NA
75.3
NA
55.1
2000
74.5
NA
NA
NA
NA
1999
73.4
NA
NA
NA
NA
treatment may be more effective and less
expensive.5
W e l l ness and P reventi o n
Results
41
42
nati o na l c o mmittee f o r qua l it y assurance
W e l l ness and P reventi o n
Cervica l Cancer Screening
Cervical cancer is nearly 100 percent preventable, yet it is the second most common cancer
among women worldwide.1,2 In the United States, about 12,000 women are diagnosed with
cervical cancer each year, resulting in more than 4,000 deaths.3,4 The Cervical Cancer Screening
measure assesses whether women between 21 and 64 years of age received screening for
cervical cancer using a Pap test.
• For women in whom pre-cancerous lesions
• All women are at risk for cervical cancer
were detected through Pap tests, the
and women with the lowest levels of
likelihood of survival is nearly 100 percent
education tend to have fewer screenings in
with appropriate evaluation, treatment and
their lifetime.4
follow up.1,3
• In 2008, the prevalence of recent Pap
test use was lowest among older women,
• A woman who does not have regular Pap
tests significantly increases her chances of
developing cervical cancer.3
women with no health insurance and recent
immigrants.1
HEDIS Measure Definition
The percentage of women 21–64 years of age
The Case for Improvement
who received one or more Pap test to screen
• The total cost of treatment for cervical
for cervical cancer in the past three years.
cancer is $300 million–$400 million
annually.2
• Between 60 percent and 80 percent of
women with advanced cervical cancer
have not had a Pap test in the past five
years.1
Results
Cervical cancer incidence and mortality rates
have decreased 67 percent over the past
three decades. Most of the reduction can
be attributed to the Pap test, which detects
cervical cancer and precancerous lesions.1
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
77.0
74.5
NA
NA
67.2
2009
77.3
74.6
NA
NA
65.8
2008
80.7
74.0
NA
NA
66.0
2007
81.7
73.5
NA
NA
64.8
2006
81.0
72.6
NA
NA
65.7
2005
81.8
74.6
NA
NA
65.2
2004
80.9
NA
NA
NA
64.7
2003
81.8
NA
NA
NA
64.0
2002
80.5
NA
NA
NA
62.2
2001
80.0
NA
NA
NA
61.1
2000
78.1
NA
NA
NA
NA
1999
71.8
NA
NA
NA
NA
W e l l ness and P reventi o n
Screening Rate
43
44
nati o na l c o mmittee f o r qua l it y assurance
W e l l ness and P reventi o n
Colorectal Cancer Screening
In 2010 an estimated 142,570 men and women were diagnosed with colon cancer, and
approximately 51,370 died from the disease, making it the second leading cause of cancer
death in the United States.1,2 The Colorectal Cancer Screening measure assesses whether adults
50–75 years of age received screening for colorectal cancer, based on the recommendation of
the U.S. Preventive Services Task Force.3
• Symptoms are not common in colorectal
• Deaths associated with colorectal cancer
cancer until the disease has progressed
declined in 2010, continuing a 15-year
and chances of survival have decreased.4
trend attributed to increased screening
Treatment in the disease’s earliest stage is
and early detection.3,10 Between 2003
highly successful, with a five-year survival
and 2007, 35 states saw decreases in the
rate of 74 percent.
number of new cases of colorectal cancer,11
5
• Most colorectal cancers occur in people
but regional variation exists.
without a family history of colorectal
• Screening for colorectal cancer is shown
cancer. While screening is extremely
to be cost effective for the health care
effective in detecting colorectal cancer, it
system. The cost of screening far outweighs
remains underutilized.
the costs of treating more progressive
6
colorectal cancer.12
The Case for Improvement
• Approximately half of American adults do
not receive the necessary colorectal cancer
screening.7 Screening rates for colorectal
cancer lag behind other cancer screening
rates.8
• Doctors’ recommendations have been
found to be a major predictor of whether
patients receive the supported screening.13
HEDIS Measure Definition
The percentage of adults 50–75 years of age
• Fecal occult blood tests, colonoscopy and
who had appropriate screening for colorectal
flexible sigmoidoscopy are shown to be
cancer with any of the following tests: fecal
effective screening methods. Colorectal
occult blood test during the measurement
screen of individuals with no symptoms
year; flexible sigmoidoscopy during the
can identify polyps whose removal can
measurement year or the four years prior to
prevent more than 90 percent of colorectal
the measurement year; or colonoscopy during
6
cancers.
9
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Screening Rate
years prior to the measurement year.
Commercial
Medicare
Medicaid
Results
Year
HMO
PPO
HMO
PPO
HMO
Colorectal cancer screening in asymptomatic
2010
62.6
47.6
57.6
41.0
NA
adults between 50 and 75 can catch
2009
60.7
47.0
54.9
40.1
NA
2008
58.6
45.3
53.1
41.8
NA
2007
55.6
42.5
50.4
39.5
NA
2006
54.5
42.1
53.3
47.1
NA
2005
52.3
43.4
54.0
49.7
NA
2004
49.0
NA
52.6
NA
NA
dangerous polyps before they become
cancerous, or can detect colorectal cancer
in its early stages, when treatment is most
effective.
W e l l ness and P reventi o n
the measurement year or in any of the nine
45
46
nati o na l c o mmittee f o r qua l it y assurance
W e l l ness and P reventi o n
Medical A ssistance With Smok ing
and Tobacc o U se Cessation
Smoking is the second most common cause of death in the world, causing almost a half-million deaths
annually,1 and it is by far the most directly preventable cause of death and disability in the United
States.2,3 In 2009, almost 18 percent of adults in the U.S.—more than 40 million people—were
smokers.2 The Medical Assistance With Smoking and Tobacco Use Cessation measure assesses whether
adults who use tobacco products receive counseling, medications and strategies to help them quit.
• Although consumption of cigarettes
economic burden of smoking is estimated
continues to decline and the number of
to be $193 billion per year.9 In an
people who are heavy smokers (i.e.,
18-month period, smokers incur 18 percent
smoke a pack each day) has dropped
higher health care charges than people
significantly,5 the consumption of cigars
who never smoked.7
and smokeless tobacco is on the rise.6
• More than 70 percent of smokers want to
quit and more than 40 percent try to quit
• Women and minorities receive advice
about quitting smoking less frequently than
men who smoke.11,12
each year.7 Less than 7 percent succeed in
kicking the habit.7
HEDIS Measure Definition
This measure evaluates three facets of
The Case for Improvement
providing medical assistance with smoking
• Studies have shown that a physician’s
and tobacco use cessations.
advice to quit is an important motivator
for smokers attempting to quit,8 but fewer
than half of smokers receive cessation
counseling.9 Doctors and other health care
providers can improve a patient’s outcome
in as little as three minutes, according to
the Public Health Service Guidelines.10
Research indicates that the more intense the
intervention, the higher the likelihood that
smokers will quit successfully.8
• Annual smoking-related health care costs
are estimated at $96 billion.9 When
productivity losses are considered, the total
• Advising Smokers and Tobacco Users to Quit.
A rolling average represents the percentage
of adults 18 years of age and older who are
current smokers or tobacco users and who
received cessation advice from a physician
during the measurement year.
• Discussing Cessation Medication. A rolling
average represents the percentage of
adults 18 years of age and older who are
current smokers or tobacco users and who
discussed or were recommended cessation
medications by a physician during the
measurement year.
47
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Discussing Cessation
Strategies
average represents the percentage of adults
18 years of age and older who are current
smokers or tobacco users who discussed or
Commercial
Medicare
Medicaid
were provided cessation methods or strategies
Year
HMO
PPO
HMO
PPO
HMO
by a physician during the measurement year.
2010
45.0
39.0
NA
NA
38.5
2008
49.7
43.3
NA
NA
40.8
2007
48.0
44.2
NA
NA
39.2
2006
43.2
42.6
NA
NA
36.7
2005
38.9
35.1
NA
NA
33.9
advantageous methods for reducing smoking-
2004
36.8
NA
NA
NA
32.7
related deaths and health care costs.2
2003
36.0
NA
NA
NA
32.3
Results
Care providers play an important role in
supporting smokers’ efforts to quit. Smoking
cessation practices are among the most
Advising Smokers and
Tobacco Users to Quit
Commercial
Medicare
Discussing Cessation
Medications
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
76.7
71.7
NA
NA
73.6
2010
52.4
47.2
NA
NA
42.7
2009
NA
NA
77.9
75.2
NA
2008
54.4
50.9
NA
NA
40.6
2008
76.7
71.6
76.9
76.5
69.3
2007
50.9
49.6
NA
NA
38.7
2007
75.8
71.0
75.8
75.4
69.4
2006
43.9
43.8
NA
NA
35.1
2006
73.8
70.1
76.1
77.3
68.2
2005
39.4
36.7
NA
NA
31.8
2005
71.2
66.9
75.5
77.3
65.6
2004
37.8
NA
NA
NA
31.3
2004
69.6
NA
64.7
NA
66.7
2003
37.6
NA
NA
NA
31.5
2003
68.6
NA
62.9
NA
65.8
2002
67.7
NA
61.6
NA
63.6
2001
65.7
NA
60.9
NA
63.9
2000
66.3
NA
NA
NA
NA
W e l l ness and P reventi o n
• Discussing Cessation Strategies. A rolling
48
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Persistence of Beta-Blocker
Treatment After a Heart Attack
Heart attacks occur when blood clots obscure the main blood vessel that feeds the heart. Loss
of blood flow may permanently damage the heart tissue.1 Each year, an estimated 785,000
Americans suffer a heart attack. Of these, 470,000 have had at least one heart attack before,
and 150,000 are under the age of 65.2,3 The Persistence of Beta-Blocker Treatment After a Heart
Attack measure reports the number of people who had a heart attack and received beta-blocker
treatment during the six months following their discharge from the hospital.
• Beta-blocker therapy has been shown to
• If beta-blocker adherence could be
reduce mortality when used after a heart
increased to 100 percent in first-time
attack.4 These drugs can also reduce
heart attack survivors for 20 years, an
patients’ risk for hospital readmission in the
estimated 62,000 heart attacks would be
first year.
prevented, 72,000 deaths from coronary
5
• Beta-blocker therapy restores blood flow,
which reduces damage to the heart muscle.
Beta-blockers slow heart rate, lower blood
heart disease avoided, 447,000 life-years
gained and $18 million saved.10,11
• Although the elderly benefit from beta-
pressure and prevent irregular heartbeats
blocker therapy, many patients are not
by blocking nervous impulses or stress
prescribed these medications. Of all adults
responses to the heart.
who are good candidates for beta-blocker
6,7
medication, only 43.8 percent of nursing
The Case for Improvement
home residents and 61.4 percent of
• Despite beta-blockers’ effectiveness,
community-dwelling residents receive beta-
adherence to beta-blocker therapy is poor.
blockers. Research has shown that mortality
Only 45 percent of patients consistently
is significantly lower for nursing home
took their medications in the first year after
patients who receive beta-blockers.12
discharge.8 Lack of adherence has been
shown to increase patients’ risk of dying.9
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Treatment Rate
The percentage of adults 18 years of age
and older during the measurement year who
Commercial
Medicare
Medicaid
were hospitalized with a diagnosis of AMI
Year
HMO
PPO
HMO
PPO
HMO
and discharged alive from July 1 of the year
2010
75.5
71.3
83.1
82.5
76.3
2009
74.4
69.6
82.6
78.9
76.6
2008
75.0
68.8
79.7
76.7
73.6
2007
71.9
62.9
75.5
70.4
62.0
2006
72.5
65.5
69.6
70.9
68.1
2005
70.2
64.3
65.4
58.5
69.8
prior to the measurement year to June 30
of the measurement year, and who received
persistent beta-blocker treatment for six
months after discharge.
Results
The Persistence of Beta-Blocker Treatment After
Heart Attack measure provides insight into
the number of heart attack patients receiving
appropriate care with medications proven
effective in reducing cardiac-related mortality.
C hr o nic D isease M anagement
HEDIS Measure Definition
49
50
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Comprehensive Diab etes Care
Diabetes is the seventh leading cause of death in the United States. For people with diabetes, the
risk of death is twice that of people without diabetes.1,2 Diabetes, especially when unmanaged,
may lead to blindness, heart disease and limb amputation.1 It is also the leading cause of kidney
failure, accounting for 45 percent of new cases.3 People with diabetes face tripled risk of stroke,
compared with people who have normal blood sugar levels.4
Almost 26 million Americans are diabetic
• Between 1980 and 2006, the number of
and an additional 79 million adults are
hospitalizations for patients with diabetes
prediabetic.1 The number of diabetics is
more than doubled.5 Diabetes was the
increasing dramatically, due in large part
primary diagnosis in almost 550,000
to the rising number of Americans who are
hospitalizations in 2009, when the average
overweight or obese.
medical charge was $12,849 for diabetes
2
The Comprehensive Diabetes Care measure
assesses whether patients receive guidelinerecommended care and achieve control levels
without complications and $29,851 for
diabetes with complications.6
• Improving blood sugar control has shown
for their blood sugar, cholesterol and blood
to result in lower health care use and
pressure.
better overall satisfaction with diabetes
treatment.7,8 People who controlled their
The Case for Improvement
diabetes also reported improved quality of
• In 2007, diabetes was estimated to cost the
life and emotional well-being.9
U.S. economy $174 billion. Of this, $116
billion was attributed to the cost of medical
HEDIS Measure Definition
care. Another $58 billion was lost through
The percentage of adults 18–75 years of age
disability, missed work days and premature
with diabetes (type 1 and type 2) who had
mortality.2
each of the following:
• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (<8.0%)
• HbA1c control (<7.0%) for a selected
population
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Blood Pressure Control
(<140/90 mm Hg)
• LDL-C control (<100 mg/dL)
• Medical attention for nephropathy
Commercial
• BP control (<140/80 mm Hg)
• BP control (<140/90 mm Hg).
Results
Although many people live with diabetes
years after diagnosis, it is a costly condition
HMO
PPO
HMO
PPO
HMO
2010
65.7
51.1
62.3
55.6
60.4
2009
65.1
46.3
60.5
49.0
59.8
2008
65.6
0.3
59.5
0.3
56.9
2007
63.9
0.1
58.9
0.3
55.6
Eye Exams
health complications. Comprehensive diabetes
control can improve the quality of life for
health care dollars.
Blood Pressure Control
(<130/80 mm Hg)
Commercial
Medicare
Medicaid
Medicaid
Year
that leads to serious and potentially fatal
millions of Americans and save billions of
Medicare
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
57.7
45.5
64.6
62.3
53.1
2009
56.5
42.6
63.5
59.4
52.7
2008
56.5
35.8
60.8
52.2
52.8
2007
55.0
34.0
62.7
50.4
49.8
Year
HMO
PPO
HMO
PPO
HMO
2006
54.6
36.1
62.3
53.8
51.4
2009
33.9
23.6
33.3
26.7
32.2
2005
54.8
42.7
66.5
53.8
48.6
2008
33.4
0.2
31.8
0.2
30.7
2004
50.9
NA
67.2
NA
44.9
2007
32.1
0.1
31.7
0.1
29.6
2003
48.8
NA
64.9
NA
45.0
2002
51.7
NA
68.4
NA
46.8
2001
52.1
NA
66.0
NA
46.4
2000
48.1
NA
NA
NA
NA
1999
45.3
NA
NA
NA
NA
C hr o nic D isease M anagement
• LDL-C screening
51
C hr o nic D isease M anagement
52
nati o na l c o mmittee f o r qua l it y assurance
HbA1c Screening
Commercial
Medicare
Good Glycemic Control
(HbA1c <8%)
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
89.9
85.2
90.4
90.6
82.0
2009
89.2
83.3
89.6
89.3
2008
89.0
79.5
88.3
2007
88.1
75.6
2006
87.5
2005
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
80.6
2010
62.3
50.2
65.6
57.3
46.9
85.7
80.5
2009
61.6
48.0
63.7
51.8
45.7
88.1
81.9
77.3
72.1
87.2
83.3
78.0
87.5
82.8
88.9
80.0
76.1
2004
86.5
NA
89.1
NA
75.9
2003
84.6
NA
87.9
NA
74.8
2002
82.6
NA
85.0
NA
73.0
2001
81.4
NA
85.7
NA
71.6
2000
78.4
NA
NA
NA
NA
1999
75.0
NA
NA
NA
NA
Good Glycemic Control (HbA1c
<7% for a Selected Population)
Commercial
Medicare
Medicaid
Poor Glycemic Control
(HbA1c >9%)
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
27.3
46.6
25.9
35.2
44.0
2009
28.2
44.6
28.0
41.3
44.9
2008
28.4
74.4
29.4
67.0
44.8
2007
29.4
84.1
29.0
74.7
48.0
2006
29.6
75.9
27.3
71.8
48.7
2005
29.7
55.4
23.6
27.3
49.2
2004
30.7
NA
22.3
NA
48.6
2003
32.0
NA
23.4
NA
48.6
2002
33.9
NA
24.5
NA
48.9
Year
HMO
PPO
HMO
PPO
HMO
2010
42.5
28.2
NA
NA
34.7
2001
36.9
NA
26.8
NA
48.3
2009
42.1
30.3
NA
NA
33.9
2000
42.5
NA
NA
NA
NA
2008
43.3
13.5
43.4
23.4
32.9
1999
44.9
NA
NA
NA
NA
2007
43.1
10.0
46.2
21.7
31.4
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
Medicare
Medical Attention
for Nephropathy
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
85.6
79.9
87.8
86.3
74.7
2009
85.0
78.6
87.3
85.5
2008
84.8
74.7
86.3
2007
83.9
72.7
2006
83.3
2005
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
74.2
2010
83.6
74.3
89.2
87.3
77.7
82.3
74.1
2009
82.9
69.9
88.6
85.2
76.9
85.7
80.0
70.8
2008
82.4
65.9
87.9
82.1
76.6
67.4
84.8
79.4
71.1
2007
80.6
64.2
85.7
81.7
74.3
92.3
87.0
93.3
87.1
80.6
2006
79.7
60.7
85.4
83.0
74.6
2004
91.0
NA
93.5
NA
79.6
2005
55.1
44.4
60.3
51.5
48.9
2003
88.4
NA
91.1
NA
75.9
2004
52.0
NA
58.6
NA
46.7
2002
85.1
NA
87.9
NA
70.8
2003
48.2
NA
53.6
NA
43.7
2001
81.4
NA
85.7
NA
66.5
2002
51.8
NA
57.3
NA
48.2
2000
76.5
NA
NA
NA
NA
2001
46.3
NA
51.9
NA
42.3
1999
69.0
NA
NA
NA
NA
2000
41.3
NA
NA
NA
NA
1999
36.0
NA
NA
NA
NA
LDL Cholesterol Control
(<100 mg/dL)
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
47.7
37.3
52.1
45.9
34.6
2009
47.0
36.8
50.0
40.5
33.5
2008
45.5
14.8
48.7
24.3
33.8
2007
43.8
10.4
46.8
22.4
31.3
2006
43.0
14.4
46.9
20.4
30.6
2005
43.8
24.4
50.0
48.4
32.7
2004
40.2
NA
47.6
NA
30.6
C hr o nic D isease M anagement
LDL Cholesterol Screening
53
54
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Contro lling High B lood Pressure
High blood pressure, or hypertension, occurs when the force of blood against artery walls
increases, leading to greater risk of heart disease. High blood pressure may result when the
arteries narrow or when the amount of blood the heart pumps increases.1 The Controlling High
Blood Pressure measure assesses whether adults with high blood pressure manage their condition
by taking steps to lower their blood pressure and keep their scores within the normal range.
• Approximately 76.4 million (33.5 percent)
of people in the United States have high
blood pressure.2, 5
• High blood pressure puts people at risk for
heart attacks and strokes.3 Over a lifetime,
people with hypertension have twice the
risk of stroke, compared with those without
hypertension.
4
• Although the risk of developing
hypertension increases with age,9 nearly
one in five young adults between the ages
of 24 and 32 has high blood pressure. Of
these, only half are aware that they have
the condition.6
• A study conducted by The National High
Blood Pressure Education Program in 2002
The Case for Improvement
• In 2007, over 46 million ambulatory care
visits were attributed to hypertension.7
Hypertension was listed as a primary or
secondary diagnosis in over 8.7 million
hospital admissions.1 The associated direct
and indirect medical costs were estimated
to be $43.5 billion.1
• Approximately 69 percent of people who
suffer a first heart attack, 77 percent of
people who have a stroke and 79 percent
of people with congestive heart failure have
high blood pressure.1
• Only half of people with hypertension
control their high blood pressure.10, 11
• Life expectancy for people with
indicated that reducing blood pressure by
hypertension is 5.1 years shorter for
5 mm Hg decreased death from stroke by
men and 4.9 years shorter for women,
14 percent, death from coronary heart
compared with individuals who have
disease by 9 percent and death from all
normal blood pressure.8
causes by 7 percent.9
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Control Rate
The percentage of adults 18–85 years of
age who had a diagnosis of hypertension
Commercial
Medicare
Medicaid
and whose blood pressure was adequately
Year
HMO
PPO
HMO
PPO
HMO
controlled (<140/90) during the measurement
2010
63.4
56.7
61.9
55.7
55.6
2009
64.1
48.3
59.8
54.8
55.3
2008
63.4
NA
58.5
NA
55.8
2007
62.2
NA
57.6
NA
53.5
step in preventing cardiovascular disease.
2006
59.7
48.9
56.8
51.2
53.1
Interventions to lower blood pressure can be
2005
68.8
60.9
66.4
60.6
61.5
an effective way to improve longevity and
2004
66.8
NA
64.6
NA
61.4
other health outcomes for a vast number of
2003
62.2
NA
61.4
NA
58.6
Americans.
2002
58.4
NA
56.9
NA
52.3
2001
55.4
NA
53.6
NA
53.0
2000
51.5
NA
NA
NA
NA
1999
39.0
NA
NA
NA
NA
year.
Results
Controlling hypertension is an important
C hr o nic D isease M anagement
HEDIS Measure Definition
55
56
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Cholesterol Management for Patients
With Cardio vascular Conditions
High cholesterol puts people at increased risk for heart disease when fatty deposits adhere to
artery walls and make it more difficult for blood to flow. Reduced blood flow limits the amount
of oxygen reaching the heart, which could lead to heart failure, and low blood circulation to
the brain could lead to a stroke.1,2 An estimated 82 million American adults have some form
of cardiovascular disease.3 Each year more than 600,000 die, making heart disease the
leading cause of death in the United States.4 The Cholesterol Management for Patients with
Cardiovascular Conditions measure assesses whether adults who have cardiovascular conditions
are screened for high cholesterol.
• High cholesterol has no symptoms, making
• Lowering the level of LDL cholesterol in
screening vital to diagnosing and treating
patients with coronary heart disease
this harbinger of heart disease before
reduces the risk that patients will suffer
serious damage occurs.
another cardiac event or stroke.8 Lifestyle
5
• Reducing LDL-C (“bad” cholesterol) levels
has been shown to lower the occurrence of
adverse cardiovascular events.6
The Case for Improvement
• Researchers from the American Heart
changes, like physical activity, a low-fat
diet and drug therapy, such as statins, have
been found to be effective ways to lower
LDL cholesterol.8,9
• If the American population decreased its
total cholesterol levels by 10 percent, new
Association predict that by 2030, more
cases of cardiovascular disease would drop
than 40 percent of the U.S. population will
an estimated 30 percent.3
have some form of cardiovascular disease.
The estimated direct medical costs to treat
HEDIS Measure Definition
these individuals will triple during this time
The percentage of adults 18–75 years of
frame, from $273 billion to $818 billion
age who were discharged alive for acute
annually.
myocardial infarction (AMI), coronary
7
artery bypass graft (CABG) or percutaneous
coronary interventions (PCI) from January
1–November 1 of the year prior to the
measurement year, or who had a diagnosis
of ischemic vascular disease (IVD) during
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
the measurement year and had each of the
LDL Cholesterol Screening
following during the measurement year:
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
88.9
81.3
88.5
87.1
82.0
2009
88.4
80.2
88.4
86.7
80.7
2008
88.9
75.2
88.6
85.6
79.6
Most high cholesterol cases are silent threats
2007
88.2
74.4
87.9
84.4
76.3
to patients’ heart health, especially for
2006
87.5
68.2
88.0
84.6
75.5
• LDL-C screening
• LDL-C control (<100 mg/dL).
Results
those who have already experienced heart
trouble. Appropriate screening helps doctors
LDL Control (<100 mg/dL)
and patients make lifestyle and medication
changes to lower high cholesterol and prevent
additional heart problems.
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
59.9
45.2
56.7
50.6
42.8
2009
59.2
42.3
55.7
47.2
41.2
2008
59.7
17.3
56.7
27.4
40.1
2007
58.7
13.4
55.9
23.2
38.3
2006
56.6
16.8
56.0
28.0
35.5
C hr o nic D isease M anagement
the measurement year and the year prior to
57
58
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Disease Modif ying Anti -Rheumatic Drug
Therapy in Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the immune system attacks
healthy joints.1 It causes joint destruction, bone erosion and damage to muscles, kidneys and other
organs.2 RA affects 1.5 million Americans.3 The Disease Modifying Anti-Rheumatic Drug Therapy
(DMARD) in Rheumatoid Arthritis measure assesses whether RA patients receive medications that
slow the disease’s progression and help them maintain functional capacity longer.
• People with persistent RA are at greater risk
The Case for Improvement
for premature death. In particular, people
• Arthritis and related conditions, including
with RA die from heart-related problems at
RA, cost the U.S. economy $128 billion
higher rates than people without RA.5
each year. Direct costs, like medical
4
• Arthritis and other rheumatic conditions
are the most common causes of disability
in the United States. Approximately
850,000 adults reported being disabled by
expenses, are estimated at $81 billion,
and indirect costs, such as lost wages and
disability payments, are estimated at $47
billion.8
RA—more than blindness, deafness, bone
• In 2009, RA was the principal diagnosis in
fracture, cancer and diabetes combined. 6
over 16,000 hospitalizations. On average,
• Although there is no cure for RA, DMARDs
may effectively protect joints and minimize
inflammation, slowing progression of the
disease and reducing pain.
7
each visit lasted 4 days and cost nearly
$36,000.9
• Approximately 60 percent of people with
RA become too ill to work after 10 years of
the disease.10
HEDIS Measure Definition
The percentage of diagnosed adults with
rheumatoid arthritis who were dispensed
at least one ambulatory prescription for a
DMARD.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Treatment Rate
RA is a debilitating disease affecting over one
million Americans. Although there is no cure
Commercial
Medicare
Medicaid
for RA, treatment with DMARDs can slow the
Year
HMO
PPO
HMO
PPO
HMO
disease’s progression, reduce pain and lower
2010
87.7
87.0
72.8
77.8
70.1
2009
86.4
86.6
72.3
76.4
70.5
2008
85.7
81.5
70.4
75.1
69.4
2007
85.3
78.9
68.7
73.5
68.1
2006
84.8
82.3
68.2
69.7
67.6
medical and disability costs.
C hr o nic D isease M anagement
Results
59
60
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Use of Appropriate Medications
for People W ith Asthma
Asthma, a long-term lung disease that affects the ability to breathe in both adults and children,
has become one of the most prevalent chronic diseases over the past 20 years.1 The Use of
Appropriate Medications for People With Asthma measure assesses whether adults and children
diagnosed with persistent asthma receive appropriate therapeutic medications.
• In 2009, approximately 24.6 million
• Adults and children with persistent asthma
Americans (17.5 million adults and 7.1
are at increased risk of complications.1
million children) reported having asthma.2
Among the four million individuals who
• Treatment that aligns with clinical
guidelines reduces the severity of symptoms
and the occurrence of asthma-related
events (e.g., hospitalizations, emergency
department visits).3
• According to the Asthma Regional Council,
reported missing at least one work or
school day due to asthma attacks, at least
one in seven (13.6 percent) required
additional outpatient treatment.6
MEASURE DEFINITION
The percentage of adults 5–50 years of
two-thirds of adults and children who
age during the measurement year who
display asthma symptoms are considered
were identified as having persistent asthma
“not well controlled” or “very poorly
and who were appropriately prescribed
controlled” as defined by clinical practice
medication during the measurement year.
guidelines.4
Results
The Case for Improvement
Adults and children with asthma can manage
• The financial burden of asthma is nearly
their symptoms through use of long-term
$56 billion annually.5
• Asthma is a leading cause of lost
productivity and absenteeism. In 2008
there were 10.5 million missed work days
for adults and 14.2 million missed school
days for children 5–17 years of age.2
control medications and environmental
changes to reduce exposure to irritants.6
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
Overall Rate
Medicare
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
96.7
97.0
NA
NA
91.8
2010
92.9
93.0
NA
NA
88.4
2009
96.6
97.0
NA
NA
91.8
2009
92.7
92.8
NA
NA
88.6
2008
92.4
92.7
NA
NA
88.7
2007
92.3
92.9
NA
NA
86.9
Medicaid
2006
91.6
92.7
NA
NA
87.1
12–50 Years
Commercial
Medicare
Year
HMO
PPO
HMO
PPO
HMO
2005
89.9
91.6
NA
NA
85.7
2010
91.8
91.8
NA
NA
85.8
2004
72.9
NA
NA
NA
64.5
2009
91.4
91.6
NA
NA
86.0
2003
71.4
NA
NA
NA
64.1
2002
67.9
NA
NA
NA
62.5
2001
65.6
NA
NA
NA
60.1
2000
62.6
NA
NA
NA
NA
1999
57.7
NA
NA
NA
NA
C hr o nic D isease M anagement
5–11 Years
61
62
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Use of Spirometry T esting in the
Assessment and Diagnosis of COPD
Chronic obstructive pulmonary disease (COPD), characterized by blocked airflow and
diminished capacity to breathe, is a major health problem in the U.S. The most significant
risk factor is long-term cigarette smoking.1,2 Other factors include old age and exposure to
occupational and environmental pollutants. The Use of Spirometry Testing in the Assessment and
Diagnosis of COPD measure evaluates whether adults with a new COPD diagnosis received a
spirometry test, which helps in early diagnosis and enables appropriate treatment planning.
• COPD ranks as the fourth leading cause of
death in the United States.
The Case for Improvement
• In 2010, total annual costs were estimated
3
to exceed $50 billion—$29.5 billion of this
• According to the Global Initiative for
was for direct health care costs, including
Chronic Obstructive Lung Disease
hospitalizations, drugs and physician
guidelines, the spirometry test is an
effective and objective screening tool. It
4
measures how much and how fast one can
breathe air in and out to assess how well
oxygen is delivered to the lungs.
• Early detection of COPD is crucial
for promoting smoking cessation and
instituting appropriate pharmacological
and nonpharmacological therapy before
office and emergency department visits.1,6
Of direct costs, 40–65-year-old patients
represented 67 percent of physician office
visits and 43 percent of hospitalizations.
• Disability and premature death from COPD
cost an additional $14.1 billion in lost
income.1
• In 2008, 13.1 million adults over 18 were
patients reach more costly stages of the
estimated to have COPD,1,5 but close to
disease.3,4
24 million U.S. adults have evidence of
impaired lung function, which indicates
underdiagnosis1,5
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Testing Rate
This measure estimates the percentage of
adults 40 years of age and older with a new
Commercial
Medicare
Medicaid
diagnosis or newly active COPD who received
Year
HMO
PPO
HMO
PPO
HMO
spirometry testing to confirm the diagnosis.
2010
41.7
40.2
33.9
35.3
31.3
2009
38.8
36.7
28.5
28.8
28.6
2008
37.6
36.4
27.7
26.5
29.3
2007
35.7
33.7
27.2
25.4
28.4
2006
36.1
33.7
26.2
30.2
27.3
Results
Spirometry tests can improve health outcomes
through early detection; promoting smoking
cessation; administration of influenza and
pneumococcal vaccines; and permitting
earlier initiation of pharmacological and
nonpharmacological treatments.7,8
C hr o nic D isease M anagement
HEDIS Measure Definition
63
64
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Pharmaco therapy Management
of COPD Exacerbation
Chronic obstructive pulmonary disease (COPD) exacerbations are characterized by acute
worsening of clinical symptoms (e.g., breathlessness or sputum production). Exacerbations
may range from temporary decline in functional status to fatal events.1,2 After an exacerbation,
patients’ symptoms and lung function can take several weeks to recover to baseline, and quality
of life declines drastically.2 The Pharmacotherapy Management of COPD Exacerbation measure
evaluates whether patients received appropriate medical treatment after an event and assesses
effective outpatient management of the disease.
• COPD exacerbations are responsible for
the majority of COPD-related costs from
The Case for Improvement
• COPD exacerbations are estimated to
unscheduled physician and emergency
result in approximately 110,000 deaths
room visits and hospitalizations.2
and more than 500,000 hospitalizations
• Exacerbations have contributed to an
increase in COPD-related mortality, from
21.4 to 43.3 deaths per 100,000 persons
in the U.S. in the last two decades.1
• According to the Global Initiative for
Chronic Obstructive Lung Disease
guidelines, inhaled bronchodilators are
a cornerstone of treatment for COPD
exacerbation.3,4 Short-term corticosteroid
therapy may also be required.5,6
annually. More than $18 billion is spent
on direct costs every year.4 Hospital
admissions for COPD exacerbations
average a 10-day length of stay, at a cost
of $10,000 per stay.5,6
• Approximately one-third of patients
discharged from the emergency department
with acute exacerbations have recurrent
symptoms within 14 days, and 17 percent
relapse and require hospitalization—a
good indicator that patients are not getting
the care they require.3
• Benefits of appropriate medical treatment
include decreased duration of hospital
stays and less likelihood of treatment
failure. Patients also exhibit decreased
frequency of exacerbations and maintain
longer disease-free intervals.5
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Bronchodilators
The percentage of adults 40 years and older
who experience an COPD exacerbation event
Commercial
Medicare
Medicaid
and who were given appropriate medication
Year
HMO
PPO
HMO
PPO
HMO
therapy to manage an exacerbation. As
2010
77.8
73.5
78.2
76.1
82.1
2009
78.0
75.0
76.2
74.9
80.7
2008
76.1
68.1
74.1
71.3
78.2
identified by claims, a COPD exacerbation
is an inpatient or ED visit with a primary
discharge diagnosis of COPD.
Systemic Corticosteroids
Results
COPD medications aimed at controlling
Commercial
Medicare
Medicaid
symptoms have been shown to increase
Year
HMO
PPO
HMO
PPO
HMO
exercise capacity, improve health status and
2010
69.8
66.2
66.6
69.6
65.3
reduce exacerbations.5,7 Decreasing the
2009
66.1
64.1
60.9
64.2
61.8
2008
67.0
58.2
60.0
60.8
61.7
frequency of an exacerbation has shown to
slow the progression of COPD and should be
a critical goal of care management.2,5
C hr o nic D isease M anagement
HEDIS Measure Definition
65
66
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Annual Monitoring for Patients
on Persistent Medicatio ns
Adverse drug events trigger 700,000 emergency department (ED) visits a year. A quarter of
those visits come from adults 65 years and older. Approximately 120,000 hospital visits a
year are attributable to adverse drug events, and older adults are seven times more likely to be
hospitalized after an ED visit compared to the rest of the population.1 The Annual Monitoring for
Patients on Persistent Medications measure assesses whether adults were properly monitored for
selected medications usually prescribed for long-term use.
• Adults over 65 consume more health care
to the ED for other reasons.5 Better methods
than any other age group, and prescribing
to identify and monitor adverse drug events
medications to the elderly is the most
may reduce avoidable hospitalizations.3,6
common clinical decision doctors make.2
• Allergic reactions and unintentional overdoses
are two of the most common adverse drug
reactions that cause hospitalization. Rates
may improve with ongoing monitoring and
quality improvement.3
The Case for Improvement
• Adverse drug events are responsible for $4
billion dollars of extra medical costs annually.4
• Adverse drug events present a public
health concern as over-the-counter drugs
HEDIS Measure Definition
This measure assesses the percentage of adults
18 years of age and older who received at least
180 treatment days of ambulatory medication
therapy for the following therapeutic agents
during the measurement year and at least one
therapeutic monitoring event for the therapeutic
agent in the measurement year.
• Angiotensin converting enzyme (ACE) inhibitors
or angiotensin receptor blockers (ARB)
• Digoxin
become more available and more drugs
• Diuretics
are prescribed in an outpatient setting.
• Anticonvulsants
• In one study, patients brought to the
A combined rate is also reported.
ED with adverse drug events caused by
outpatient medications were shown to
Results
spend between three and eight more days
When patients do not adhere to a drug
in the hospital in the six-month period post
regimen, they have high rates of inpatient and
ED visit, compared with patients admitted
outpatient health resource use.7 Continued
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Digoxin
would reduce the likelihood of hospitalization
and ED visits and increase adherence rates.
Medicare
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
84.6
79.1
93.1
92.7
89.7
Medicaid
2009
83.6
77.9
92.0
92.2
88.9
2008
81.9
76.6
90.4
91.1
88.5
ACE Inhibitors or ARBs
Commercial
Commercial
Year
HMO
PPO
HMO
PPO
HMO
2010
81.6
78.4
90.7
90.8
86.0
2007
79.7
75.7
87.9
90.4
84.9
2009
80.8
77.6
89.6
89.8
85.9
2006
77.3
64.2
86.2
87.1
83.0
2008
79.4
76.4
86.7
88.8
84.8
2007
77.2
75.6
84.8
87.8
82.5
2006
74.8
66.3
82.7
83.9
79.9
Medicare
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
81.0
78.1
90.9
91.2
85.5
Medicaid
2009
80.4
77.2
89.8
90.3
85.4
2008
79.1
76.1
87.1
89.1
84.2
Anticonvulsants
Commercial
Diuretics
Year
HMO
PPO
HMO
PPO
HMO
2010
60.4
57.9
68.2
69.1
67.7
2007
76.8
75.2
84.8
87.6
81.3
2009
62.0
59.2
69.7
68.5
68.7
2006
74.4
65.7
83.0
84.1
79.1
2008
61.7
59.0
67.5
70.0
68.7
2007
59.6
56.3
65.1
66.0
65.9
2006
59.4
49.8
63.6
64.9
63.6
Combined
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
80.9
77.8
90.2
90.6
83.9
2009
80.3
77.0
89.2
89.7
83.2
2008
78.9
75.8
86.3
88.6
82.6
2007
76.6
74.9
84.3
87.2
80.1
2006
74.3
65.6
82.2
83.6
77.7
C hr o nic D isease M anagement
monitoring of patients on persistent medications
67
68
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Antidepressant M edication Management
Major depression is considered a serious medical illness; it affects approximately 5 percent–
8 percent of American adults.1 Depression is the leading cause of disability in the United States.1
Symptoms include persistent sadness, loss of energy, loss of appetite and inability to concentrate.2
The Antidepressant Medication Management measure assesses short-term and long-term
medication adherence rates for adults newly diagnosed with depression.
• According to evidence-based guidelines,
• Inefficiencies in diagnosing and applying
medication management reduces the risk
evidence-based treatments for depression
of relapse and reoccurrence for patients
add to loss of productivity and affect
with depression. Without antidepressant
mental and physical well-being.7,8
medication, 50 percent–80 percent of
patients have major depressive relapses
and reoccurrences.3
• The risk of physical and functional
impairments because of missed work
or school can increase as well-being
• The need for antidepressant medication
deteriorates. Responsible, evidence-based
increases as the severity of depression
medication management may improve the
intensifies.
secondary impact of the disease.9
2
The Case for Improvement
HEDIS Measure Definition
• Major depression accounts for a variety
The percentage of adults 18 years of age
of indirect economic costs resulting from
and older who were diagnosed with a new
personal developmental delays and
episode of major depression and treated with
productivity losses. Personal income
antidepressant medication, and who remained
loss for people with depression reaches
on an antidepressant medication treatment.
an average of $10,400 annually, with a
Two rates are reported.
4
lifetime total cost of $300,000. Individuals
5
with depression take an average of 10
sick days a year.6 Time missed from work
or school due to depression is higher than
many anxiety and emotional disorders.
• Effective Acute Phase Treatment. The
percentage of newly diagnosed and treated
people who remained on an antidepressant
medication for at least 84 days (12 weeks).
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Continuation Phase
The percentage of newly diagnosed and
treated people who remained on an
Commercial
Medicare
Medicaid
antidepressant medication for at least 180
Year
HMO
PPO
HMO
PPO
HMO
days (6 months).
2010
48.3
48.1
51.9
55.7
34.4
2009
46.2
46.4
50.6
51.0
33.0
2008
46.3
46.4
49.3
48.9
31.8
2007
46.1
47.6
48.7
48.7
27.4
antidepressants that contribute to negative
2006
45.1
46.6
45.1
40.9
27.5
economic, clinical and public health
2005
45.0
48.4
41.1
31.1
29.7
outcomes.10 Improvements in antidepressant
2004
44.3
NA
42.4
NA
30.4
medication adherence will reduce the burden
2003
44.1
NA
39.2
NA
29.3
of relapse and reoccurrence.11
2002
42.8
NA
37.7
NA
32.4
2001
40.1
NA
36.8
NA
30.0
2000
40.1
NA
NA
NA
NA
1999
42.1
NA
NA
NA
NA
Results
Measurement of both rates will address
the incomplete prescribing and use of
Acute Phase
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
64.7
64.3
65.0
67.4
50.7
2009
62.9
63.2
63.7
63.4
49.6
2008
63.1
63.1
62.5
61.6
48.2
2007
62.9
63.8
61.2
61.0
42.8
2006
61.1
63.6
58.2
56.7
42.9
2005
61.3
65.6
55.0
49.2
45.1
2004
60.9
NA
56.4
NA
46.4
2003
60.7
NA
53.3
NA
46.2
2002
59.8
NA
52.1
NA
47.5
2001
56.9
NA
51.2
NA
45.5
2000
57.4
NA
NA
NA
NA
1999
58.8
NA
NA
NA
NA
C hr o nic D isease M anagement
• Effective Continuation Phase Treatment.
69
70
nati o na l c o mmittee f o r qua l it y assurance
C hr o nic D isease M anagement
Initiation and Engagement of Alcohol
and Other Drug Dependence Treatment
In 2009, an estimated 21.8 million persons 12 or older were classified with substance
dependence or abuse. Of these, 70 percent were dependent on or abused alcohol, 15 percent
abused or were dependent on both alcohol and illicit drugs and 16 percent were dependent on
or abused illicit drugs.1,2 The Initiation and Engagement of Alcohol and Other Drug Dependence
Treatment measure monitors whether adolescents and adult members with an episode of alcohol
or drug dependence initiated and followed up on necessary treatment.
• The primary goals of drug abuse or
• Treatment is essential to stem the economic
addiction treatment are abstinence, relapse
and human costs associated AOD
prevention and rehabilitation. Less than
dependence or addiction. Treatment
20 percent of people diagnosed with
frequency and intensity of engagement is
substance abuse and less than 40 percent
important for successful outcomes.3,7
of those with addiction problems seek
treatment.3
• One in four deaths in the U.S. is attributed
to alcohol, tobacco or illicit drugs.6
The Case for Improvement
• Total overall costs of substance abuse in
HEDIS Measure Definition
This measure asses the percentage of adolescent
and adults with a new episode of AOD
dependence who received the following care.
• Initiation of AOD Treatment. The
percentage of people who initiated
the U.S., including productivity, health and
treatment through an inpatient AOD
crime-related costs, exceed $600 billion
admission, outpatient visit, intensive
annually. Every American adult pays
outpatient encounter or partial
nearly $1,000 per year for the damages of
hospitalization within 14 days of the
addiction.
diagnosis.
4,5
• The health burden of substance use
• Engagement of AOD Treatment. The
includes the harmful effects of acute
percentage of people with a diagnosis of
intoxication, substance use-associated
AOD use or dependence who initiated
injury and violence and the consequences
treatment and had two or more additional
of numerous medical and psychiatric
services within 30 days of the initiation visit.
disorders associated with chronic alcohol
and other drug (AOD) use.6
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Initiation
Research suggests that treatment reduces drug
use, improves health and job performance,
Commercial
Medicare
Medicaid
reduces involvement with the criminal justice
Year
HMO
PPO
HMO
PPO
HMO
system, reduces family dysfunction and
2010
42.7
40.8
44.6
57.4
42.9
2009
42.7
41.8
46.2
57.4
44.3
2008
42.4
42.6
45.9
49.1
44.5
2007
44.5
46.0
50.4
56.5
45.6
2006
43.2
49.0
50.3
50.0
43.3
2005
44.5
45.8
50.9
52.3
40.7
2004
45.9
NA
52.6
NA
45.7
improves quality of life.3,7
Engagement
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
15.6
16.0
3.7
4.8
14.2
2009
16.1
15.7
4.6
4.2
12.3
2008
16.2
16.2
4.3
9.4
12.4
2007
15.2
15.2
4.5
6.3
14.4
2006
13.8
16.0
4.5
7.0
11.7
2005
14.1
15.3
4.7
3.2
9.7
2004
15.5
NA
7.1
NA
11.9
C hr o nic D isease M anagement
Results
71
72
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Appro priate Treatment for Chil dren
With Upper Respiratory In fectio n
Upper respiratory infections (URI) are self-regulating viral infections that cannot be treated
by antibiotics.1 Despite this, clinical practice trends show that antibiotics are often prescribed,
leading to a trend in overuse and growing antimicrobial resistance among patients.1 Also known
as the “common cold,” URIs target the lining of the throat and nose, resulting in fever, congestion,
coughing and other symptoms.2 The Appropriate Treatment for Children With Upper Respiratory
Infection measure evaluates whether children were properly treated for URIs by not receiving
antibiotics unless deemed appropriate by a clinician.
• Approximately over 100 million antibiotic
• Studies have shown that up to 60 percent
prescriptions are written in the ambulatory
of patients with colds or URIs seen in the
care setting every year.3
emergency department are prescribed
• According to the Centers for Disease
Control and Prevention, antibiotics were
prescribed during 68 percent of URI visits.
antibiotics, which have not demonstrated
improvement in clinical outcomes.5
• Overuse of antibiotics is a significant issue
Of these visits, 80 percent did not require
in URI treatment. A survey conducted
the prescription of antibiotics as defined by
in 2004 illustrated that among children
practice guidelines.
seen in a primary practice, outpatient
4
• In 2005, there were 1.17 billion visits
to ambulatory clinics and emergency
departments. 11 percent (130 million visits)
were for acute respiratory infections.7
The Case for Improvement
• In the U.S., URIs are responsible for
nearly $17 billion in direct costs (e.g.,
physician services and treatment because
of complications) and $22.5 billion in
indirect costs (e.g., absenteeism and lost
productivity) every year.6
or emergency department setting, those
diagnosed with viral URIs experienced
even higher rates of antibiotic prescription,
even though antibiotics are ineffective for
treating viral infections.8
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Treatment Rate
The percentage of children 3 months–18 years
of age who were diagnosed with a URI and
were not dispensed an antibiotic prescription.
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
85.1
83.7
NA
NA
87.2
2009
84.1
82.5
NA
NA
86.0
2008
83.9
83.3
NA
NA
85.5
2007
83.5
83.0
NA
NA
84.1
necessary, as well as educating patients
2006
82.8
82.1
NA
NA
83.4
and clinicians about the use of antibiotics in
2005
82.9
81.9
NA
NA
82.4
treating URIs.8
2004
82.7
NA
NA
NA
79.9
Results
Antibiotic treatment is only infrequently
appropriate for URIs. Misuse or overuse can
be avoided by prescribing treatment when
M easures T argeted at C hi l dren and A d o l escents
HEDIS Measure Definition
73
74
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Lead Screening in Chil dren
Lead poisoning is highly toxic and can cause cognitive impairment, behavioral disorders,
seizures and death.1,2 Children are especially at risk for developing lead poisoning.
Approximately 250,000 children under the age of 5 have elevated blood lead levels (>10
micrograms of lead per deciliter of blood).3 The Lead Screening in Children measure gauges the
number of children tested for lead poisoning before they turn 2.
• The two most common methods of
remained consistently high, even though
screening children for lead poisoning are
they have declined for the overall
venous blood sampling (inserting a needle
population by 84 percent since 1988.8
into a vein) and capillary blood sampling
(finger or heel stick).4
• Children with elevated blood lead levels
have increased all-cause mortality.5
The Case for Improvement
• Although lead-based paints were
banned for use in housing units in 1978,
approximately 24 million homes in the
United States contain lead paint and
elevated levels of lead-contaminated house
dust. More than 4 million of these homes
are inhabited by young children.6
HEDIS Measure Definition
This measure assesses the percentage of
children 2 years of age who had one or more
capillary or venous lead blood test for lead
poisoning by their second birthday.
Results
Lead poisoning is a common medical
condition causing serious bodily harm in
children, one of the most vulnerable of
populations. Screening is an inexpensive
way to detect the presence of lead in a child’s
environment and reduce further exposure.
• The total annual costs of environmental
Screening Rate
pollutants are estimated at $76.6 billion.
Of this, $50.9 billion is attributable to lead
poisoning.
7
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
NA
NA
NA
NA
66.2
children and children living in housing
2009
NA
NA
NA
NA
66.4
built before 1950 are disproportionately
2008
NA
NA
NA
NA
66.7
• Low-income children, non-Hispanic Black
affected by lead poisoning. For these
populations, blood lead levels have
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
75
Ambulatory Care: Emergenc y Department Visits
unnecessary use of emergency care may signal a lack of access to more appropriate sources of
medical attention.1 The Ambulatory Care: ED Visits measure assesses the number of people who
visited the ED during the measurement year. In 2007 there were nearly 120 million ED visits,
an increase of 23 percent from 1997. Of these, more than 34 percent occurred during normal
business hours.2
• Approximately 40 percent of ED visits are
• Time spent waiting is costly in terms of
not urgent. Many of these visits occur when
productivity. More than 65 percent of
patients cannot be seen by their primary
people visiting the ED spent over two hours
care physician.
in the facility. Almost 9 percent left before
3
being seen by a physician.2
The Case for Improvement
• Avoidable use of urgent care contributes to
HEDIS Measure Definition
ED overcrowding, an increasingly common
This measure summarizes utilization of
problem in the United States. More than
ambulatory care by calculating the number of
48 percent of EDs are at or over patient
ED visits per measurement year.
4
capacity, which can be a threat to patient
5
safety and public health.6
• Increased ED wait time is frustrating for
patients, especially when they visit the ED
for routine care. Research has shown that
patients with urgent symptoms are more
satisfied with their emergency care than
patients with nonurgent symptoms.7
Results
When possible, unnecessary ED visits should
be avoided; they lead to ED overcrowding,
increased wait time and lower patient
satisfaction. Access to other sources of
ambulatory care can improve patient
outcomes and keep the quality of care high.
M easures T argeted at C hi l dren and A d o l escents
Although visits to the emergency department (ED) do not indicate poor quality of care,
M easures T argeted at C hi l dren and A d o l escents
76
nati o na l c o mmittee f o r qua l it y assurance
Visits Per 1,000 Member Months
Commercial
Year
HMO
PPO
Medicare
HMO
PPO
Medicaid
HMO
2010 187.4 174.0 450.3 379.0
62.0
2009 196.7 182.5 461.4 371.1
67.4
2008 194.5 181.3 459.1 395.7
60.2
2007 200.8 191.1 457.9 411.3
61.4
2006 200.5 188.7 403.9 375.2
56.6
2005 187.5 186.0 316.0 264.0
54.4
2004 177.5
NA
306.3
NA
48.5
2003 181.3
NA
292.3
NA
49.2
2002 182.6
NA
279.8
NA
49.4
2001 176.9
NA
276.1
NA
46.2
2000 164.3
NA
NA
NA
NA
1999 150.3
NA
NA
NA
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
77
Prenatal and Postpartum Care &
Frequency of Ongo ing Prenatal C are
complication.1,2 Each year, more than 500,000 pregnant women across the U.S. deliver babies
with potentially avoidable complications such as preterm birth, low birthweight and pre-eclampsia.2
The Prenatal and Postpartum Care and Frequency of Ongoing Prenatal Care measures assess
whether women have access to timely and consistent prenatal and postpartum care.
for $17.4 billion, or nearly 5 percent of
• Diabetes, hypertension and postpartum
depression are the most commonly reported
health conditions among pregnant women.3
total hospital costs in the U.S.1
• Women who failed to receive prenatal care
were almost three times more likely to have
• Prenatal care during the first trimester
helps to improve maternal health and
a low-birthweight infant than women who
survival, and results in improved infant
had care, resulting in expected hospital
survival by linking women who have high-
cost savings of more than $1,000 for
risk pregnancies to better obstetrical and
women who received prenatal care.5
neonatal care.3
• Women who receive only the minimal
• Postpartum care encompasses management
amount of prenatal care are at high risk
of the mother and the newborn infant
for pregnancy complication and negative
and is aimed at detecting early parenting
birth outcomes.8,10 More than 11 percent
problems and performing physical exams
of pregnant women receive inadequate
and postpartum depression screenings.
prenatal care each year.9
4
The Case for Improvement
• Hospital stays with pregnancy-related
complications tended to be longer
(2.7–2.9 days) than without complicating
conditions (1.9 days). Maternal stays with
complicating conditions were also about
50 percent more costly ($8,000) than
those without complications ($2,600). In
2008, maternal stays with pregnancy and
delivery-related complications accounted
• Early, comprehensive and continuous
prenatal and postpartum care can promote
healthier pregnancies and reduce the
risk of costly, adverse birth outcomes and
postpartum depression.6,7
M easures T argeted at C hi l dren and A d o l escents
Among the 4.3 million deliveries in 2008, 94 percent listed some type of pregnancy
M easures T argeted at C hi l dren and A d o l escents
78
nati o na l c o mmittee f o r qua l it y assurance
HEDIS Measure Definition
Results
This measure has two indicators related to
Research confirms that maternal health before
deliveries of live births between November 6
conception, throughout pregnancy and during
of the year prior to the measurement year and
the postpartum period influences not only birth
November 5 of the measurement year.
outcomes but also morbidity, as infants move
• Timeliness of Prenatal Care: The percentage
of deliveries that received a prenatal care
into adulthood.6,7
Timeliness of Prenatal Care
visit in the first trimester or within 42 days
of enrollment in the health plan.
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
91.0
75.7
NA
NA
83.7
2009
93.1
61.9
NA
NA
83.4
2008
92.4
55.5
NA
NA
81.9
The Frequency of Ongoing Prenatal Care
2007
91.9
46.0
NA
NA
81.5
measure assesses the percentage of Medicaid
2006
90.6
61.9
NA
NA
81.2
deliveries between November 6 of the year
2005
91.8
74.6
NA
NA
79.6
2004
90.8
NA
NA
NA
78.2
2003
89.4
NA
NA
NA
76.5
2002
86.7
NA
NA
NA
70.4
2001
85.1
NA
NA
NA
72.9
• Postpartum Care: The percentage of
deliveries that had a postpartum visit on or
between 21 and 56 days after delivery.
prior to the measurement year and November
5 of the measure year that received the
following number of expected prenatal visits:
• <21 percent of expected visits
• 21 percent–40 percent of expected visits
• 41 percent–60 percent of expected visits
• 61 percent–80 percent of expected visits
• ≥81 percent of expected visits.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
Medicare
Frequency of Prenatal Care
Visits—>80% of Expected Visits
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
80.7
65.9
NA
NA
64.4
2010
NA
NA
NA
NA
61.1
2009
83.6
54.1
NA
NA
64.1
2009
NA
NA
NA
NA
61.6
2008
82.8
45.8
NA
NA
62.6
2008
NA
NA
NA
NA
58.7
2007
82.0
41.6
NA
NA
58.6
2007
NA
NA
NA
NA
59.6
2006
79.9
46.3
NA
NA
59.1
2006
NA
NA
NA
NA
58.6
2005
81.5
62.8
NA
NA
57.2
2005
NA
NA
NA
NA
55.8
2004
80.6
NA
NA
NA
56.5
2004
NA
NA
NA
NA
51.5
2003
80.3
NA
NA
NA
55.3
2003
NA
NA
NA
NA
48.2
2002
77.0
NA
NA
NA
52.1
2002
NA
NA
NA
NA
41.0
2001
77.0
NA
NA
NA
53.0
2001
NA
NA
NA
NA
39.2
M easures T argeted at C hi l dren and A d o l escents
Postpartum Visit Between 21
and 56 Days After Delivery
79
80
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Chlamydia Screening in Women
Chlamydia is the most commonly reported bacterial sexually transmitted disease in the United
States, occurring most often among adolescent and young adult females.1,2 Chlamydia is
often known as a “silent” disease because most infected people are asymptomatic.1 Untreated
chlamydia infections can lead to serious and irreversible complications, including pelvic
inflammatory disease (PID), infertility and increased risk of becoming infected with HIV.1,3 The
Chlamydia Screening in Women measure looks at the percentage of non-pregnant, sexually
active women 24 years of age and younger who are screened annually for chlamydia, as
recommended by the U.S. Preventive Services Task Force.4
• Approximately 75 percent of chlamydia
infections in women and 95 percent in men
are asymptomatic, resulting in delayed
medical care and treatment.5
partners of infected women and difficulties
in measuring the public health impact.2
• Multiple chlamydia infections increase a
woman’s risk of serious reproductive health
• Between 10 percent and 15 percent of
complications.7
untreated chlamydia infections result in
PID, which can lead to ectopic pregnancy
HEDIS Measure Definition
and infertility. As many as 15 percent of
The percentage of women 16–24 years of age
women with PID will become infertile.5
who were identified as sexually active and
1
who had at least one test for chlamydia during
The Case for Improvement
the measurement year.
• The estimated annual cost of chlamydia
infections is approximately $647 million.
Results
The lifetime medical cost of chlamydia is
If recommended annual chlamydia screening
about $315 per case for females. If the
guidelines were followed, as many as 60,000
infection leads to PID, treatment can range
cases of PID, 8,000 cases of chronic pelvic
between $1,060 to $3,180 per case.
pain and 7,500 cases of infertility could be
6
• Chlamydia is easily detected and treated,
but screening remains underutilized.
Challenges affecting annual screening
rates include lack of awareness, social
stigma, barriers to finding and treating sex
prevented each year.8
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
21–24 Years
Medicare
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
40.8
38.1
NA
NA
54.6
2010
45.7
41.9
NA
NA
62.3
2009
41.0
37.7
NA
NA
54.4
2009
45.4
41.4
NA
NA
61.6
2008
40.1
36.7
NA
NA
52.7
2008
43.5
39.4
NA
NA
59.4
2007
36.4
32.4
NA
NA
48.6
2007
39.2
34.9
NA
NA
54.0
2006
36.2
29.4
NA
NA
50.5
2006
38.0
31.2
NA
NA
55.0
2005
34.4
26.2
NA
NA
49.2
2005
35.2
27.6
NA
NA
52.5
2004
32.6
NA
NA
NA
45.9
2004
31.7
NA
NA
NA
49.0
2003
30.4
NA
NA
NA
44.3
2003
29.1
NA
NA
NA
46.0
2002
26.7
NA
NA
NA
40.8
2002
24.5
NA
NA
NA
41.5
2001
24.5
NA
NA
NA
39.6
2001
22.1
NA
NA
NA
41.1
2000
23.6
NA
NA
NA
NA
2000
20.7
NA
NA
NA
NA
1999
18.5
NA
NA
NA
NA
1999
16.0
NA
NA
NA
NA
Total Rate
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
43.1
40.0
NA
NA
57.5
2009
43.1
39.5
NA
NA
56.7
2008
41.7
38.0
NA
NA
54.9
2007
38.1
33.8
NA
NA
50.7
2006
37.3
30.4
NA
NA
52.4
2005
34.9
26.9
NA
NA
50.7
2004
32.2
NA
NA
NA
47.2
2003
29.7
NA
NA
NA
44.9
2002
25.4
NA
NA
NA
40.9
2001
23.1
NA
NA
NA
40.4
M easures T argeted at C hi l dren and A d o l escents
16–20 Years
81
82
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Follow-U p After Hospita liz ation
for Mental Illness
Mental illness affects about 1 in 4 adults, and approximately 15 million adults in the United
States suffer from a serious mental illness.1,2 Less than half of adults with a serious mental illness
receive treatment or counseling.2 The Follow-Up After Hospitalization for Mental Illness measure
assesses whether patients 6 years of age and older who were hospitalized for treatment of
selected mental health disorders were seen by a mental health provider.
• Mental illness accounts for more burden
from disease than all forms of cancer
combined.3
deaths each year, and could be caused by
untreated depression.8
• In 2008, 30 million adults received
• The World Health Organization has
treatment for mental health problems.9 In
reported that 4 of the 10 leading causes of
2005, more than 2 million patients were
disability in the U.S. and other developed
discharged from a hospital with a mental
countries are mental disorders. By 2020,
disorder.10
it is expected that mental illness will be the
leading cause of disability in the world for
HEDIS Measure Definition
women and children.
The percentage of discharges for members
4
• Half of first-time psychiatric patients were
readmitted within two years of hospital
discharge; appropriate follow-up care
is known to reduce the risk of repeat
hospitalization.5,6
The Case for Improvement
• The economic burden of serious mental
illness is estimated at $317 billion dollars
and includes the cost of health services,
loss of earning and disability benefits.7
• Suicide is the 11th leading cause of
death in the U.S., accounting for 30,000
6 years of age and older who were
hospitalized for treatment of selected mental
health disorders and who had an outpatient
visit, an intensive outpatient encounter or
partial hospitalization with a mental health
practitioner. The measure separately identifies
the percentage of members who received
follow-up within 7 and 30 days of discharge.
Results
Proper follow-up treatment for psychiatric
hospitalization can lead to improved quality
of life for patients, families and society as a
whole.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
Medicare
Within 30 Days Post-Discharge
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
59.7
54.2
37.4
39.1
44.6
2010
77.4
74.1
55.4
61.2
63.8
2009
58.7
52.6
37.3
40.6
42.9
2009
76.8
72.1
54.8
60.5
60.2
2008
57.2
49.8
38.1
37.3
42.6
2008
76.1
71.4
56.5
55.5
61.7
2007
55.6
41.9
37.0
33.3
42.5
2007
74.0
63.4
54.4
50.2
61.0
2006
56.7
48.3
36.9
38.5
39.1
2006
75.8
68.1
56.3
58.3
57.7
2005
55.8
49.9
39.2
47.1
39.2
2005
75.9
70.7
59.4
60.1
56.8
2004
55.9
NA
40.1
NA
38.0
2004
75.9
NA
60.7
NA
54.9
2003
54.4
NA
38.8
NA
37.7
2003
74.4
NA
60.3
NA
56.4
2002
52.7
NA
38.7
NA
37.2
2002
73.6
NA
60.6
NA
56.7
2001
51.3
NA
37.2
NA
33.2
2001
73.2
NA
60.6
NA
52.2
2000
48.2
NA
NA
NA
NA
2000
71.2
NA
NA
NA
NA
1999
47.4
NA
NA
NA
NA
1999
70.1
NA
NA
NA
NA
M easures T argeted at C hi l dren and A d o l escents
Within 7 Days Post-Discharge
83
84
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Appro priate Testing for Children
With Pharyngitis
Over the last 10 years, the Centers for Disease Control and Prevention (CDC) have increased
efforts to prevent the misuse of antibiotics to treat respiratory infections, particularly pharyngitis.
Pharyngitis, or sore throat, is common in children and adolescents and can be caused by a
bacteria or virus.1 The Appropriate Testing for Children With Pharyngitis measure evaluates
whether children are properly treated for pharyngitis after undergoing diagnostic testing, thereby
avoiding the build-up of antibiotic resistance.
• Pharyngitis affects a large number of
• Infections resulting from pharyngitis can
individuals and is responsible for 12
have lifestyle and productivity effects. One
million primary care visits each year in the
study found that both children and parents
U.S.2
missed a notable number of school and
• The bacteria most commonly associated
with pharyngitis (Group A streptococcus)
is responsible for up to 30 percent of
pharyngitis cases in children.3 In winter
and early spring, up to 15 percent of
school-age children may carry the bacteria
without displaying symptoms.4
The Case for Improvement
• Pharyngitis has a significant financial
burden on children and adults alike,
costing an estimated $224 million–
$539 million and resulting in 1,300 deaths
every year.5
• Pharyngitis often is overdiagnosed. While
work days because of pharyngitis-related
treatment and management.7
HEDIS Measure Definition
The percentage of children 2–18 years of
age who were diagnosed with pharyngitis
and dispensed an antibiotic, and who also
received a group A streptococcus test for
the episode. A higher rate represents better
performance (i.e., appropriate testing).
Results
Antibiotic treatment is only infrequently
appropriate for pharyngitis. The availability
of RADT has made it easier to perform
diagnostics, thereby potentially reducing
there are differing opinions on performing
antibiotic use and preventing the spread of
rapid antigen detection testing (RADT) and
drug-resistant strains of pharyngitis.8
throat cultures, clinical guidelines strongly
recommend performing a diagnostic test or
a throat culture before treatment.6
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
77.6
76.6
NA
NA
64.9
2009
77.4
75.5
NA
NA
62.3
2008
75.6
74.1
NA
NA
61.4
2007
74.7
73.5
NA
NA
58.7
2006
72.7
69.4
NA
NA
56.0
2005
69.7
64.5
NA
NA
52.0
2004
72.6
NA
NA
NA
54.4
M easures T argeted at C hi l dren and A d o l escents
Testing Rate
85
86
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Well-Child Visits in the First 15 Months of Life and
in the Third, Fourth, Fifth and Sixth Years of Life
The beginning years of childhood are filled with rapid growth and development. Well-child visits
offer doctors the opportunity to evaluate children’s physical, emotional and social developmental
progress.1,2 The Well-Child Visits measures assess the number of children that met with a primary
care practitioner during their most important developmental milestones.
• Primary care practitioners may detect
• Development delays occur in approximately
health problems and developmental
13 percent of American children and have
delays early and initiate interventions that
high costs to society.7,8 Over the course
eliminate problems or lessen their effect
of a lifetime, untreated developmental
over the long term.1,2
delays and disabilities are estimated to cost
• Well-child visits facilitate communication
between children, care providers and
doctors.3 Primary care practitioners can
promote healthy behaviors and provide
anticipatory guidance on a variety of
topics, including injury prevention, physical
activity and nutrition.4
The Case for Improvement
• The number of children younger than 6
between $417,000 in direct medical costs
and indirect lost productivity per child.9
HEDIS Measure Definition
Well-Child Visits in the First 15 Months of Life:
The percentage of children who turned 15
months old during the measurement year and
had the following number of well-child visits
with a primary care physician during the first
15 months of life:
who received well-child visits increased
• No well-child visits
from 84 percent in 2000 to 87 percent
• One well-child visit
in 2008,1 but almost one million children
under 6 received no preventive medical
care of any kind in 2007.5
• Children with incomplete well-child care
during the first six months of life are 60
percent more likely to visit the emergency
department than children with complete
well-child care.6
• Two well child visits
• Three well-child visits
• Four well-child visits
• Five well-child visits
• Six or more well-child visits.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Ages 3–6 Years: One or
More Well-Child Visits
and Sixth Years of Life: The percentage of
children 3–6 years of age who received one
or more well-child visits with a primary care
practitioner during the measurement year.
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
71.6
67.8
NA
NA
71.9
Results
2009
70.3
66.0
NA
NA
71.6
Primary care doctors are an important
2008
69.8
63.6
NA
NA
69.7
2007
67.8
60.7
NA
NA
65.3
2006
66.7
61.6
NA
NA
66.8
emotional, social and developmental progress
2005
65.6
54.5
NA
NA
63.6
is vital to ensuring the health of children
2004
64.4
NA
NA
NA
62.4
during their most vulnerable years and well
2003
62.7
NA
NA
NA
60.7
into adulthood.
2002
60.4
NA
NA
NA
58.2
2001
57.5
NA
NA
NA
56.0
2000
54.2
NA
NA
NA
NA
1999
51.3
NA
NA
NA
NA
resource for parents. Well-child visits facilitate
communication about health between care
givers and physicians. Screening for physical,
M easures T argeted at C hi l dren and A d o l escents
Well-Child Visits in the Third, Fourth, Fifth
87
88
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Adolescent We ll-Care Visits
Adolescence is a time marked by transition. As children become adults, they face new physical,
emotional and social challenges that may affect their health.1 Because of changing patterns
of illness and death among youth over the last two decades, increased screening and health
counseling have become especially important.2,3 The Adolescent Well-Care Visits measure
assesses the number of adolescents who received preventive care.
• Risk taking behaviors, such as substance
use, drunk driving, risky sexual activity and
doctors can provide counseling or initiate
health interventions.6
smoking, often begin in adolescence. These
behaviors put youth at increased risk for
The Case for Improvement
sexually transmitted diseases, unintended
• Adolescents are the least likely to have
pregnancy, injury or death.
2,3
In 2009,
access to health care, and use less primary
almost 20 percent of high school students
care, than any age group.3 The proportion
smoked tobacco. More than 6 percent used
of children who receive well-care visits
cocaine and 24 percent reported binge
declines with age. Only 70 percent of
drinking (i.e., had five or more alcoholic
10–14-year-olds and 67 percent of
drinks within a couple of hours).
15–17-year-olds received preventive health
4
• Many chronic diseases seen in adults begin
in childhood, when eating habits and
physical activity levels are often established.3
With obesity among adolescents in the
care in 2008.2 For those who did have a
well-child visit, only 10 percent received all
recommended preventive services.7
• In 2007, nearly 13,299 deaths from
U.S. on the rise, this is especially troubling.
unintentional injury (such as from a car
Obesity can lead to type 2 diabetes, heart
accident) were reported among adolescents
disease and certain cancers.5
between the ages of 15 and 19.8 The total
• Adolescent well-care visits are an
effective way for doctors to present health
promotion advice that is timely and
relevant to adolescents’ development and
well-being. The average preventive visit
lasts about 20 minutes; during this time,
lifetime medical costs for adolescents who
survive is estimated to be $25 billion.9
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
cost an estimated $33.5 billion in direct
medical costs, and lifetime indirect and
At Least One Comprehensive
Well-Care Visit
direct costs are more than $700 billion.10
Commercial
Medicare
Medicaid
For those that survive, the total lifetime
Year
HMO
PPO
HMO
PPO
HMO
medical costs for these individuals is
2010
42.7
39.2
NA
NA
48.1
estimated to be $25 billion.
2009
42.5
38.3
NA
NA
47.7
2008
42.9
36.2
NA
NA
45.9
2007
41.8
34.7
NA
NA
42.1
2006
40.3
34.6
NA
NA
43.6
least one comprehensive well-care visit with
2005
38.8
29.3
NA
NA
40.7
a primary care practitioner or an OB/GYN
2004
38.2
NA
NA
NA
40.0
practitioner during the measurement year.
2003
37.1
NA
NA
NA
37.5
2002
35.8
NA
NA
NA
37.1
2001
33.1
NA
NA
NA
32.6
2000
30.9
NA
NA
NA
NA
1999
28.9
NA
NA
NA
NA
9
HEDIS Measure Definition
The percentage of enrolled adolescents and
young adults 12–21 years of age who had at
Results
While most adolescents are healthy, changes
in their physical and social circumstances put
them at increased risk for serious and longterm health effects of risky behaviors. Yearly
well-care visits offer primary care providers
the opportunity to provide the screening and
health counseling services adolescents need to
stay healthy.
M easures T argeted at C hi l dren and A d o l escents
• Each year, preventable adolescent deaths
89
90
nati o na l c o mmittee f o r qua l it y assurance
M easures T argeted at C hi l dren and A d o l escents
Children and Ad olescents’ Access
to P rimary Care Practitioners
Children and adolescents need access to primary care practitioners (PCP) to ensure their optimal
health and well-being.1 PCPs play an important role in preventing illness and death in the
young.2 The Children and Adolescents’ Access to Primary Care Practitioners measure assesses
whether children and adolescents were able to obtain medical attention from a PCP, such as a
family doctor, internist, pediatrician or general practitioner.
• In 2007, more than five million children
• For adolescents, inaccessible care can put
0–17 years of age had no usual source
them at risk for developing chronic disease,
of care; the same number had one or
substance-use disorders and risk-taking
more unmet medical need during the year.
sexual behaviors.8-10
Almost six million children were without a
doctor or nurse who knew their medical
HEDIS Measure Definition
history.
The percentage of children and young adults
4
• Although the primary care workforce
increased by 35 percent between 1996
and 2006, almost one million children
live in areas with no PCP. Children and
adolescents living in rural areas are
affected disproportionately.
12 months to 19 years of age who had a
visit with a PCP. The measure reports on four
separate percentages:
• Children 12–24 months who had a visit
with a PCP during the measurement year
5
The Case for Improvement
• Fewer than half of children and
adolescents in the United States receive the
recommended amount of preventive care.3
• Accessible primary care reduces hospital
use and maintains quality of care.6 Access
to primary care is an effective way to
reduce expensive hospitalizations and curb
rising health care costs.7
• Children 25 months–6 years who had a
visit with a PCP during the measure year
• Children 7–11 years who had a visit with
a PCP during the measure year or the year
prior to the measurement year
• Adolescents 12–19 years who had a visit
with a PCP during the measurement year or
the year prior to the measurement year.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Children 25 Months–6 Years
Improving access to PCPs may reduce
unnecessary medical costs and advance health
Commercial
Medicare
Medicaid
outcomes for children and adolescents by
Year
HMO
PPO
HMO
PPO
HMO
enabling them to receive preventive services,
2010
91.2
89.1
NA
NA
88.3
2009
91.6
89.1
NA
NA
88.3
2008
89.7
87.4
NA
NA
87.2
2007
89.4
86.3
NA
NA
84.3
2006
89.3
86.3
NA
NA
84.9
Medicaid
2005
89.3
85.7
NA
NA
83.1
screening and timely treatment from clinicians
who know their medical histories and serve as
a medical home.
Children 12–24 Months
Commercial
Medicare
Year
HMO
PPO
HMO
PPO
HMO
2004
88.1
NA
NA
NA
81.9
2010
97.5
96.9
NA
NA
96.1
2003
88.5
NA
NA
NA
82.1
2009
97.5
96.2
NA
NA
95.2
2002
87.2
NA
NA
NA
80.0
2008
96.7
95.4
NA
NA
95.0
2001
85.7
NA
NA
NA
79.3
2007
96.9
93.7
NA
NA
93.4
2000
82.4
NA
NA
NA
NA
2006
97.0
94.2
NA
NA
94.1
1999
81.3
NA
NA
NA
NA
2005
97.0
95.0
NA
NA
92.6
2004
96.8
NA
NA
NA
92.3
2003
96.3
NA
NA
NA
92.4
2002
95.7
NA
NA
NA
91.1
2001
95.2
NA
NA
NA
90.7
2000
92.5
NA
NA
NA
NA
1999
91.2
NA
NA
NA
NA
M easures T argeted at C hi l dren and A d o l escents
Results
91
M easures T argeted at C hi l dren and A d o l escents
92
nati o na l c o mmittee f o r qua l it y assurance
Children 7–11 Years
Commercial
Medicare
Adolescents 12–19 Years
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
91.6
89.4
NA
NA
90.2
2010
89.2
86.8
NA
NA
88.1
2009
91.4
89.0
NA
NA
90.3
2009
89.0
86.1
NA
NA
87.9
2008
89.9
87.4
NA
NA
87.8
2008
87.3
84.2
NA
NA
85.3
2007
89.5
86.8
NA
NA
85.9
2007
86.9
83.4
NA
NA
82.7
2006
89.2
85.7
NA
NA
85.9
2006
86.6
82.3
NA
NA
83.2
2005
88.6
83.4
NA
NA
83.4
2005
86.1
79.8
NA
NA
80.9
2004
88.5
NA
NA
NA
82.5
2004
85.5
NA
NA
NA
79.3
2003
88.5
NA
NA
NA
82.1
2003
85.8
NA
NA
NA
79.6
2002
87.4
NA
NA
NA
80.3
2001
85.8
NA
NA
NA
79.3
2000
83.6
NA
NA
NA
NA
1999
82.6
NA
NA
NA
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
93
Follow-U p Care for Chil dren
Prescri bed ADHD Medication
into adulthood.1 The disorder is characterized by inattention and impulsiveness, which can result
in academic underachievement, family issues and behavioral problems.2,3 The Follow-Up Care
for Children Prescribed ADHD Medication measure assesses two rates of follow-up care for
children between 6 and 12 years of age who are prescribed ADHD medication.
HEDIS Measure Definition
• ADHD is one of the most common mental
disorders in children. Almost 4 percent of
The following two rates of this measure assess
children in the United States between the ages
follow-up care for children prescribed an
of 4 and 10 are medicated for ADHD.
ADHD medication:
1,4,5
• Data from the National Health Interview
• Initiation Phase: The percentage of children
Survey suggest that roughly half of children
between 6 and 12 years of age diagnosed
between 6 and 11 who are diagnosed with
with ADHD who had one follow-up
ADHD may also have a learning disorder.
visit with a practitioner with prescribing
The combination of attention problems
authority within 30 days of their first
caused by ADHD and the learning disorder
prescription of ADHD medication.
3
can make it hard for a child to succeed
• Continuation and Maintenance Phase:
in school. Boys are twice as likely to have
The percentage of children between 6
ADHD than girls.1,3
and 12 years of age with a prescription
for ADHD medication who remained on
The Case for Improvement
the medication for at least 210 days and
• The annual cost of illness for ADHD in the
U.S. is estimated to be more than $42 billion.6
had at least two follow-up visits with a
practitioner in the 9 months subsequent to
the Initiation Phase.
• ADHD may culminate in significant health
care-related costs, including frequent
Results
unintentional injuries, co-occurring
psychiatric conditions and productivity loss.
7
• Combining behavioral therapy with
medication has been shown to improve
behavior and could lead to a decrease in
medication dependence.8
Medications used to treat ADHD have known
side effects and, like all medications, need to
be closely monitored by a practitioner with
prescribing authority.
M easures T argeted at C hi l dren and A d o l escents
Attention deficit/hyperactivity disorder (ADHD) typically begins in childhood and often persists
M easures T argeted at C hi l dren and A d o l escents
94
nati o na l c o mmittee f o r qua l it y assurance
Initiation
Commercial
Continuation
Medicare
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
38.8
38.1
NA
NA
38.1
2010
43.4
43.3
NA
NA
43.9
2009
36.6
35.4
NA
NA
36.6
2009
41.7
39.0
NA
NA
41.7
2008
35.8
34.1
NA
NA
34.4
2008
40.2
37.1
NA
NA
39.5
2007
33.7
31.8
NA
NA
33.5
2007
38.7
34.2
NA
NA
38.9
2006
33.0
30.6
NA
NA
31.8
2006
38.1
30.0
NA
NA
34.0
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
95
Childh ood Immunization Status
especially for those who are not immunized.1 Infants and toddlers are particularly vulnerable
to infectious diseases because their immune systems have not built up the necessary defenses to
fight infection.2,3 The Childhood Immunization Status measure looks at the percentage of children
2 years of age who receive all immunizations recommended by the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention (CDC).4
• Most childhood vaccines are between
• The perception among some parents that
90 percent and 99 percent effective in
vaccines are unsafe for their children was
preventing diseases.5
heightened in recent years by several
factors, including the number of vaccines in
• Statistics show dramatic declines in
vaccine-preventable diseases in the U.S.
when compared with the pre-vaccine
the recommended childhood immunization
schedule, the presence of conflicting
vaccine-safety information and scientifically
era. Cases of diphtheria, polio and
smallpox declined by 100 percent; cases
of bacterial meningitis, measles, mumps,
rubella, congenital rubella syndrome and
tetanus, by 98 percent–99 percent; cases
refuted—yet widely publicized—theories that
link vaccines to chronic health problems or
developmental disabilities such as autism.10
• According to the CDC’s National
of hepatitis A, by 91 percent; cases of
Immunization Survey, nearly 40 percent of
whooping cough, by 93 percent; cases
parents of toddlers delay or refuse at least
of chickenpox, by 89 percent; cases of
one recommended immunization for their
hepatitis B, by 83 percent; and cases of
children each year.11
pneumonia, by 74 percent.6
HEDIS Measure Definition
The Case for Improvement
The percentage of children 2 years of
• Vaccination of each U.S. child according
age who had four diphtheria, tetanus and
to the current childhood immunization
acellular pertussis (DTaP); three polio (IPV);
schedule prevents approximately 42,000
one measles, mumps and rubella (MMR);
deaths and 20 million cases of disease and
three H influenza type B (HiB); three hepatitis
saves nearly $14 billion in direct costs and
B (HepB); one chickenpox (VZV); four
$69 billion in societal costs each year.
pneumococcal conjugate (PCV); two hepatitis
8,9
M easures T argeted at C hi l dren and A d o l escents
Immunizing a child not only protects the child’s health but also the health of the community,
M easures T argeted at C hi l dren and A d o l escents
96
nati o na l c o mmittee f o r qua l it y assurance
A (HepA); two or three rotavirus (RV); and
DTaP/DT
two influenza (flu) vaccines by their second
birthday. This measure calculates a rate for
Commercial
Medicare
Medicaid
each vaccine and nine separate combination
Year
HMO
PPO
HMO
PPO
HMO
rates; including a comprehensive rate.
2010
86.3
64.7
NA
NA
80.2
2009
85.4
59.9
NA
NA
79.6
2008
87.2
47.7
NA
NA
78.6
2007
86.9
42.4
NA
NA
77.8
diseases childhood vaccines are meant to
2006
87.2
39.2
NA
NA
79.3
prevent are most likely to occur when children
2005
86.1
62.8
NA
NA
76.9
are very young and the risk of complications
2004
85.9
NA
NA
NA
75.6
is highest. Without these recommended
2003
84.3
NA
NA
NA
72.6
vaccines, a child must contract a disease
2002
80.1
NA
NA
NA
69.4
2001
81.5
NA
NA
NA
71.2
2000
80.4
NA
NA
NA
NA
1999
78.7
NA
NA
NA
NA
Results
Immunizations are a safe and important way
parents protect their children’s health.2 The
in order to become immune to the germ or
virus that causes it, which can be extremely
dangerous for younger children whose
immune systems may not be strong enough to
fight off infections. It is because of childhood
immunizations that the majority of many
once-common diseases are now at their lowest
levels in history.12
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
HiB
Medicare
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
90.2
58.7
NA
NA
90.1
2010
94.3
75.5
NA
NA
90.3
2009
90.1
53.7
NA
NA
89.1
2009
94.8
74.8
NA
NA
93.7
2008
91.8
38.7
NA
NA
88.3
2008
94.8
66.3
NA
NA
93.4
2007
91.3
35.8
NA
NA
87.2
2007
93.1
53.6
NA
NA
87.7
2006
91.0
31.1
NA
NA
88.4
2006
93.4
49.2
NA
NA
89.1
2005
90.0
57.7
NA
NA
85.4
2005
92.9
72.6
NA
NA
86.8
2004
87.2
NA
NA
NA
81.9
2004
87.7
NA
NA
NA
79.1
2003
85.8
NA
NA
NA
79.5
2003
86.1
NA
NA
NA
77.7
2002
81.9
NA
NA
NA
76.2
2002
83.2
NA
NA
NA
73.8
2001
79.9
NA
NA
NA
75.4
2001
83.4
NA
NA
NA
74.9
2000
77.9
NA
NA
NA
NA
2000
82.7
NA
NA
NA
NA
1999
75.5
NA
NA
NA
NA
1999
80.7
NA
NA
NA
NA
M easures T argeted at C hi l dren and A d o l escents
Hepatitis B
97
M easures T argeted at C hi l dren and A d o l escents
98
nati o na l c o mmittee f o r qua l it y assurance
IPV
Commercial
MMR
Medicare
Medicaid
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Year
HMO
PPO
HMO
PPO
HMO
2010
91.8
71.1
NA
NA
90.8
2010
90.8
82.7
NA
NA
90.6
2009
91.1
65.3
NA
NA
89.0
2009
90.6
80.5
NA
NA
91.2
2008
92.1
52.6
NA
NA
87.9
2008
93.5
76.4
NA
NA
90.9
2007
91.5
47.5
NA
NA
87.3
2007
93.5
76.3
NA
NA
90.4
2006
91.4
43.0
NA
NA
87.9
2006
93.6
75.0
NA
NA
91.1
2005
90.3
66.7
NA
NA
84.7
2005
93.0
86.2
NA
NA
89.6
2004
90.1
NA
NA
NA
84.8
2004
92.3
NA
NA
NA
88.1
2003
88.7
NA
NA
NA
83.1
2003
91.5
NA
NA
NA
87.4
2002
86.0
NA
NA
NA
80.3
2002
90.1
NA
NA
NA
84.4
2001
85.4
NA
NA
NA
79.1
2001
89.4
NA
NA
NA
83.7
2000
84.2
NA
NA
NA
NA
2000
88.4
NA
NA
NA
NA
1999
82.6
NA
NA
NA
NA
1999
87.0
NA
NA
NA
NA
Pneumococcal Conjugate (PCV)
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
85.6
65.6
NA
NA
79.4
2009
84.6
60.1
NA
NA
77.6
2008
84.8
47.8
NA
NA
75.6
2007
83.6
42.3
NA
NA
73.8
2006
72.8
37.1
NA
NA
68.3
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
90.8
82.2
NA
NA
90.0
2009
90.6
79.7
NA
NA
2008
92.0
74.8
NA
2007
91.9
74.4
2006
90.9
2005
Combination 2 (DTaP, IPV, MMR,
HiB, Hepatitis B and VZV)
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
90.6
2010
78.5
48.5
NA
NA
74.1
NA
89.7
2009
77.7
43.1
NA
NA
74.3
NA
NA
88.7
2008
81.2
30.6
NA
NA
73.7
72.0
NA
NA
88.9
2007
80.8
30.1
NA
NA
72.1
89.9
82.0
NA
NA
86.6
2006
79.8
24.5
NA
NA
73.4
2004
87.5
NA
NA
NA
84.7
2005
77.7
54.8
NA
NA
70.5
2003
85.7
NA
NA
NA
81.8
2004
72.5
NA
NA
NA
63.1
2002
82.0
NA
NA
NA
76.4
2003
69.8
NA
NA
NA
58.5
2001
75.3
NA
NA
NA
73.6
2002
62.5
NA
NA
NA
53.2
2000
70.5
NA
NA
NA
NA
2001
57.6
NA
NA
NA
52.5
1999
63.8
NA
NA
NA
NA
2000
53.5
NA
NA
NA
NA
1999
47.5
NA
NA
NA
NA
Combination 3 (DTaP, IPV, MMR,
HiB, Hepatitis B, VZV and PCV)
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
75.1
46.1
NA
NA
69.9
2009
73.4
40.4
NA
NA
69.4
2008
76.6
28.5
NA
NA
67.6
2007
75.5
27.6
NA
NA
65.4
2006
65.7
22.4
NA
NA
60.9
M easures T argeted at C hi l dren and A d o l escents
VZV
99
M easures T argeted at C hi l dren and A d o l escents
100
nati o na l c o mmittee f o r qua l it y assurance
Hepatitis A
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
35.4
28.6
NA
NA
36.5
Immunizations for
Adolescents: Meningococcal
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
55.2
43.8
NA
NA
56.3
Rotavirus
Commercial
Medicare
Year
HMO
PPO
HMO
PPO
HMO
2010
63.5
51.9
NA
NA
57.6
Influenza
Commercial
Medicare
Immunizations for
Adolescents: Tdap/Td
Medicaid
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
57.1
51.1
NA
NA
43.6
Commercial
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
18.5
10.4
NA
NA
15.2
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
69.5
55.3
NA
NA
67.8
Immunizations for
Adolescents: Combination 1
(Meningococcal, Tdap/Td)
Commercial
Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV,
PCV, Rotavirus and Influenza)
Medicare
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
51.6
39.4
NA
NA
52.2
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
101
Immuni zatio ns for Adolescents
childhood immunizations. Recommended adolescent immunizations can help maintain wellbeing and provide protection against vaccine-preventable diseases that extend into adulthood.1
The Immunizations for Adolescents measure assesses the percentage of adolescents who were
vaccinated against four vaccine-preventable diseases: meningococcal meningitis, tetanus,
diphtheria and pertussis (whooping cough).
• Protection against some childhood
• Despite what is understood about
vaccinated diseases can wear off as
the effectiveness of recommended
children get older, requiring booster shots
immunizations in protecting against
to maintain immunity. For example,
serious, sometimes fatal diseases,
Tdap is the booster shot for the tetanus,
adolescent immunization rates are low.5
2
diphtheria and pertussis vaccine received
in childhood.3
• Reasons frequently cited for low adolescent
immunization rates include lack of
• Prior to vaccines, the U.S. averaged
regular preventive care visits that provide
approximately 500–600 cases of tetanus,
an opportunity for vaccination; lack of
100,000–200,000 cases of diphtheria and
awareness of the need for immunizations;
175,000 cases of pertussis each year.3
inaccurate risk assessments by parents and
Today, because of vaccines, the number of
adolescents about vaccine-preventable
tetanus cases has declined by 98 percent,
diseases; and financial barriers.1,6,7
diphtheria cases by 100 percent and
pertussis cases by 93 percent.4
HEDIS Measure Definition
The percentage of adolescents 13 years of
The Case for Improvement
age who had one dose of meningococcal
• Vaccine-preventable diseases not only
vaccine and one tetanus, diphtheria toxoids
have a direct impact on the infected and
and acellular pertussis vaccine (Tdap) or one
their families, but also carry a high price
tetanus, diphtheria toxoids vaccine (Td) by
tag for society as a whole. Direct medical
their 13th birthday. The measure calculates a
costs and indirect societal costs exceed $10
rate for each vaccine and one combination
billion per year.
rate.
5
M easures T argeted at C hi l dren and A d o l escents
Adolescence is considered the healthiest period of one’s life. This is, in large part, thanks to
M easures T argeted at C hi l dren and A d o l escents
102
nati o na l c o mmittee f o r qua l it y assurance
Results
Immunizations for
Adolescents—Tdap/Td
Today, fewer infections are seen, thanks to
vaccines, but that does not mean the viruses
and bacteria that cause the infections do not
Commercial
Medicare
Medicaid
still exist. Infectious diseases and death are still
Year
HMO
PPO
HMO
PPO
HMO
common among the unimmunized. Americans
2010
69.5
55.3
NA
NA
67.8
should continue to be immunized, to prevent
future cases of illness.5
Immunizations for
Adolescents—Meningococcal
Immunizations for
Adolescents—Combination 1
(Meningococcal, Tdap/Td)
Commercial
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
55.2
43.8
NA
NA
56.3
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
51.6
39.4
NA
NA
52.2
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
103
Weight Assessment and Counseling for Nutrition
and Physical Activity for Children/Adolescents
dramatically in the past few decades; it has more than doubled in children and tripled in
adolescents.1 Childhood obesity has become a health crisis that affects children’s healthy growth
and development and increases their risks for serious health problems later in life.2 The Weight
Assessment and Counseling for Nutrition and Physical Activity in Children/Adolescents measure
evaluates the percentage of children and adolescents who are regularly screened for weight
problems and have received counseling about healthy eating and physical activity.
• An estimated 17 percent (12.5 million) of
all children and adolescents in the U.S. are
overweight or obese.2,3
direct and indirect costs of obesity—9.1
percent of medical spending.6,7
• Obese children are more likely to have high
• Overweight and obesity occurs when more
blood pressure and high cholesterol, risk
calories are consumed than the body can
factors for cardiovascular disease; increased
burn during physical activity.
risk of impaired glucose tolerance, insulin
4
• Childhood overweight and obesity is
determined by measuring body mass index
(BMI). A child with a BMI at or above the
85th percentile but lower than the 95th
percentile for children of the same sex and
age is classified as overweight. A child
resistance and type 2 diabetes; breathing
problems, including sleep apnea and
asthma; joint problems and musculoskeletal
discomfort; fatty liver disease; gallstones;
and gastroesophageal reflux.7
• Obese children and adolescents are
with a BMI at or above the 95th percentile
at greater risk of having social and
for children of the same age and sex is
psychological problems, including
classified as obese.
discrimination and poor self-esteem, which
5
can continue into adulthood.7
The Case for Improvement
• According to a 2009 study, the cost of
HEDIS Measure Definition
hospitalizations related to childhood
The percentage of children 3–17 years of age
obesity rose from $125.9 million in 2001
who had an outpatient visit with a primary
to $237.6 million in 2005. America spends
care physician or an OB/GYN and who had
as much as $147 billion annually on the
evidence of BMI percentile documentation and
counseling for nutrition and physical activity
M easures T argeted at C hi l dren and A d o l escents
The prevalence of overweight and obesity among young people in the U.S. has increased
M easures T argeted at C hi l dren and A d o l escents
104
nati o na l c o mmittee f o r qua l it y assurance
during the measurement year. Because BMI
Counseling for Physical
Activity (Overall)
norms for youths vary with age and gender,
this measure evaluates whether BMI percentile
is assessed rather than an absolute BMI value.
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
Results
2010
35.3
10.5
NA
NA
36.7
If children are overweight or obese, obesity
2009
36.5
17.6
NA
NA
32.5
in adulthood is likely to be more severe. Adult
obesity is associated with a number of serious
health conditions, including heart disease,
diabetes and some cancers.8 It is important for
parents and care providers to monitor a child’s
Frequency of Prenatal Care
Visits—<21% of Expected Visits
Commercial
Medicare
Medicaid
weight status. Children need guidance on
Year
HMO
PPO
HMO
PPO
HMO
maintaining healthy eating and exercising habits.
2010
NA
NA
NA
NA
10.4
2009
NA
NA
NA
NA
10.3
2008
NA
NA
NA
NA
11.9
Medicaid
2007
NA
NA
NA
NA
12.4
BMI Percentile (Overall)
Commercial
Medicare
Year
HMO
PPO
HMO
PPO
HMO
2006
NA
NA
NA
NA
13.5
2010
35.2
10.9
NA
NA
37.3
2005
NA
NA
NA
NA
16.7
2009
35.4
17.4
NA
NA
30.3
2004
NA
NA
NA
NA
17.9
2003
NA
NA
NA
NA
21.3
2002
NA
NA
NA
NA
27.6
2001
NA
NA
NA
NA
33.1
Counseling for
Nutrition (Overall)
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
37.4
11.8
NA
NA
45.6
2009
41.0
20.3
NA
NA
41.9
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
105
Fall Ris k Management
costs associated with falls and the expanding body of evidence that falls can be reduced.1,2 The Fall
Risk Management measure assesses whether adults over 65 years of age who are at risk of falling
discussed their problem with their practitioner and received an appropriate intervention, if necessary.
• Among adults 65 and older, falls are the
• Many older adults who fall develop a fear
leading cause of injury and death—each
of falling that may cause them to limit
year one in every three adults experiences
their activities, leading to reduced mobility
a fall. Falls are also the most common
and loss of physical fitness, which in turn
cause of nonfatal injuries and hospital
increases their actual risk of falling.3
2
admissions for trauma.3 The chances of
falling and of being seriously injured in a
HEDIS Measure Definition
fall increase with age.
The two components of this survey measure
2,3
assess different facets of fall risk management.
• Most falls result in fractures.3,4
• The percentage of Medicare adults 75
The Case for Improvement
years of age and older, or adults 65–74
• Direct medical costs of falls total more than
years of age with balance or walking
$19.3 billion—$349 million for fatal falls
problems or a fall in the past 12 months,
and $19 billion for nonfatal fall injuries.
who were seen by a practitioner in the
This translates to $26 billion in dollars.
past 12 months and who discussed falls
6,7
7
Hospitalizations and visits to the emergency
or problems with balance or walking with
department make up more than 80 percent
their current practitioner.
of the costs.
7
• In 2009, 2.2 million adults were treated
• The percentage of Medicare adults 65
years of age and older who had a fall or
in emergency departments for nonfatal
had problems with balance or walking in
fall injuries; more than 581,000 of these
the past 12 months, who were seen by a
patients were hospitalized.5
practitioner in the past 12 months and who
received fall risk intervention from their
current practitioner.
M easures T argeted at O l der A du l ts
Falls among older adults are a growing national concern because of the financial and societal
M easures T argeted at O l der A du l ts
106
nati o na l c o mmittee f o r qua l it y assurance
Results
Management
A discussion between provider and patient
regarding falls identifies risk factors related
Commercial
Medicare
Medicaid
to vision, muscle strength and reflexes—
Year
HMO
PPO
HMO
PPO
HMO
important information for developing an
2010
NA
NA
60.1
55.3
NA
2009
NA
NA
57.7
54.7
NA
2008
NA
NA
57.8
54.6
NA
2007
NA
NA
55.8
53.4
NA
2006
NA
NA
56.0
54.2
NA
appropriate intervention plan.2
Discussion
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
NA
NA
32.8
31.1
NA
2009
NA
NA
31.1
30.3
NA
2008
NA
NA
31.3
30.7
NA
2007
NA
NA
29.4
28.1
NA
2006
NA
NA
27.5
26.9
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
107
Medicatio n in the Elder ly
seven times more likely to be hospitalized as the result of an adverse drug event.1 The Use
of High-Risk Medications in the Elderly measure assesses how often elderly individuals are
exposed to potentially harmful drugs.2-4 The Potentially Harmful Drug-Disease Interactions in the
Elderly measure assesses how often patients with a specific diagnosis are prescribed high-risk
medications that are considered potentially dangerous.
medications are more likely to be admitted
• In a 2002–2005 study of 384 American
hospitals, 49 percent of patients received
at least one potentially inappropriate
to long-term care facilities.9
• Prescribing harmful drugs to the elderly
medication; among patients 65 years of
population puts them at risk for further
age and older, 13 percent were given a
complications, which include falls,
potentially harmful medication.5
fractures and longer duration of illnesses.
Data from a multidisciplinary falls clinic
• In a study that measured potentially
inappropriate medication use in the elderly,
and a cooperative adverse drug event
40 percent of the population filled at least
surveillance project show that patients
one prescription for such medications and
on five or more medications are twice as
13 percent filled two or more.6
likely to have impaired balance and are
at higher risk for further inappropriate
medication use.1,10
The Case for Improvement
• Exposure to high-risk medications increases
HEDIS Measure Definition
health care costs, including medication
costs, an estimated $7.2 billion annually.
7
• The use of high-risk medications increases
the risk for hospitalization, death and
adverse health outcomes.6,8
• Mobility problems from dementia are
exacerbated by the use of high-risk
medications, and patients exposed to these
The measures assess two different dimensions
of medication management in the Medicare
population 65 years of age and older.
Potentially Harmful Drug-Disease
Interactions in the Elderly
The percentage of adults 65 and older who
have evidence of an underlying disease,
condition or health concern and who were
dispensed an ambulatory prescription for a
M easures T argeted at O l der A du l ts
The elderly are twice as likely as younger adults to have an adverse drug reaction and are
M easures T argeted at O l der A du l ts
108
nati o na l c o mmittee f o r qua l it y assurance
contraindicated medication, concurrent with or
after the diagnosis.
Use of High-Risk Medications in the Elderly
Use of High-Risk Medications
in the Elderly: At Least
One Medication*
Commercial
The percentage of adults 65 and older who
Medicare
Medicaid
received at least one high-risk medication
Year
HMO
PPO
HMO
PPO
HMO
and the percentage of adults 65 and older
2010
NA
NA
22.1
21.9
NA
who received at least two different high-risk
2009
NA
NA
23.0
22.3
NA
medications. A combined rate is reported.
2008
NA
NA
23.4
22.1
NA
2007
NA
NA
23.2
22.1
NA
2006
NA
NA
23.1
23.1
NA
Results
Currently, close to a quarter of all Medicare
patients are prescribed one potentially harmful
medication. Although some drugs are harmful
regardless of a patient’s current health, some
drugs prescribed for patients with a specific
Use of High-Risk Medications
in the Elderly: At Least
Two Medications*
Commercial
disease are associated with poor physical
Medicare
Medicaid
and cognitive performance, including balance
Year
HMO
PPO
HMO
PPO
HMO
disorders and an increased likelihood of falls.9,11
2010
NA
NA
5.1
5.1
NA
2009
NA
NA
5.7
5.3
NA
2008
NA
NA
6.0
5.4
NA
2007
NA
NA
6.0
5.3
NA
2006
NA
NA
5.9
6.5
NA
Potentially Harmful DrugDisease Interactions in the
Elderly: Overall Rate*
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
NA
NA
23.3
21.8
NA
2009
NA
NA
23.2
21.8
NA
2008
NA
NA
23.0
21.7
NA
2007
NA
NA
21.8
21.5
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
109
Management of Urinary Incontinence
in Older Adults
fewer than half of affected patients report it to their providers, partly because it is believed to
be an inevitable part of aging.3 In the older population, UI is the result of several factors that
include comorbid conditions, multiple medications and functional and cognitive impairment.1 The
Management of Urinary Incontinence in Older Adults measure assesses whether adults over the
age of 65 were asked about UI symptoms and received appropriate treatment.
• UI prevalence increases with age and is
a major cause of admittance to nursing
homes. It is more common in older
women—its prevalence in older men is
approximately one-third that of women.1
• Many studies report that females with UI
elderly, the incidence of UI is 15 percent–
33 percent.5,6
• UI further puts older adults at risk for falls,
fractions and functional impairment. It is
associated with poor self-rated health,
impaired quality of life, social isolation,
seek help in very low percentages (ranging
depressive symptoms and dependence on
from 14 percent–38 percent). Another
caregivers. 8
study found that 74 percent of women with
UI symptoms waited for one year before
HEDIS Measure Definition
seeking help, and 46 percent waited for
This patient survey measure assesses the
three years.
diagnosis and management of UI in older adults.
4,5
The Case for Improvement
• The estimated total annual cost of UI
is about $32 billion, or approximately
$3,565 per individual with UI. The largest
components are management costs and
expenses associated with nursing home
admissions attributable to UI.7
• Given a rapidly aging population, the
incidence and prevalence of UI continues to
be a major problem. Among homebound
• Discussing UI. The percentage of Medicare
adults 65 and older who reported having a
problem with urine leakage in the past six
months and discussed their problem with
their current practitioner.
• Receiving UI Treatment. The percentage
of Medicare adults 65 and older who
reported having a urine leakage problem
in the past six months and received
treatment for their current urine leakage
problem.
M easures T argeted at O l der A du l ts
Urinary incontinence (UI) is involuntary loss of urine.1,2 It is largely underestimated because
M easures T argeted at O l der A du l ts
110
nati o na l c o mmittee f o r qua l it y assurance
Results
Treatment
Routinely asking older patients about their
symptoms, combined with appropriate
Commercial
Medicare
Medicaid
treatment, is associated with minimal adverse
Year
HMO
PPO
HMO
PPO
HMO
outcomes, satisfactory results for many
2010
NA
NA
36.0
36.3
NA
2009
NA
NA
35.5
37.4
NA
2008
NA
NA
35.4
36.3
NA
2007
NA
NA
35.4
35.6
NA
2006
NA
NA
35.3
36.8
NA
2005
NA
NA
33.3
34.8
NA
patients and possible prevention of the need
for medical or surgical intervention.9
Discussion
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
NA
NA
58.2
57.9
NA
2009
NA
NA
57.1
58.2
NA
2008
NA
NA
57.3
58.0
NA
2007
NA
NA
57.8
57.7
NA
2006
NA
NA
56.8
57.3
NA
2005
NA
NA
56.0
55.8
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
111
Physical Activit y in Ol der Adults
obesity and high blood pressure. Physical activity helps older adults maintain their ability to live
independently and reduces the risk of falling and fracturing bones.1,2 The Physical Activity in
Older Adults measure assesses whether older adults have either discussed or received advice
from their physician about exercise.
• Lack of physical activity is one of the major
$2,200 per person could be saved in
health care costs every year.3,5
causes of obesity. About 14 percent of
all deaths in the U.S. can be attributed to
insufficient physical activity and inadequate
nutrition.3
• The number of older Americans is
expected to double in the next two
decades. Approximately 95 percent of
health care spending for older adults is
• Physical inactivity increases with age.
Data from the Centers for Disease Control
attributed to chronic conditions. Lack of
and Prevention reveal that 28 percent–34
physical activity among older adults is
percent of adults 65–74 are inactive and
an independent risk factor for a range of
engage in little or no physical activity, and
chronic diseases.3,5 80 percent of older
35 percent–44 percent of adults 75 or
adults have at least one chronic condition;
older are not as active as they should be.
4
• Regular exercise and increased aerobic
50 percent have at least two.
• Regular physical activity for older adults
fitness are associated with a decrease in
has beneficial health effects on a variety of
all-cause mortality and morbidity in older
health outcomes, including decreased risk
adults.1 Research proves that older adults
of early death, heart disease and diabetes;
have more to gain from physical activity
weight loss; fall prevention; reduced
than younger adults.
depression; and improved cognitive
1,2
function.6,7
The Case for Improvement
• The medical costs for inactive adults are
HEDIS Measure Definition
substantially higher than for active adults,
This survey-based measure assesses the
and the cost of inactivity increases with
percentage of Medicare adults age 65 and
age. If inactive older adults increased their
older who had a doctor’s visit in the past 12
physical activity to 90 minutes per week,
months and who:
M easures T argeted at O l der A du l ts
Physical activity in older adults is an important part of managing chronic diseases like diabetes,
M easures T argeted at O l der A du l ts
112
nati o na l c o mmittee f o r qua l it y assurance
• Spoke with a with a doctor or other health
Advice
provider about their level of exercise or
physical activity
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
NA
NA
47.9
47.6
NA
2009
NA
NA
46.9
47.8
NA
2008
NA
NA
47.0
47.1
NA
Results
2007
NA
NA
46.1
46.7
NA
Strong evidence suggests that physical activity
2006
NA
NA
45.2
48.8
NA
reduces the risk of developing chronic diseases
2005
NA
NA
43.7
46.3
NA
• Received advice to start, increase or
maintain their level of exercise or physical
activity.
and should be a high priority for preventing
and treating disease and disability in older
Discussion
adults.7
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
NA
NA
52.3
53.9
NA
2009
NA
NA
51.3
54.4
NA
2008
NA
NA
51.5
54.0
NA
2007
NA
NA
51.1
53.0
NA
2006
NA
NA
50.3
53.6
NA
2005
NA
NA
50.6
53.7
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
113
Glauco ma Screening in O lder Adults
changes in the visual field (narrowing of the eyes’ usual scope of vision). Disease development
is gradual, starting with “blind spots” and progressing up to complete blindness, with little or no
warning signs or symptoms.1 The Glaucoma Screening in Older Adults measure assesses whether
older adults received an eye exam to check for this condition.
• Elevated eye pressure and older age are
• Glaucoma-associated visual impairment
key risk factors. With an aging population,
affects the quality of life and the ability to
the prevalence and incidence of glaucoma
function independently, hampering basic
continue to rise.2,3
daily activities. Vision loss among the elderly
• Untreated glaucoma is the second leading
cause of irreversible blindness in the U.S.1,2
has been shown to result in social isolation,
family stress and a greater tendency to
experience other health conditions.2,3
• Among African Americans, glaucoma is
the leading cause of blindness—African
HEDIS Measure Definition
Americans are six to eight times more likely
The percentage of Medicare adults 65
than Caucasians to have glaucoma.3,4
years and older without a prior diagnosis
of glaucoma or glaucoma suspect, who
The Case for Improvement
• Managed care organizations spend
approximately $1 billion ($2,000 per
patient) annually to treat glaucoma.
Treatment costs increase significantly as the
disease progresses.6
• At least 4.2 million people in the United
States have glaucoma, but only half of
them know that they have it. Another 5–10
million have elevated eye pressure and are
at risk of developing glaucoma.5
received a glaucoma eye exam by an eyecare professional for the early identification of
glaucomatous conditions.
M easures T argeted at O l der A du l ts
Glaucoma represents a family of diseases commonly associated with optic nerve damage and
M easures T argeted at O l der A du l ts
114
nati o na l c o mmittee f o r qua l it y assurance
Results
Screening Rate
Glaucoma’s asymptomatic progression points
to the importance of early detection and
Commercial
Medicare
Medicaid
treatment, which can prevent, slow or stop
Year
HMO
PPO
HMO
PPO
HMO
vision loss.
2010
NA
NA
63.8
65.1
NA
2009
NA
NA
62.3
63.7
NA
2008
NA
NA
59.8
62.2
NA
2007
NA
NA
59.5
62.6
NA
2006
NA
NA
62.2
63.3
NA
2005
NA
NA
61.5
64.5
NA
6
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
115
Osteopo ro sis Testing in Ol der Wo men
tissue, leading to bone fragility and an increased susceptibility to fractures. It mostly affects
elderly women. Disease development is gradual, progressing without symptoms until a lowenergy fall or minor activity fractures a bone.1 The Osteoporosis Testing in Older Women
measure assesses whether women over the age of 65 reported receiving a bone density test.
• According to the National Osteoporosis
• Osteoporosis is responsible for more than
Foundation, about 12 million Americans
1.5 million fractures each year, and results
have osteoporosis and approximately 52.4
in 500,000 hospital admissions, 800,000
million over the age of 50 have low bone
emergency room visits, 2.6 million
density—which puts them at increased
physician visits and 180,000 nursing home
risk for developing the disease. About 80
admissions annually.4,5
percent of those affected are women.2
• One in two women and one in four men
• Despite being a covered service under
Medicare with no out-of-pocket costs, bone
over 50 will have an osteoporosis-related
density tests are underutilized by elderly,
fracture in their lifetime, most commonly of
at-risk populations. In 2005 only an
the hip, wrist or spine.
estimated 30 percent of Medicare women
1,2
enrollees received a bone density test.5
The Case for Improvement
• In 2008, the annual direct medical costs
HEDIS Measure Definition
of osteoporosis and fractures ranged from
This survey based measure assesses the
$17 billion to $22 billion. By 2025, annual
percentage of Medicare women 65 years
fractures and costs are expected to rise by
of age and older who report ever having
almost 50 percent. The most rapid growth
received a bone density test to check for
is estimated for people 65–74 years of
osteoporosis.
age.3,4
M easures T argeted at O l der A du l ts
Osteoporosis is a disease characterized by low bone mass and structural deterioration of bone
M easures T argeted at O l der A du l ts
116
nati o na l c o mmittee f o r qua l it y assurance
Results
Testing
Bone density screenings are an important
strategy for reducing the rate of fractures
among women over the age of 65.
6,7
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
NA
NA
68.5
73.4
NA
2009
NA
NA
68.0
72.8
NA
2008
NA
NA
66.7
72.0
NA
2007
NA
NA
65.7
70.3
NA
2006
NA
NA
64.4
71.3
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • H E D I S M easures o f C are
117
Osteopo ro sis M anagement in
Women Who Had a Fracture
fractures, like those caused by osteoporosis, are associated with chronic pain, skeletal deformities,
loss of independence and increased mortality.6 By 2012, over 12 million Americans over the age
of 50 are expected to have osteoporosis.4 The Osteoporosis Management in Women Who Had a
Fracture measure assesses whether women suffering from bone fractures received a bone density
test to determine if bone fragility was the underlying cause of the fracture.
• Women are more likely to develop
• Osteoporosis is underdiagnosed and
osteoporosis than men. Women lose bone
undertreated. Only one-third of patients
density with age, and a woman over
with fragility fractures receive appropriate
50 has a 50 percent chance of having
testing and treatment for osteoporosis.6
an osteoporosis-related fracture in her
Osteoporosis is asymptomatic in the early
lifetime.3 Once a woman has a fracture,
stages of the disease, so most people are
she is at four times greater risk for another
not aware that they have the condition.6
fracture.3
A fracture may be an indicator of the
2
• A bone mineral density test is the most
effective method for determining bone
presence of osteoporosis.3,5
• Osteoporosis treatment costs $17 billion
health, and can identify osteoporosis,
annually.7 Direct medical costs are
determine risk for fractures and assess
predicted to increase to $25.3 billion
response to osteoporosis treatment.
annually by 2025.8 Each year, fragility
The U.S. Preventive Services Task Force
fractures are estimated to result in 500,000
recommends that osteoporosis screening
hospitalizations, 800,000 emergency
begin at 65 for most women. Women at
department visits, 2.6 million doctors’ visits
increased risk for osteoporotic fractures
and 180,000 nursing home placements.9
3
should begin screening at age 60.4
The Case for Improvement
• More than 300,000 hip fractures occur
each year due to osteoporosis. Of these,
42,000 people die as a result.7
M easures T argeted at O l der A du l ts
Osteoporosis is a weakening of the bones that puts patients at risk for bone fracture.1 Fragility
M easures T argeted at O l der A du l ts
118
nati o na l c o mmittee f o r qua l it y assurance
HEDIS Measure Definition
Treatment Rate
The percentage of women 67 years of age
and older who suffered a fracture and who
Commercial
Medicare
Medicaid
had either a bone mineral density test or
Year
HMO
PPO
HMO
PPO
HMO
prescription for a drug to treat or prevent
2010
NA
NA
20.7
18.5
NA
2009
NA
NA
20.7
18.1
NA
2008
NA
NA
20.7
18.0
NA
2007
NA
NA
20.4
17.8
NA
osteoporosis in the six months after the
fracture.
Results
Osteoporosis may lead to painful bone
fractures that limit mobility and put patients
at risk for other adverse health conditions.
Osteoporosis therapy has the potential to
reduce the risk of fracture by nearly 50
percent.10 Screening and treatment can
significantly improve health outcomes by
preventing fractures.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • C A H P S
119
Consumer and Patient Engagement and Experience
private initiative to develop standardized surveys of patients’ experiences with ambulatory and
facility-level care in commercial and Medicaid plans. Surveys were developed with the Agency
for Healthcare Research and Quality (AHRQ). CAHPS data address areas such as patient ease
of obtaining information from a health plan; timeliness of service; and speed and accuracy of
claim processing.
CAHPS results offer an indication of how well health care organizations meet member expectations.
Rating of Health Plan
Respondents were asked to give their health plan an overall rating, with 0 equaling “worst health
plan possible” and 10 equaling “best health plan possible.” The tables below represent the
percentage of respondents who rated their health plans either 9 or 10.
Rating of Health Plan:
Rating of 9 or 10
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
40.3
33.7
NA
NA
54.7
2009
38.3
32.4
59.0
52.2
52.5
2008
39.1
34.2
60.7
53.4
55.3
2007
37.1
31.8
61.1
52.9
53.3
2006
38.0
35.9
61.7
53.9
52.4
2005
39.8
43.1
61.3
54.2
54.0
2004
38.4
NA
57.5
NA
52.3
2003
36.7
NA
53.3
NA
51.7
2002
36.0
NA
60.5
NA
51.5
2001
37.4
NA
62.4
NA
69.1
2000
34.7
NA
NA
NA
NA
1999
32.6
NA
NA
NA
NA
C o nsumer and P atient E ngagement and E x perience
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a public/
C o nsumer and P atient E ngagement and E x perience
120
nati o na l c o mmittee f o r qua l it y assurance
Rating of Health Care
Respondents were asked to give their health care an overall rating, with 0 equaling “worst health
plan possible” and 10 equaling “best health plan possible.” The tables below represent the
percentage of respondents who rated their health plans either 9 or 10.
Rating of Health Care:
Rating of 9 or 10
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
50.7
48.1
NA
NA
48.8
2009
48.7
46.6
56.2
57.4
47.0
2008
48.7
46.7
56.2
56.4
48.1
2007
47.2
45.8
55.9
55.0
46.8
2006
47.0
48.3
62.0
62.7
46.2
2005
53.4
55.6
69.1
72.2
54.1
2004
52.1
NA
68.7
NA
53.5
2003
51.5
NA
67.5
NA
52.8
2002
49.4
NA
67.8
NA
53.0
2001
47.5
NA
68.8
NA
71.3
2000
45.6
NA
NA
NA
NA
1999
44.1
NA
NA
NA
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • C A H P S
121
The Getting Needed Care composite measures members’ perception of how easy it was to get
care from their doctor and from specialists in the last 12 months. Members were asked how often
they were able to:
• See a specialist when they needed one
• Obtain the care, tests or treatment they believed were necessary.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
Getting Needed Care: Always
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
53.9
53.9
NA
NA
50.1
2009
52.9
52.7
63.6
64.4
48.5
2008
52.6
52.6
62.4
61.9
49.4
2007
50.4
49.5
62.0
63.4
48.7
2006
50.1
51.2
62.6
64.6
46.7
2005
80.1
84.7
95.9
97.0
73.4
2004
79.3
NA
95.7
NA
73.8
2003
78.4
NA
94.9
NA
72.1
2002
76.9
NA
94.8
NA
72.3
2001
76.7
NA
94.9
NA
75.4
2000
75.4
NA
NA
NA
NA
C o nsumer and P atient E ngagement and E x perience
Getting Needed Care
C o nsumer and P atient E ngagement and E x perience
122
nati o na l c o mmittee f o r qua l it y assurance
Getting Care Quickly
The Getting Care Quickly composite measures members’ perception of how quickly they received
care when it was sought in the last 12 months. Members were asked how often they were able to:
• Receive needed care right away
• Get an appointment for health care at a doctor’s office or clinic as soon as they thought care
was needed.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
Getting Care Quickly: Always
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
58.2
57.7
NA
NA
56.2
2009
57.8
57.4
64.0
64.7
54.7
2008
57.6
56.2
63.7
64.6
55.7
2007
56.0
55.6
63.5
65.0
55.6
2006
56.8
57.5
65.4
67.0
53.4
2005
46.5
46.2
58.7
60.2
44.5
2004
45.5
NA
58.5
NA
44.2
2003
45.0
NA
57.2
NA
42.6
2002
43.9
NA
55.8
NA
44.1
2001
44.8
NA
60.0
NA
46.5
2000
45.8
NA
NA
NA
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • C A H P S
123
The How Well Doctors Communicate composite measures members’ perception of the quality of
communication with their personal doctor in the last 12 months. Members were asked how often
their doctor:
• Explained things in a way that was easy to understand
• Listened carefully to them
• Showed respect for what they had to say
• Spent enough time with them.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
How Well Doctors
Communicate: Always
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
73.5
73.5
NA
NA
69.1
2009
72.0
71.7
74.7
74.8
67.5
2008
71.1
70.7
75.3
74.8
68.0
2007
70.2
70.1
74.6
75.7
67.7
2006
70.3
71.5
75.0
76.2
66.7
2005
61.3
58.8
69.5
71.6
61.5
2004
60.2
NA
69.0
NA
60.8
2003
59.4
NA
68.6
NA
59.1
2002
57.7
NA
68.0
NA
59.9
2001
57.1
NA
68.5
NA
60.4
2000
58.4
NA
NA
NA
NA
C o nsumer and P atient E ngagement and E x perience
How Well Doctors Communicate
C o nsumer and P atient E ngagement and E x perience
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nati o na l c o mmittee f o r qua l it y assurance
Rating of Personal Doctor
Respondents were asked to give their personal doctor an overall rating, with 0 equaling “worst
personal doctor possible” and 10 equaling “best personal doctor possible.” The tables below
represent the percentage of respondents who rated their personal doctor either 9 or 10.
Rating of Personal Doctor:
Rating of 9 or 10
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
65.0
62.8
NA
NA
61.1
2009
63.2
61.2
73.3
73.9
60.1
2008
63.3
61.9
73.6
73.3
61.1
2007
62.1
61.7
73.6
73.8
60.4
2006
62.3
63.2
73.8
75.0
60.3
2005
52.8
54.0
67.8
70.9
59.2
2004
51.7
NA
67.5
NA
58.4
2003
51.9
NA
66.4
NA
58.9
2002
49.7
NA
65.2
NA
58.0
2001
50.5
NA
65.8
NA
76.5
2000
48.3
NA
NA
NA
NA
1999
47.0
NA
NA
NA
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • C A H P S
125
Respondents were asked to give their specialist an overall rating, with 0 equaling “worst
specialist possible” and 10 equaling “best specialist possible.” The tables below represent the
percentage of respondents who rated their specialist either 9 or 10.
Rating of Specialist:
Rating of 9 or 10
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
64.1
61.9
NA
NA
61.3
2009
61.8
60.4
69.3
70.8
60.5
2008
62.3
60.5
68.9
69.9
60.7
2007
61.7
60.5
69.2
70.2
60.8
2006
60.7
62.4
70.7
73.0
59.3
2005
57.2
59.1
67.7
71.7
60.2
2004
56.2
NA
67.5
NA
59.2
2003
55.8
NA
67.7
NA
58.3
2002
54.4
NA
67.7
NA
57.8
2001
54.6
NA
68.5
NA
75.3
2000
53.7
NA
NA
NA
NA
1999
51.8
NA
NA
NA
NA
C o nsumer and P atient E ngagement and E x perience
Rating of Specialist
C o nsumer and P atient E ngagement and E x perience
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nati o na l c o mmittee f o r qua l it y assurance
Customer Service
The Customer Service composite measures members’ perception of the usefulness and quality of
customer service they experienced in the last 12 months (for those who tried to get information
or help from their plan’s customer service). Members were asked how often their health plan’s
customer service:
• Gave them the information or help they needed
• Treated them with courtesy and respect.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
Customer Service: Always
Commercial
Medicare
Medicaid
Year
HMO
PPO
HMO
PPO
HMO
2010
59.4
55.5
NA
NA
59.5
2009
57.9
54.5
66.4
NA
57.9
2008
57.2
53.5
66.6
64.3
59.0
2007
55.4
50.7
66.5
62.5
57.3
2006
54.2
53.9
NA
NA
49.7
2005
71.2
69.7
91.5
87.7
68.6
2004
71.0
NA
94.8
NA
69.8
2003
70.8
NA
94.5
NA
69.7
2002
70.4
NA
94.3
NA
67.4
2001
67.2
NA
94.8
NA
67.5
2000
66.6
NA
NA
NA
NA
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • M eth o d o l o g y Overview
127
Methodology Overview
General Methods
Data in this report are from HEDIS year 2011, which is measure year 2010 (January 1–
December 31, 2010). Unless otherwise noted, all references to “years” in charts and tables are
to measure years, not HEDIS years.
Because The State of Health Care Quality Report focuses on health plan performance, summary
tables are not weighted for the size of eligible populations. Most tables and appendices provide
mean rates separately for each measure, or for each indicator in a measure.
In most tables and appendices, rate means are provided side-by-side for commercial, Medicare
and Medicaid product lines. Results for HMO and PPO plans are shown in separate tables. HMO
plans include HMOs, HMO/POS combined, HMO/PPO/POS combined, HMO/PPO combined
and POS. Only plans with the sole designation of PPO are shown as PPOs in tables.
Some reporting periods are limited. For example, PPOs have reported substantial HEDIS data
only since measure year 2005; Medicare and Medicaid performance data are reported only as
far back as measure year 2001.
Best States
Identification of high-performing state cohorts is based on the state means of five measures:
Diabetes (nine indicators), Hypertension (one indicator), Persistence of Beta-Blockers After a
Heart Attack (one indicator) and Cholesterol Management for Patients With Cardiovascular
Conditions (two indicators).
The unweighted average of all indicators across all plans in a state is calculated for each state.
No distinction is made among plans with respect to product line or reporting type. The
composite means are ranked in descending order. The top 10 states compose the “Best” cohort.
In the Diabetes quality composite, the Poor Glycemic Control Indicator is inverted before
calculating the composite so that higher performance is indicated by a higher rate.
Composite Measure Means by Region
Analysis provides mean rates for several composite measures by U.S. Census region. The
Childhood and Adolescent Immunizations summary rate comprises the rates for vaccinations
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appropriate to each age group. Childhood vaccinations included in the composite are DTaP/
DT, hepatitis A, hepatitis B, HIB, IPV, MMR, pneumococcal conjugate and chicken pox vaccines,
rotavirus, influenza and combinations. Adolescent vaccinations included in the composite are
meningococcal, Tdap/Td and combinations.
Consumer Experience is a summary of the following indicators: Getting Needed Care, Getting
Care Quickly, How Well Doctors Communicate, Claims Processing, Customer Service, Rating of
Personal Doctor, Rating of Specialist, Rating of All Health Care and Rating of Plan.
All rating summaries reflect ratings of 9 or 10 and all composites correspond to responses of
“Always.” The Diabetes composite summarizes the mean for the following indicators: Blood
Pressure Control (<140/90 mm Hg), Eye Exams, HbA1c Screening, Poor Glycemic Control
(>9%), LDL Cholesterol Screening, LDL Cholesterol Control (<100 mg/dL) and Medical Attention
for Nephropathy. The Heart Disease composite summarizes performance on the following
indicators: Persistence of Beta-Blockers After a Heart Attack; Controlling High Blood Pressure;
Cholesterol Screening; and Management for Patients With Cardiovascular Conditions.
The final rates presented are the unweighted averages of all indicators in the composites defined
above, across all plans (by product line and reporting type) in each U.S. Census region. Plans
that operate in more than one region are counted in each region summary. For example, a plan
that operates in the Mountain and Pacific regions contributed data to the composite mean once
for the Mountain region and once for the Pacific region.
Relative Resource Use
Health plans report case mix-adjusted measures of resource use related to five chronic illnesses:
asthma, cardiovascular conditions, COPD, diabetes and hypertension. These measures
incorporate cost and service frequency for each eligible member during the measurement year.
All services administered to members identified with one of these conditions are attributed to the
RRU measure for that condition.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • M eth o d o l o g y Overview
129
Each of the five RRU measures summarizes a health plan’s utilization of several service
categories:
• Inpatient Facility
• Evaluation and Management (E&M—Inpatient and Outpatient)
• Procedure and Surgery (Inpatient and Outpatient)
• Ambulatory Pharmacy Services.
NCQA calculates two observed-to-expected (O/E) ratios for each health plan, one for quality
and one for resource use. An O/E ratio is a plan’s actual quality level or resource use (the
“observed”), divided by an estimate of the quality level or resource use the plan would have if its
population was the same as the average population of all other plans submitting data to NCQA
(the “expected”).
To enable comparison within plan types (HMO or PPO), NCQA indexes O/E ratios by dividing
each plan’s ratio by the national average O/E for all HMOs or PPOs.
For the resource use index, shown as the horizontal axis on RRU scatter plots, a ratio of 1.00
represents the average resource utilization for all HMOs or PPOs nationally. A ratio greater than
1.00 represents higher-than-expected use; a ratio less than 1.00 represents lower-than-expected use.
For the quality index, otherwise known as the Effectiveness of Care ratio and shown as the
vertical axis on RRU scatter plots, a ratio greater than 1.00 represents better-than-expected
performance; a ratio less than 1.00 represents lower-than-expected performance. For example,
a PPO with a ratio of 1.12 for quality and 1.15 for resource use delivered quality that was
12 percent better than the average PPO serving similar patients, and used 15 percent more
resources than the PPO average.
Descriptive statistics are provided for composites with up to 10 indicators. With the exception of
the COPD quality RRU composite, the summary statistics for composite measures are the simple,
unweighted average of all measures and indicators in the composite. Since 2 of the 3 COPD
indicators describe the same dimension of care (Pharmacotherapy Management), each indicator
receives a weight of one-half.
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nati o na l c o mmittee f o r qua l it y assurance
Appendi x 1: HEDIS Effectiveness of Care
Measures: 2010 N ati onal HMO Averages
HEDIS EFFECTIVENESS OF CARE MEASURES
NATIONAL HMO AVERAGES—2010
MEASURE
COMMERCIAL MEDICARE MEDICAID
Safety and Potential Waste
Imaging Studies for Low Back Pain
74.2
NA
75.5
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
22.5
NA
23.5
Ambulatory Care—ED Visits per 1,000 Member Months
187.4
450.3
62.0
Adult BMI Assessment
40.7
50.4
42.2
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
76.7
NA
73.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
45.0
NA
38.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
52.4
NA
42.7
Wellness and Prevention
Flu Shots for Adults
52.5
NA
NA
Prenatal and Postpartum Care—Timeliness of Prenatal Care
91.0
NA
83.7
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
80.7
NA
64.4
Breast Cancer Screening
70.8
68.5
51.3
Cervical Cancer Screening
77.0
NA
67.2
Colorectal Cancer Screening
62.6
57.6
NA
Chlamydia Screening in Women—16–20 Years
40.8
NA
54.6
Chlamydia Screening in Women—21–24 Years
45.7
NA
62.3
Chlamydia Screening in Women—Total Rate
43.1
NA
57.5
Chronic Disease Management
Persistence of Beta-Blocker Treatment After a Heart Attack
75.5
83.1
76.3
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
65.7
62.3
60.4
Comprehensive Diabetes Care—Eye Exams
57.7
64.6
53.1
Comprehensive Diabetes Care—HbA1c Screening
89.9
90.4
82.0
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
42.5
NA
34.7
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
62.3
65.6
46.9
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
27.3
25.9
44.0
Comprehensive Diabetes Care—LDL Cholesterol Screening
85.6
87.8
74.7
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
47.7
52.1
34.6
Comprehensive Diabetes Care—Medical Attention for Nephropathy
83.6
89.2
77.7
Controlling High Blood Pressure
63.4
61.9
55.6
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
88.9
88.5
82.0
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
131
HEDIS EFFECTIVENESS OF CARE MEASURES
NATIONAL HMO AVERAGES—2010
MEASURE
COMMERCIAL MEDICARE MEDICAID
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
59.9
56.7
42.8
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
87.7
72.8
70.1
Use of Appropriate Medications for People With Asthma—5–11 Years
96.7
NA
91.8
Use of Appropriate Medications for People With Asthma—12–50 Years
91.8
NA
85.8
Use of Appropriate Medications for People With Asthma—Overall Rate
92.9
NA
88.4
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
41.7
33.9
31.3
Pharmacotherapy Management of COPD—Bronchodilators
77.8
78.2
82.1
Pharmacotherapy Management of COPD—Systemic Corticosteroids
69.8
66.6
65.3
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
81.6
90.7
86.0
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
60.4
68.2
67.7
Annual Monitoring for Patients on Persistent Medications—Digoxin
84.6
93.1
89.7
Annual Monitoring for Patients on Persistent Medications—Diuretics
81.0
90.9
85.5
Annual Monitoring for Patients on Persistent Medications—Combined
80.9
90.2
83.9
Antidepressant Medication Management—Acute Phase
64.7
65.0
50.7
Antidepressant Medication Management—Continuation Phase
48.3
51.9
34.4
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
59.7
37.4
44.6
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
77.4
55.4
63.8
Alcohol and Other Drug Dependence Treatment—Engagement
15.6
3.7
14.2
Alcohol and Other Drug Dependence Treatment—Initiation
42.7
44.6
42.9
77.6
NA
64.9
Measures Targeted Toward Children and Adolescents
Appropriate Testing for Children With Pharyngitis
Appropriate Testing for Children With Upper Respiratory Infection
85.1
NA
87.2
Childhood Immunization Status—DTaP/DT
86.3
NA
80.2
Childhood Immunization Status—Hepatitis B
90.2
NA
90.1
Childhood Immunization Status—HiB
94.3
NA
90.3
Childhood Immunization Status—IPV
91.8
NA
90.8
Childhood Immunization Status—MMR
90.8
NA
90.6
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
85.6
NA
79.4
Childhood Immunization Status—VZV
90.8
NA
90.0
Childhood Immunization Status—Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
78.5
NA
74.1
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
75.1
NA
69.9
Childhood Immunization Status—Hepatitis A
35.4
NA
36.5
Childhood Immunization Status—Rotavirus
63.5
NA
57.6
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HEDIS EFFECTIVENESS OF CARE MEASURES
NATIONAL HMO AVERAGES—2010
MEASURE
COMMERCIAL MEDICARE MEDICAID
Childhood Immunization Status—Influenza
57.1
NA
43.6
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
18.5
NA
15.2
Immunizations for Adolescents—Meningococcal
55.2
NA
56.3
Immunizations for Adolescents—Tdap/Td
69.5
NA
67.8
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
51.6
NA
52.2
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
38.8
NA
38.1
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.4
NA
43.9
Lead Screening in Children
NA
NA
66.2
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
35.2
NA
37.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
37.4
NA
45.6
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
35.3
NA
36.7
Frequency of Prenatal Care Visits—<21% of Expected Visits
NA
NA
10.4
Frequency of Prenatal Care Visits—21–40% of Expected Visits
NA
NA
6.9
Frequency of Prenatal Care Visits—41–60% of Expected Visits
NA
NA
8.1
Frequency of Prenatal Care Visits—61–80% of Expected Visits
NA
NA
13.6
Frequency of Prenatal Care Visits—>80% of Expected Visits
NA
NA
61.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
1.6
NA
2.2
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.1
NA
2.2
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
1.3
NA
3.3
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
2.2
NA
5.7
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
4.9
NA
10.1
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
12.8
NA
16.1
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
76.3
NA
60.2
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
71.6
NA
71.9
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
42.7
NA
48.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 12–24 Months
97.5
NA
96.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 25 Months–6 Years
91.2
NA
88.3
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
91.6
NA
90.2
Children and Adolescents’ Access to Primary Care Practitioners—Adolescents 12–19 Years
89.2
NA
88.1
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
133
HEDIS EFFECTIVENESS OF CARE MEASURES
NATIONAL HMO AVERAGES—2010
MEASURE
COMMERCIAL MEDICARE MEDICAID
Measures Targeted Toward Older Adults
Fall Risk Management—Discussion
NA
32.8
NA
Fall Risk Management—Management
NA
60.1
NA
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
NA
11.6
NA
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
NA
28.7
NA
Potentially Harmful Drug-Disease Interactions in the Elderly—
Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
NA
17.1
NA
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
NA
23.3
NA
Use of High-Risk Medications in the Elderly—At Least One Medication*
NA
22.1
NA
Use of High-Risk Medications in the Elderly—At Least Two Medications*
NA
5.1
NA
Management of Urinary Incontinence—Discussion
NA
58.2
NA
Management of Urinary Incontinence—Treatment
NA
36.0
NA
Physical Activity in Older Adults—Advice
NA
47.9
NA
Physical Activity in Older Adults—Discussion
NA
52.3
NA
Osteoporosis Testing in Older Women
NA
68.5
NA
Osteoporosis Management in Women Who Had a Fracture
NA
20.7
NA
Glaucoma Screening in Older Adults
NA
63.8
NA
*Lower rates signify better performance.
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Appendi x 2: HEDIS Effectiveness of Care
Measures: 2010 N ati onal PPO Averages
�HEDIS EFFECTIVENESS OF CARE MEASURES
NATIONAL PPO AVERAGES—2010
MEASURE
COMMERCIAL
MEDICARE
Imaging Studies for Low Back Pain
73.3
NA
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
21.3
NA
Ambulatory Care—ED Visits per 1,000 Member Months
174
379
Adult BMI Assessment
11.6
36.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
71.7
NA
Medical Assistance With Smoking and Tobacco Use Cessation—Discussing Cessation Strategies
39.0
NA
Safety and Potential Waste
Wellness and Prevention
Medical Assistance With Smoking and Tobacco Use Cessation—Discussing Cessation Medications
47.2
NA
Flu Shots for Adults
51.6
NA
Prenatal and Postpartum Care—Timeliness of Prenatal Care
75.7
NA
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
65.9
NA
Breast Cancer Screening
67.0
65.8
Cervical Cancer Screening
74.5
NA
Colorectal Cancer Screening
47.6
41.0
Chlamydia Screening in Women—16–20 Years
38.1
NA
Chlamydia Screening in Women—21–24 Years
41.9
NA
Chlamydia Screening in Women—Total Rate
40.0
NA
Persistence of Beta-Blocker Treatment After a Heart Attack
71.3
82.5
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
51.1
55.6
Comprehensive Diabetes Care—Eye Exams
45.5
62.3
Comprehensive Diabetes Care—HbA1c Screening
85.2
90.6
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <7% for a Selected Population)
28.2
NA
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
50.2
57.3
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
46.6
35.2
Comprehensive Diabetes Care—LDL Cholesterol Screening
79.9
86.3
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
37.3
45.9
Comprehensive Diabetes Care—Medical Attention for Nephropathy
74.3
87.3
Controlling High Blood Pressure
56.7
55.7
Cholesterol Management for Patients With Cardiovascular Conditions—LDL Cholesterol Screening
81.3
87.1
Cholesterol Management for Patients With Cardiovascular Conditions—LDL Control (<100 mg/dL)
45.2
50.6
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
87.0
77.8
Use of Appropriate Medications for People With Asthma—5–11 Years
97.0
NA
Use of Appropriate Medications for People With Asthma—12–50 Years
91.8
NA
Use of Appropriate Medications for People With Asthma—Overall Rate
93.0
NA
Chronic Disease Management
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
135
�HEDIS EFFECTIVENESS OF CARE MEASURES
NATIONAL PPO AVERAGES—2010
MEASURE
COMMERCIAL
MEDICARE
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
40.2
35.3
Pharmacotherapy Management of COPD—Bronchodilators
73.5
76.1
Pharmacotherapy Management of COPD—Systemic Corticosteroids
66.2
69.6
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
78.4
90.8
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
57.9
69.1
Annual Monitoring for Patients on Persistent Medications—Digoxin
79.1
92.7
Annual Monitoring for Patients on Persistent Medications—Diuretics
78.1
91.2
Annual Monitoring for Patients on Persistent Medications—Combined
77.8
90.6
Antidepressant Medication Management—Acute Phase
64.3
67.4
Antidepressant Medication Management—Continuation Phase
48.1
55.7
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
54.2
39.1
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
74.1
61.2
Alcohol and Other Drug Dependence Treatment—Engagement
16.0
4.8
Alcohol and Other Drug Dependence Treatment—Initiation
40.8
57.4
Appropriate Testing for Children With Pharyngitis
76.6
NA
Appropriate Testing for Children With Upper Respiratory Infection
83.7
NA
Childhood Immunization Status—DTaP/DT
64.7
NA
Measures Targeted Toward Children and Adolescents
Childhood Immunization Status—Hepatitis B
58.7
NA
Childhood Immunization Status—HiB
75.5
NA
Childhood Immunization Status—IPV
71.1
NA
Childhood Immunization Status—MMR
82.7
NA
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
65.6
NA
Childhood Immunization Status—VZV
82.2
NA
Childhood Immunization Status—Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
48.5
NA
Childhood Immunization Status—Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
46.1
NA
Childhood Immunization Status—Hepatitis A
28.6
NA
Childhood Immunization Status—Rotavirus
51.9
NA
Childhood Immunization Status—Influenza
51.1
NA
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR, HiB,
Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
10.4
NA
Immunizations for Adolescents—Meningococcal
43.8
NA
Immunizations for Adolescents—Tdap/Td
55.3
NA
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
39.4
NA
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
38.1
NA
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.3
NA
136
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�HEDIS EFFECTIVENESS OF CARE MEASURES
NATIONAL PPO AVERAGES—2010
MEASURE
COMMERCIAL
MEDICARE
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
10.9
NA
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
11.8
NA
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
10.5
NA
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
2.9
NA
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.5
NA
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
1.7
NA
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
2.7
NA
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
5.3
NA
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
13.0
NA
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
72.8
NA
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
67.8
NA
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
39.2
NA
Children and Adolescents’ Access to Primary Care Practitioners—Children 12–24 Months
96.9
NA
Children and Adolescents’ Access to Primary Care Practitioners—Children 25 Months–6 Years
89.1
NA
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
89.4
NA
Children and Adolescents’ Access to Primary Care Practitioners—Adolescents 12–19 Years
86.8
NA
Fall Risk Management—Discussion
NA
31.1
Fall Risk Management—Management
NA
55.3
Potentially Harmful Drug-Disease Interactions in the Elderly—Chronic Renal Failure
and NSAIDS or Cox-2 Selective NSAIDS*
NA
11.7
Potentially Harmful Drug-Disease Interactions in the Elderly—Dementia and Tricyclic
Antidepressants or Anticholinergic Agents*
NA
27.3
Potentially Harmful Drug-Disease Interactions in the Elderly—Falls and Tricyclic Antidepressants,
Antipsychotics and Sleep Agents*
NA
16.3
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
NA
21.8
Use of High-Risk Medications in the Elderly—At Least One Medication*
NA
21.9
Measures Targeted Toward Older Adults
Use of High-Risk Medications in the Elderly—At Least Two Medications*
NA
5.1
Management of Urinary Incontinence—Discussion
NA
57.9
Management of Urinary Incontinence—Treatment
NA
36.3
Physical Activity in Older Adults—Advice
NA
47.6
Physical Activity in Older Adults—Discussion
NA
53.9
Osteoporosis Testing in Older Women
NA
73.4
Osteoporosis Management in Women Who Had a Fracture
NA
18.5
Glaucoma Screening in Older Adults
NA
65.1
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
137
Appendix 3A: CAHPS Memb er Satisfaction
Measures: 2010 N ati onal HMO Averages
�CAHPS MEMBER SATISFACTION MEASURES
NATIONAL HMO AVERAGES—2010
MEASURE
COMMERCIAL MEDICARE MEDICAID
Consumer and Patient Engagement and Experience
Rating of Health Plan—Rating of 8, 9 or 10
64.2
NA
72.4
Rating of Health Plan—Rating of 9 or 10
40.3
NA
54.7
Rating of Health Care—Rating of 8, 9 or 10
76.6
NA
68.9
Rating of Health Care—Rating of 9 or 10
50.7
NA
48.8
Getting Needed Care—Usually or Always
86.2
NA
76.0
Getting Needed Care—Always
53.9
NA
50.1
Getting Care Quickly—Usually or Always
86.5
NA
80.6
Getting Care Quickly—Always
58.2
NA
56.2
How Well Doctors Communicate—Usually or Always
93.9
NA
87.8
How Well Doctors Communicate—Always
73.5
NA
69.1
Rating of Personal Doctor—Rating of 8, 9 or 10
83.2
NA
76.4
Rating of Personal Doctor—Rating of 9 or 10
65.0
NA
61.1
Rating of Specialist—Rating of 8, 9 or 10
82.3
NA
76.9
Rating of Specialist—Rating of 9 or 10
64.1
NA
61.3
Customer Service—Usually or Always
84.5
NA
79.7
Customer Service—Always
59.4
NA
59.5
Claims Processing—Usually or Always
88.6
NA
NA
Claims Processing—Always
55.5
NA
NA
138
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Appendi x 3B: CAHPS Memb er Satisfaction
Measures: 2010 N ati onal PPO Averages
�CAHPS MEMBER SATISFACTION MEASURES
NATIONAL PPO AVERAGES—2010
MEASURE
COMMERCIAL
MEDICARE
Rating of Health Plan—Rating of 8, 9 or 10
58.6
NA
Rating of Health Plan—Rating of 9 or 10
33.7
NA
Rating of Health Care—Rating of 8, 9 or 10
75.6
NA
Rating of Health Care—Rating of 9 or 10
48.1
NA
Getting Needed Care—Usually or Always
86.6
NA
Getting Needed Care—Always
53.9
NA
Getting Care Quickly—Usually or Always
87.1
NA
Getting Care Quickly—Always
57.7
NA
How Well Doctors Communicate—Usually or Always
94.6
NA
How Well Doctors Communicate—Always
73.5
NA
Rating of Personal Doctor—Rating of 8, 9 or 10
82.8
NA
Rating of Personal Doctor—Rating of 9 or 10
62.8
NA
Rating of Specialist—Rating of 8, 9 or 10
81.6
NA
Rating of Specialist—Rating of 9 or 10
61.9
NA
Customer Service—Usually or Always
83.0
NA
Customer Service—Always
55.5
NA
Claims Processing—Usually or Always
87.8
NA
Claims Processing—Always
50.7
NA
Consumer and Patient Engagement and Experience
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
139
Appendix 4A: Accredited vs . No naccredited
Plans: 2010 Co mmercial HM O Averages
HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: COMMERCIAL HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Safety and Potential Waste
Imaging Studies for Low Back Pain
74.5
73.2
1.2
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
22.3
23.3
-0.9
Ambulatory Care—ED Visits per 1,000 Member Months
188.6
183.2
5.4
Wellness and Prevention
Adult BMI Assessment
41.4
38.1
3.2
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
76.8
76.1
0.7
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
45.1
44.6
0.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
52.4
52.2
0.3
Flu Shots for Adults
52.1
54.1
-2.0
Prenatal and Postpartum Care—Timeliness of Prenatal Care
92.1
86.6
5.5
Prenatal and Postpartum Care—Postpartum Visit
Between 21 and 56 Days After Delivery
81.5
77.6
3.9
Breast Cancer Screening
71.2
69.5
1.7
Cervical Cancer Screening
77.7
74.5
3.2
Colorectal Cancer Screening
63.7
58.8
4.9
Chlamydia Screening in Women—16–20 Years
42.1
36.4
5.6
Chlamydia Screening in Women—21–24 Years
46.9
41.4
5.5
Chlamydia Screening in Women—Total Rate
44.4
39.0
5.4
Chronic Disease Management
Persistence of Beta-Blocker Treatment After a Heart Attack
75.5
75.5
0.0
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
66.7
62.3
4.4
Comprehensive Diabetes Care—Eye Exams
59.0
53.7
5.4
Comprehensive Diabetes Care—HbA1c Screening
90.2
89.0
1.2
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
43.1
40.3
2.7
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
63.3
58.9
4.5
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
26.1
31.4
-5.2
Comprehensive Diabetes Care—LDL Cholesterol Screening
86.3
83.3
3.0
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
48.8
44.2
4.6
Comprehensive Diabetes Care—Medical Attention for Nephropathy
84.2
81.3
2.9
Controlling High Blood Pressure
64.8
58.9
6.0
140
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HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: COMMERCIAL HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
89.6
86.4
3.2
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
61.7
53.0
8.7
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
88.0
86.4
1.7
Use of Appropriate Medications for People With Asthma—5–11 Years
96.6
97.0
-0.5
Use of Appropriate Medications for People With Asthma—12–50 Years
91.9
91.4
0.5
Use of Appropriate Medications for People With Asthma—Overall Rate
92.9
92.7
0.2
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
42.2
40.1
2.1
Pharmacotherapy Management of COPD—Bronchodilators
77.4
79.4
-2.0
Pharmacotherapy Management of COPD—Systemic Corticosteroids
69.3
72.1
-2.8
Annual Monitoring for Patients on Persistent Medications—
ACE Inhibitors or ARBs
81.6
81.5
0.2
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
60.6
59.6
1.0
Annual Monitoring for Patients on Persistent Medications—Digoxin
84.7
84.4
0.3
Annual Monitoring for Patients on Persistent Medications—Diuretics
80.9
81.3
-0.4
Annual Monitoring for Patients on Persistent Medications—Combined
80.9
81.0
-0.1
Antidepressant Medication Management—Acute Phase
64.6
65.1
-0.5
Antidepressant Medication Management—Continuation Phase
48.1
49.1
-1.0
Follow-Up After Hospitalization for Mental Illness—
Within 7 Days Post-Discharge
60.2
57.6
2.6
Follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
77.9
75.1
2.8
Alcohol and Other Drug Dependence Treatment—Engagement
16.0
14.3
1.7
Alcohol and Other Drug Dependence Treatment—Initiation
42.9
42.0
0.9
Measures Targeted Toward Children and Adolescents
Appropriate Testing for Children With Pharyngitis
79.3
71.3
8.0
Appropriate Testing for Children With Upper Respiratory Infection
86.0
81.9
4.1
Childhood Immunization Status—DTaP/DT
87.6
81.4
6.2
Childhood Immunization Status—Hepatitis B
91.9
83.8
8.1
Childhood Immunization Status—HiB
95.5
89.8
5.7
Childhood Immunization Status—IPV
92.8
88.1
4.7
Childhood Immunization Status—MMR
91.3
89.0
2.3
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
86.9
80.7
6.3
Childhood Immunization Status—VZV
91.5
88.4
3.1
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
80.1
72.6
7.5
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141
HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: COMMERCIAL HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
76.5
69.4
7.1
Childhood Immunization Status—Hepatitis A
35.0
37.0
-2.1
Childhood Immunization Status—Rotavirus
63.8
62.1
1.7
Childhood Immunization Status—Influenza
58.1
53.5
4.6
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
18.9
17.3
1.6
Immunizations for Adolescents—Meningococcal
55.9
52.2
3.7
Immunizations for Adolescents—Tdap/Td
69.6
69.0
0.7
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
52.3
49.1
3.2
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
39.3
36.5
2.9
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.8
41.0
2.8
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
35.7
33.6
2.0
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
38.1
34.9
3.1
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
35.9
33.1
2.8
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
1.6
1.6
0.0
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.1
1.0
0.1
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
1.2
1.7
-0.4
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
2.1
2.6
-0.4
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
4.6
5.8
-1.2
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
12.3
14.7
-2.5
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
77.3
72.7
4.6
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
72.9
66.7
6.3
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
44.2
37.4
6.8
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
97.5
97.7
-0.2
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
91.4
90.4
1.1
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 Years
91.9
90.5
1.5
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
89.5
88.1
1.4
*Lower rates signify better performance.
142
nati o na l c o mmittee f o r qua l it y assurance
Appendi x 4B: Accredited vs . Nonaccredited
Plans: 2010 Co mmercial PPO Averages
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: COMMERCIAL PPO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Safety and Potential Waste
Imaging Studies for Low Back Pain
73.0
73.9
-1.0
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
21.3
21.2
0.1
Ambulatory Care—ED Visits per 1,000 Member Months
180.8
159.9
20.9
Adult BMI Assessment
11.5
12.0
-0.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
71.7
71.6
0.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
39.0
38.9
0.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
47.3
46.9
0.4
Flu Shots for Adults
51.8
51.2
0.6
Prenatal and Postpartum Care—Timeliness of Prenatal Care
72.5
82.2
-9.7
Prenatal and Postpartum Care—Postpartum Visit
Between 21 and 56 Days After Delivery
63.9
70.0
-6.1
Breast Cancer Screening
67.5
66.1
1.3
Cervical Cancer Screening
74.8
74.0
0.8
Colorectal Cancer Screening
49.1
44.2
4.9
Chlamydia Screening in Women—16–20 Years
38.1
38.1
0.0
Chlamydia Screening in Women—21–24 Years
41.7
42.4
-0.7
Chlamydia Screening in Women—Total Rate
39.9
40.2
-0.2
Persistence of Beta-Blocker Treatment After a Heart Attack
71.5
70.9
0.6
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
47.7
59.2
-11.5
Comprehensive Diabetes Care—Eye Exams
45.9
44.7
1.2
Comprehensive Diabetes Care—HbA1c Screening
84.5
86.7
-2.2
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
27.2
31.8
-4.6
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
48.0
55.2
-7.2
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
44.7
50.0
-5.3
Comprehensive Diabetes Care—LDL Cholesterol Screening
79.4
80.9
-1.6
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
35.7
41.2
-5.5
Comprehensive Diabetes Care—Medical Attention for Nephropathy
72.2
79.0
-6.8
Controlling High Blood Pressure
55.7
58.3
-2.6
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
80.6
82.8
-2.1
Wellness and Prevention
Chronic Disease Management
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
143
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: COMMERCIAL PPO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
42.1
53.5
-11.4
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
86.6
87.9
-1.2
Use of Appropriate Medications for People With Asthma—5–11 Years
96.8
97.5
-0.7
Use of Appropriate Medications for People With Asthma—12–50 Years
91.8
91.8
0.0
Use of Appropriate Medications for People With Asthma—Overall Rate
93.0
93.0
0.0
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
39.8
41.0
-1.1
Pharmacotherapy Management of COPD—Bronchodilators
75.1
70.2
4.8
Pharmacotherapy Management of COPD—Systemic Corticosteroids
66.9
64.7
2.2
Annual Monitoring for Patients on Persistent Medications—
ACE Inhibitors or ARBs
78.1
79.2
-1.1
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
57.3
59.3
-2.1
Annual Monitoring for Patients on Persistent Medications—Digoxin
79.2
78.9
0.3
Annual Monitoring for Patients on Persistent Medications—Diuretics
77.8
78.7
-0.9
Annual Monitoring for Patients on Persistent Medications—Combined
77.5
78.5
-1.0
Antidepressant Medication Management—Acute Phase
64.3
64.5
-0.3
Antidepressant Medication Management—Continuation Phase
48.0
48.2
-0.2
Follow-Up After Hospitalization for Mental Illness—
Within 7 Days Post-Discharge
56.3
49.8
6.5
Follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
75.0
72.4
2.6
Alcohol and Other Drug Dependence Treatment—Engagement
16.0
15.9
0.1
Alcohol and Other Drug Dependence Treatment—Initiation
40.5
41.5
-0.9
Measures Targeted Toward Children and Adolescents
Appropriate Testing for Children With Pharyngitis
76.5
77.0
-0.6
Appropriate Testing for Children With Upper Respiratory Infection
83.4
84.3
-1.0
Childhood Immunization Status—DTaP/DT
62.9
68.3
-5.3
Childhood Immunization Status—Hepatitis B
54.8
66.3
-11.5
Childhood Immunization Status—HiB
74.2
78.0
-3.8
Childhood Immunization Status—IPV
69.5
74.3
-4.8
Childhood Immunization Status—MMR
82.3
83.6
-1.3
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
64.1
68.7
-4.7
Childhood Immunization Status—VZV
81.5
83.5
-1.9
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
44.4
56.7
-12.3
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
42.2
54.0
-11.8
144
nati o na l c o mmittee f o r qua l it y assurance
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: COMMERCIAL PPO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Childhood Immunization Status—Hepatitis A
28.1
29.6
-1.4
Childhood Immunization Status—Rotavirus
49.9
55.9
-6.0
Childhood Immunization Status—Influenza
50.3
52.7
-2.4
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
9.5
12.0
-2.5
Immunizations for Adolescents—Meningococcal
43.7
43.8
-0.1
Immunizations for Adolescents—Tdap/Td
55.3
55.1
0.2
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
39.5
39.2
0.3
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
37.7
39.1
-1.4
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.5
42.7
0.8
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
10.9
11.2
-0.4
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
11.6
12.4
-0.8
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
10.4
10.9
-0.5
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
2.3
4.4
-2.1
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.3
2.0
-0.7
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
1.6
2.0
-0.4
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
2.6
3.0
-0.4
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
5.3
5.3
-0.1
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
13.3
12.2
1.1
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
73.6
71.0
2.6
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
68.2
66.9
1.3
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
39.5
38.6
1.0
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
97.3
96.2
1.0
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
89.6
88.0
1.5
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 Years
90.0
88.3
1.7
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
87.2
85.9
1.3
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
145
Appendix 5: Accredited vs. Nonaccredited
Plans: 2010 M edicaid HMO Averages
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: MEDICAID HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Safety and Potential Waste
Imaging Studies for Low Back Pain
74.9
76.0
-1.1
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
22.4
24.5
-2.2
Ambulatory Care—ED Visits per 1,000 Member Months
64.1
60.1
4.0
Adult BMI Assessment
45.6
38.1
7.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
74.3
72.7
1.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
39.5
37.1
2.4
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
44.0
40.8
3.2
Prenatal and Postpartum Care—Timeliness of Prenatal Care
85.2
82.4
2.8
Prenatal and Postpartum Care—Postpartum Visit
Between 21 and 56 Days After Delivery
65.2
63.7
1.4
Breast Cancer Screening
52.0
50.8
1.2
Cervical Cancer Screening
69.1
65.8
3.3
Chlamydia Screening in Women—16–20 Years
55.1
54.2
1.0
Chlamydia Screening in Women—21–24 Years
63.5
61.2
2.3
Chlamydia Screening in Women—Total Rate
58.2
56.8
1.4
Persistence of Beta-Blocker Treatment After a Heart Attack
77.4
74.1
3.3
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
62.0
59.1
2.9
Comprehensive Diabetes Care—Eye Exams
54.9
51.8
3.1
Comprehensive Diabetes Care—HbA1c Screening
83.0
81.3
1.8
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
35.8
33.2
2.6
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
48.8
45.5
3.3
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
41.5
45.8
-4.4
Comprehensive Diabetes Care—LDL Cholesterol Screening
76.3
73.5
2.8
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
36.8
32.9
3.9
Comprehensive Diabetes Care—Medical Attention for Nephropathy
79.2
76.5
2.6
Wellness and Prevention
Chronic Disease Management
Controlling High Blood Pressure
57.9
53.0
4.9
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
82.8
80.8
2.0
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
45.1
39.2
5.9
146
nati o na l c o mmittee f o r qua l it y assurance
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: MEDICAID HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
71.1
68.4
2.7
Use of Appropriate Medications for People With Asthma—5–11 Years
91.7
91.9
-0.2
Use of Appropriate Medications for People With Asthma—12–50 Years
85.8
85.8
0.0
Use of Appropriate Medications for People With Asthma—Overall Rate
88.4
88.4
0.0
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
30.4
32.9
-2.4
Pharmacotherapy Management of COPD—Bronchodilators
82.3
81.7
0.6
Pharmacotherapy Management of COPD—Systemic Corticosteroids
65.7
64.8
0.9
Annual Monitoring for Patients on Persistent Medications—
ACE Inhibitors or ARBs
86.3
85.7
0.6
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
67.9
67.5
0.4
Annual Monitoring for Patients on Persistent Medications—Digoxin
89.0
91.0
-2.1
Annual Monitoring for Patients on Persistent Medications—Diuretics
86.0
84.9
1.0
Annual Monitoring for Patients on Persistent Medications—Combined
83.9
83.8
0.1
Antidepressant Medication Management—Acute Phase
50.4
50.9
-0.5
Antidepressant Medication Management—Continuation Phase
33.5
35.1
-1.5
Follow-Up After Hospitalization for Mental Illness—
Within 7 Days Post-Discharge
48.2
41.8
6.4
Follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
66.8
61.4
5.4
Alcohol and Other Drug Dependence Treatment—Engagement
15.6
13.1
2.5
Alcohol and Other Drug Dependence Treatment—Initiation
47.2
39.5
7.7
Appropriate Testing for Children With Pharyngitis
63.9
65.9
-2.0
Appropriate Testing for Children With Upper Respiratory Infection
86.3
88.0
-1.7
Childhood Immunization Status—DTaP/DT
81.3
79.3
1.9
Childhood Immunization Status—Hepatitis B
91.0
89.3
1.7
Childhood Immunization Status—HiB
91.3
89.4
1.9
Childhood Immunization Status—IPV
91.6
90.2
1.5
Childhood Immunization Status—MMR
91.5
89.9
1.6
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
80.9
78.1
2.8
Childhood Immunization Status—VZV
91.1
89.2
1.9
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
75.8
72.6
3.2
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
71.6
68.5
3.1
Childhood Immunization Status—Hepatitis A
37.9
35.1
2.7
Childhood Immunization Status—Rotavirus
59.8
55.6
4.2
Measures Targeted Toward Children and Adolescents
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
147
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: MEDICAID HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Childhood Immunization Status—Influenza
45.0
42.2
2.7
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
16.6
13.9
2.7
Immunizations for Adolescents—Meningococcal
57.4
55.1
2.3
Immunizations for Adolescents—Tdap/Td
68.7
66.9
1.8
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
53.4
50.9
2.5
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
38.0
38.2
-0.1
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.1
45.0
-1.9
Lead Screening in Children
69.0
63.4
5.6
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
37.4
37.1
0.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
47.4
43.9
3.4
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
37.5
35.9
1.6
Frequency of Prenatal Care Visits—<21% of Expected Visits
9.3
11.6
-2.3
Frequency of Prenatal Care Visits—21–40% of Expected Visits
6.4
7.4
-1.1
Frequency of Prenatal Care Visits—41–60% of Expected Visits
7.8
8.4
-0.6
Frequency of Prenatal Care Visits—61–80% of Expected Visits
13.2
14.1
-0.9
Frequency of Prenatal Care Visits—>80% of Expected Visits
63.5
58.5
5.0
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
1.8
2.5
-0.7
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.9
2.4
-0.5
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
3.0
3.7
-0.7
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
5.3
6.1
-0.8
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
9.1
10.9
-1.8
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
14.8
17.2
-2.5
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
63.9
57.1
6.8
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
73.7
70.6
3.1
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
50.8
46.1
4.8
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
96.5
95.7
0.9
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
89.0
87.6
1.4
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 Years
90.5
89.9
0.6
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
88.3
88.0
0.2
*Lower rates signify better performance.
148
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Appendi x 6A: Accredited vs . No naccredited
Plans: 2010 M edicare HMO Averages
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: MEDICARE HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
362.5
501
-138.5
Safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months
Wellness and Prevention
Adult BMI Assessment
56.0
47.1
9.0
Breast Cancer Screening
72.1
66.3
5.7
Colorectal Cancer Screening
64.9
53.3
11.6
83.9
82.2
1.7
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
65.4
60.4
4.9
Comprehensive Diabetes Care—Eye Exams
70.0
61.4
8.6
Comprehensive Diabetes Care—HbA1c Screening
92.2
89.3
2.9
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
72.3
61.7
10.6
Chronic Disease Management
Persistence of Beta-Blocker Treatment After a Heart Attack
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
19.0
29.9
-10.9
Comprehensive Diabetes Care—LDL Cholesterol Screening
89.8
86.7
3.2
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
58.2
48.6
9.6
Comprehensive Diabetes Care—Medical Attention for Nephropathy
90.2
88.7
1.5
Controlling High Blood Pressure
66.5
59.1
7.4
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
90.6
87.2
3.4
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
63.5
52.5
11.0
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
76.4
70.2
6.1
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
37.5
31.4
6.1
Pharmacotherapy Management of COPD—Bronchodilators
78.5
78.1
0.4
Pharmacotherapy Management of COPD—Systemic Corticosteroids
69.6
64.6
5.0
Annual Monitoring for Patients on Persistent Medications—
ACE Inhibitors or ARBs
91.2
90.4
0.8
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
68.9
67.8
1.1
Annual Monitoring for Patients on Persistent Medications—Digoxin
93.7
92.7
0.9
Annual Monitoring for Patients on Persistent Medications—Diuretics
91.4
90.6
0.8
Annual Monitoring for Patients on Persistent Medications—Combined
90.9
89.7
1.2
Antidepressant Medication Management—Acute Phase
67.4
63.0
4.4
Antidepressant Medication Management—Continuation Phase
54.1
50.1
4.1
Follow-Up After Hospitalization for Mental Illness—
Within 7 Days Post-Discharge
44.7
32.5
12.2
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
149
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: MEDICARE HMO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
63.8
49.4
14.4
Alcohol and Other Drug Dependence Treatment—Engagement
4.2
3.4
0.8
Alcohol and Other Drug Dependence Treatment—Initiation
48.8
41.9
6.9
Fall Risk Management—Discussion
28.8
35.2
-6.3
Fall Risk Management—Management
58.0
61.3
-3.4
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
9.0
14.0
-4.9
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
24.2
31.6
-7.4
Potentially Harmful Drug-Disease Interactions in the Elderly—
Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
15.5
18.3
-2.8
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
19.9
25.3
-5.4
Use of High-Risk Medications in the Elderly—At Least One Medication*
18.6
24.1
-5.5
Measures Targeted Toward Older Adults
Use of High-Risk Medications in the Elderly—At Least Two Medications*
3.7
5.9
-2.2
Management of Urinary Incontinence—Discussion
57.3
58.8
-1.5
Management of Urinary Incontinence—Treatment
35.8
36.1
-0.2
Physical Activity in Older Adults—Advice
47.3
48.3
-1.0
Physical Activity in Older Adults—Discussion
53.3
51.8
1.6
Osteoporosis Testing in Older Women
73.0
65.9
7.1
Osteoporosis Management in Women Who Had a Fracture
23.5
18.5
5.0
Glaucoma Screening in Older Adults
67.0
61.9
5.1
* Lower rates signify better performance.
150
nati o na l c o mmittee f o r qua l it y assurance
Appendi x 6B: Accredited vs . Nonaccredited
Plans: 2010 M edicare PPO Averages
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: MEDICARE PPO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
382.8
377.9
4.9
Adult BMI Assessment
42.1
34.9
7.1
Breast Cancer Screening
66.7
65.5
1.2
Colorectal Cancer Screening
45.3
39.8
5.5
82.0
82.7
-0.7
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
61.3
53.9
7.4
Comprehensive Diabetes Care—Eye Exams
66.5
61.1
5.5
Comprehensive Diabetes Care—HbA1c Screening
91.7
90.2
1.5
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
68.2
54.3
13.9
Safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months
Wellness and Prevention
Chronic Disease Management
Persistence of Beta-Blocker Treatment After a Heart Attack
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
23.8
38.5
-14.6
Comprehensive Diabetes Care—LDL Cholesterol Screening
87.9
85.8
2.1
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
53.5
43.7
9.8
Comprehensive Diabetes Care—Medical Attention for Nephropathy
87.8
87.2
0.5
Controlling High Blood Pressure
61.7
53.9
7.9
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
88.3
86.7
1.6
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
57.9
48.3
9.6
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
79.2
77.4
1.8
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
32.4
36.5
-4.1
Pharmacotherapy Management of COPD—Bronchodilators
77.5
75.7
1.8
Pharmacotherapy Management of COPD—Systemic Corticosteroids
66.9
70.3
-3.4
Annual Monitoring for Patients on Persistent Medications—
ACE Inhibitors or ARBs
90.4
90.9
-0.5
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
68.0
69.4
-1.3
Annual Monitoring for Patients on Persistent Medications—Digoxin
93.0
92.6
0.4
Annual Monitoring for Patients on Persistent Medications—Diuretics
91.0
91.3
-0.3
Annual Monitoring for Patients on Persistent Medications—Combined
90.3
90.7
-0.4
Antidepressant Medication Management—Acute Phase
65.9
67.9
-2.0
Antidepressant Medication Management—Continuation Phase
55.0
55.9
-0.9
Follow-Up After Hospitalization for Mental Illness—
Within 7 Days Post-Discharge
42.1
38.2
3.9
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
151
�HEDIS EFFECTIVENESS OF CARE MEASURES
ACCREDITED VS. NONACCREDITED PLANS: MEDICARE PPO AVERAGES—2010
MEASURE
ACCREDITED
NONACCREDITED
DIFFERENCE
Follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
63.1
60.7
2.4
Alcohol and Other Drug Dependence Treatment—Engagement
4.4
4.9
-0.4
Alcohol and Other Drug Dependence Treatment—Initiation
50.3
59.4
-9.1
Fall Risk Management—Discussion
30.1
31.3
-1.3
Fall Risk Management—Management
55.8
55.2
0.6
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
9.5
12.5
-2.9
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
24.0
28.5
-4.5
Potentially Harmful Drug-Disease Interactions in the Elderly—Falls
and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
14.0
17.1
-3.1
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
19.1
22.7
-3.6
Use of High-Risk Medications in the Elderly—At Least One Medication*
19.7
22.5
-2.8
Measures Targeted Toward Older Adults
Use of High-Risk Medications in the Elderly—At Least Two Medications*
4.3
5.3
-1.0
Management of Urinary Incontinence—Discussion
57.1
58.1
-1.0
Management of Urinary Incontinence—Treatment
37.1
36.1
1.0
Physical Activity in Older Adults—Advice
48.5
47.3
1.1
Physical Activity in Older Adults—Discussion
55.6
53.4
2.2
Osteoporosis Testing in Older Women
75.0
73.0
2.0
Osteoporosis Management in Women Who Had a Fracture
19.5
18.1
1.4
Glaucoma Screening in Older Adults
65.2
65.1
0.2
*Lower rates signify better performance.
152
nati o na l c o mmittee f o r qua l it y assurance
Appendi x 7A: Publicly Reporting vs. No npub licly
Reporting Plans: 2010 Commercial HM Os
�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
COMMERCIAL HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
74.4
72.7
1.7
Safety and Potential Waste
Imaging Studies for Low Back Pain
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
22.4
24.1
-1.7
Ambulatory Care—ED Visits per 1,000 Member Months
186.9
192.3
-5.4
Adult BMI Assessment
40.8
38.5
2.3
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
76.8
75.2
1.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
45.2
43.0
2.3
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
52.5
51.0
1.5
Wellness and Prevention
Flu Shots for Adults
52.3
54.4
-2.1
Prenatal and Postpartum Care—Timeliness of Prenatal Care
91.8
83.3
8.5
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
81.6
72.7
9.0
Breast Cancer Screening
71.1
68.6
2.5
Cervical Cancer Screening
77.3
73.6
3.8
Colorectal Cancer Screening
63.1
58.7
4.4
Chlamydia Screening in Women—16–20 Years
41.3
36.6
4.7
Chlamydia Screening in Women—21–24 Years
46.2
41.4
4.8
Chlamydia Screening in Women—Total Rate
43.6
39.1
4.5
Persistence of Beta-Blocker Treatment After a Heart Attack
75.6
75.0
0.6
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
66.0
62.6
3.5
Comprehensive Diabetes Care—Eye Exams
58.5
51.9
6.6
Comprehensive Diabetes Care—HbA1c Screening
90.1
88.5
1.6
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
42.8
38.7
4.1
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
62.8
58.1
4.7
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
26.8
31.6
-4.8
Comprehensive Diabetes Care—LDL Cholesterol Screening
85.7
84.3
1.4
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
48.0
45.4
2.6
Comprehensive Diabetes Care—Medical Attention for Nephropathy
83.9
80.8
3.1
Controlling High Blood Pressure
63.8
59.6
4.3
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
89.3
85.5
3.7
Chronic Disease Management
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
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�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
COMMERCIAL HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
60.8
51.0
9.8
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
87.8
86.9
0.8
Use of Appropriate Medications for People With Asthma—5–11 Years
96.7
96.7
0.0
Use of Appropriate Medications for People With Asthma—12–50 Years
91.7
92.1
-0.4
Use of Appropriate Medications for People With Asthma—Overall Rate
92.8
93.3
-0.5
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
42.0
37.9
4.1
Pharmacotherapy Management of COPD—Bronchodilators
77.6
80.1
-2.5
Pharmacotherapy Management of COPD—Systemic Corticosteroids
69.6
72.2
-2.5
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
81.7
80.6
1.1
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
60.4
59.7
0.7
Annual Monitoring for Patients on Persistent Medications—Digoxin
84.4
87.5
-3.0
Annual Monitoring for Patients on Persistent Medications—Diuretics
81.0
81.0
0.0
Annual Monitoring for Patients on Persistent Medications—Combined
81.0
80.4
0.6
Antidepressant Medication Management—Acute Phase
64.6
66.0
-1.4
Antidepressant Medication Management—Continuation Phase
48.2
49.4
-1.1
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
59.9
57.0
2.9
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
77.5
75.2
2.3
Alcohol and Other Drug Dependence Treatment—Engagement
15.9
12.4
3.5
Alcohol and Other Drug Dependence Treatment—Initiation
43.2
37.4
5.7
Appropriate Testing for Children With Pharyngitis
78.8
67.7
11.1
Appropriate Testing for Children With Upper Respiratory Infection
85.5
81.4
4.1
Childhood Immunization Status—DTaP/DT
87.3
77.4
9.9
Measures Targeted Toward Children and Adolescents
Childhood Immunization Status—Hepatitis B
91.6
77.4
14.2
Childhood Immunization Status—HiB
95.2
86.1
9.1
Childhood Immunization Status—IPV
92.7
83.8
8.9
Childhood Immunization Status—MMR
91.2
87.5
3.7
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
86.7
76.2
10.5
Childhood Immunization Status—VZV
91.3
87.0
4.2
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
79.6
68.7
10.9
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
76.0
65.6
10.4
Childhood Immunization Status—Hepatitis A
35.2
36.8
-1.6
154
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�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
COMMERCIAL HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
Childhood Immunization Status—Rotavirus
63.8
60.9
2.9
Childhood Immunization Status—Influenza
58.0
49.4
8.7
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
18.7
16.7
2.0
Immunizations for Adolescents—Meningococcal
55.2
54.2
1.0
Immunizations for Adolescents—Tdap/Td
69.6
67.7
2.0
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
51.7
51.2
0.4
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
39.1
34.3
4.8
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.7
37.6
6.2
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI percentile (Overall)
35.5
32.3
3.2
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
37.6
35.1
2.4
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
35.6
31.9
3.6
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
1.6
1.8
-0.2
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.1
0.6
0.5
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
1.3
1.8
-0.5
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
2.2
2.4
-0.2
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
4.8
5.7
-1.0
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
12.5
15.9
-3.5
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
76.8
71.7
5.2
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
72.4
64.5
7.8
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
43.5
35.7
7.8
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
97.5
97.1
0.5
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
91.4
89.3
2.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
91.9
89.3
2.6
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
89.5
86.9
2.6
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
155
Appendix 7B: Public ly R eporting vs . No npub licly
Reporting Plans: 2010 Commercial PPOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
COMMERCIAL PPO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
73.2
77.8
-4.6
Safety and Potential Waste
Imaging Studies for Low Back Pain
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
21.3
19.5
1.8
Ambulatory Care—ED Visits per 1,000 Member Months
175.1
131.7
43.3
Adult BMI Assessment
11.4
16.1
-4.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
71.7
71.7
0.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
39.0
35.2
3.8
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
47.3
41.6
5.7
Flu Shots for Adults
51.7
47.3
4.4
Prenatal and Postpartum Care—Timeliness of Prenatal Care
76.1
62.0
14.1
Wellness and Prevention
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
65.9
68.1
-2.2
Breast Cancer Screening
67.1
63.9
3.2
Cervical Cancer Screening
74.5
73.1
1.5
Colorectal Cancer Screening
47.8
39.0
8.8
Chlamydia Screening in Women—16–20 Years
38.3
31.1
7.2
Chlamydia Screening in Women—21–24 Years
42.1
34.1
8.0
Chlamydia Screening in Women—Total Rate
40.2
32.8
7.4
Persistence of Beta-Blocker Treatment After a Heart Attack
71.3
69.5
1.8
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
51.6
37.7
13.9
Comprehensive Diabetes Care—Eye Exams
45.6
43.9
1.7
Comprehensive Diabetes Care—HbA1c Screening
85.4
80.1
5.2
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
28.1
29.7
-1.6
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
50.6
36.1
14.5
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
46.3
58.6
-12.3
Comprehensive Diabetes Care—LDL Cholesterol Screening
80.0
75.7
4.3
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
37.7
25.3
12.4
Comprehensive Diabetes Care—Medical Attention for Nephropathy
74.3
76.0
-1.6
Controlling High Blood Pressure
57.0
46.0
11.0
Chronic Disease Management
156
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�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
COMMERCIAL PPO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
81.4
78.1
3.3
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
45.6
32.2
13.3
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
87.0
88.2
-1.3
Use of Appropriate Medications for People With Asthma—5–11 Years
97.1
95.8
1.3
Use of Appropriate Medications for People With Asthma—12–50 Years
91.8
90.4
1.4
Use of Appropriate Medications for People With Asthma—Overall Rate
93.1
91.6
1.4
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
40.2
37.5
2.7
Pharmacotherapy Management of COPD—Bronchodilators
73.4
76.8
-3.4
Pharmacotherapy Management of COPD—Systemic Corticosteroids
66.3
59.2
7.1
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
78.4
77.6
0.8
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
57.9
60.5
-2.6
Annual Monitoring for Patients on Persistent Medications—Digoxin
79.1
82.1
-3.1
Annual Monitoring for Patients on Persistent Medications—Diuretics
78.1
77.3
0.8
Annual Monitoring for Patients on Persistent Medications—Combined
77.9
76.9
1.0
Antidepressant Medication Management—Acute Phase
64.5
60.3
4.2
Antidepressant Medication Management—Continuation Phase
48.2
43.6
4.5
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
54.3
50.2
4.0
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
74.4
64.6
9.7
Alcohol and Other Drug Dependence Treatment—Engagement
16.0
12.8
3.2
Alcohol and Other Drug Dependence Treatment—Initiation
40.9
40.1
0.8
Appropriate Testing for Children With Pharyngitis
76.9
66.9
9.9
Appropriate Testing for Children With Upper Respiratory Infection
83.7
81.5
2.3
Measures Targeted Toward Children and Adolescents
Childhood Immunization Status—DTaP/DT
65.0
52.8
12.2
Childhood Immunization Status—Hepatitis B
59.0
46.0
13.0
Childhood Immunization Status—HiB
75.8
61.5
14.3
Childhood Immunization Status—IPV
71.5
57.4
14.0
Childhood Immunization Status—MMR
82.9
76.7
6.1
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
65.9
52.5
13.5
Childhood Immunization Status—VZV
82.4
74.8
7.6
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
48.5
46.7
1.8
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�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
COMMERCIAL PPO AVERAGES—2010
MEASURE
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
PUBLIC
NONPUBLIC
DIFFERENCE
46.1
44.9
1.2
Childhood Immunization Status—Hepatitis A
28.6
30.2
-1.6
Childhood Immunization Status—Rotavirus
52.3
38.5
13.7
Childhood Immunization Status—Influenza
51.3
42.7
8.6
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
10.3
12.3
-1.9
Immunizations for Adolescents—Meningococcal
44.1
32.5
11.6
Immunizations for Adolescents—Tdap/Td
55.5
46.5
9.0
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
39.7
29.6
10.1
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
38.0
41.2
-3.2
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.2
47.5
-4.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI percentile (Overall)
10.8
15.5
-4.7
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
11.8
10.5
1.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
10.5
12.4
-1.9
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
2.9
6.3
-3.5
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.5
1.8
-0.2
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
1.7
2.8
-1.1
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
2.6
6.1
-3.5
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
5.2
9.1
-3.9
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
13.0
14.0
-1.1
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
73.1
59.9
13.2
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
68.1
56.8
11.3
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
39.5
28.2
11.3
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
97.0
92.4
4.7
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
89.2
82.6
6.7
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
89.6
82.5
7.1
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
86.9
83.2
3.7
* Lower rates signify better performance.
158
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Appendi x 8: Publ ic ly R eporting vs. Nonpub licly
Reporting Plans: 2010 Medicaid HMOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
MEDICAID HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
75.1
76.4
-1.3
Safety and Potential Waste
Imaging Studies for Low Back Pain
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
23.1
24.4
-1.3
Ambulatory Care—ED Visits per 1,000 Member Months
62.2
61.4
0.8
Adult BMI Assessment
45.5
34.1
11.4
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
74.0
72.7
1.3
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
39.1
36.9
2.2
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
43.7
40.0
3.7
Prenatal and Postpartum Care—Timeliness of Prenatal Care
85.2
80.4
4.8
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
65.2
62.5
2.7
Wellness and Prevention
Breast Cancer Screening
51.2
51.6
-0.4
Cervical Cancer Screening
67.6
66.3
1.3
Chlamydia Screening in Women—16–20 Years
55.1
53.8
1.2
Chlamydia Screening in Women—21–24 Years
62.3
62.2
0.1
Chlamydia Screening in Women—Total Rate
57.7
57.0
0.8
Persistence of Beta-Blocker Treatment After a Heart Attack
77.6
69.9
7.7
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
61.6
57.6
4.0
Comprehensive Diabetes Care—Eye Exams
53.4
52.4
1.1
Comprehensive Diabetes Care—HbA1c Screening
82.8
80.4
2.3
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
35.9
30.6
5.3
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
48.3
43.9
4.4
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
42.4
47.4
-5.0
Comprehensive Diabetes Care—LDL Cholesterol Screening
75.0
74.1
0.9
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
35.7
32.1
3.6
Comprehensive Diabetes Care—Medical Attention for Nephropathy
78.2
76.4
1.9
Controlling High Blood Pressure
56.9
52.2
4.7
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
82.7
79.9
2.8
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
44.6
36.7
7.9
Chronic Disease Management
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
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�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
MEDICAID HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
70.6
68.7
1.9
Use of Appropriate Medications for People With Asthma—5–11 Years
91.8
91.8
0.0
Use of Appropriate Medications for People With Asthma—12–50 Years
85.8
85.9
-0.2
Use of Appropriate Medications for People With Asthma—Overall Rate
88.5
88.1
0.4
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
30.4
34.2
-3.8
Pharmacotherapy Management of COPD—Bronchodilators
82.5
81.1
1.4
Pharmacotherapy Management of COPD—Systemic Corticosteroids
65.4
65.2
0.2
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
86.3
85.5
0.8
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
68.4
66.1
2.4
Annual Monitoring for Patients on Persistent Medications—Digoxin
89.3
91.1
-1.8
Annual Monitoring for Patients on Persistent Medications—Diuretics
85.9
84.6
1.2
Annual Monitoring for Patients on Persistent Medications—Combined
84.0
83.6
0.4
Antidepressant Medication Management—Acute Phase
50.0
52.0
-1.9
Antidepressant Medication Management—Continuation Phase
33.5
36.0
-2.5
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
45.9
42.0
3.9
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
65.2
61.1
4.1
Alcohol and Other Drug Dependence Treatment—Engagement
14.8
13.3
1.4
Alcohol and Other Drug Dependence Treatment—Initiation
44.5
40.5
4.1
64.3
66.1
-1.8
Measures Targeted Toward Children and Adolescents
Appropriate Testing for Children With Pharyngitis
Appropriate Testing for Children With Upper Respiratory Infection
86.9
87.8
-0.9
Childhood Immunization Status—DTaP/DT
80.4
79.7
0.7
Childhood Immunization Status—Hepatitis B
90.9
88.1
2.8
Childhood Immunization Status—HiB
90.7
89.1
1.7
Childhood Immunization Status—IPV
91.3
89.7
1.6
Childhood Immunization Status—MMR
91.2
89.4
1.8
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
80.0
77.7
2.3
Childhood Immunization Status—VZV
90.6
88.8
1.7
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
74.8
72.5
2.3
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
70.7
67.9
2.8
Childhood Immunization Status—Hepatitis A
37.4
34.1
3.3
Childhood Immunization Status—Rotavirus
58.7
55.0
3.7
Childhood Immunization Status—Influenza
43.9
42.6
1.3
160
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�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
MEDICAID HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
16.0
13.3
2.8
Immunizations for Adolescents—Meningococcal
56.9
54.9
2.1
Immunizations for Adolescents—Tdap/Td
67.5
68.5
-1.0
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
52.9
50.6
2.3
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
38.8
36.7
2.1
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
45.0
41.3
3.7
Lead Screening in Children
66.7
65.1
1.7
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI percentile (Overall)
38.8
33.6
5.2
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
48.2
39.1
9.1
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
38.2
32.8
5.5
Frequency of Prenatal Care Visits—<21% of Expected Visits
8.8
14.3
-5.4
Frequency of Prenatal Care Visits—21–40% of Expected Visits
6.1
8.8
-2.7
Frequency of Prenatal Care Visits—41–60% of Expected Visits
7.6
9.3
-1.7
Frequency of Prenatal Care Visits—61–80% of Expected Visits
13.3
14.3
-1.0
Frequency of Prenatal Care Visits—>80% of Expected Visits
64.2
53.3
10.9
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
2.1
2.3
-0.2
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
2.1
2.3
-0.2
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
3.3
3.5
-0.2
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
5.7
5.8
-0.2
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
9.7
10.8
-1.2
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
15.5
17.3
-1.8
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
61.4
57.5
4.0
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
72.2
71.2
0.9
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
48.9
46.2
2.7
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
96.0
96.2
-0.2
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
88.1
88.6
-0.5
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
90.2
90.2
0.0
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
88.1
88.2
-0.1
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
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Appendix 9A: Public ly R eporting vs. No npub licly
Reporting Plans: 2010 M edicare HMOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
MEDICARE HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
412.5
611.4
-198.8
Adult BMI Assessment
53.4
37.6
15.8
Breast Cancer Screening
69.8
62.8
7.0
Colorectal Cancer Screening
59.6
49.0
10.6
Persistence of Beta-Blocker Treatment After a Heart Attack
83.2
82.4
0.8
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
63.5
56.7
6.9
Comprehensive Diabetes Care—Eye Exams
65.9
58.6
7.4
Comprehensive Diabetes Care—HbA1c Screening
91.3
86.5
4.7
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
67.9
55.6
12.3
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
23.6
36.2
-12.5
Comprehensive Diabetes Care—LDL Cholesterol Screening
88.5
84.9
3.6
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
53.7
44.7
9.0
Comprehensive Diabetes Care—Medical Attention for Nephropathy
89.7
87.2
2.5
Controlling High Blood Pressure
63.2
56.0
7.2
Cholesterol Management for Patients with Cardiovascular Conditions—
LDL Cholesterol Screening
89.2
85.8
3.4
Cholesterol Management for Patients with Cardiovascular Conditions—
LDL Control (<100 mg/dL)
58.6
48.4
10.2
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
73.9
66.3
7.5
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
35.1
28.2
6.9
Pharmacotherapy Management of COPD—Bronchodilators
78.2
78.3
-0.1
Pharmacotherapy Management of COPD—Systemic Corticosteroids
67.8
61.0
6.8
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
91.2
88.5
2.6
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
68.2
68.2
0.0
Annual Monitoring for Patients on Persistent Medications—Digoxin
93.2
92.8
0.3
Annual Monitoring for Patients on Persistent Medications—Diuretics
91.4
88.8
2.6
Annual Monitoring for Patients on Persistent Medications—Combined
90.7
87.7
3.0
Antidepressant Medication Management—Acute Phase
66.0
58.6
7.3
Safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months
Wellness and Prevention
Chronic Disease Management
Antidepressant Medication Management—Continuation Phase
52.7
47.1
5.5
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
38.9
30.0
8.9
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
56.6
48.6
8.0
162
nati o na l c o mmittee f o r qua l it y assurance
�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
MEDICARE HMO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
Alcohol and Other Drug Dependence Treatment—Engagement
3.8
3.5
0.3
Alcohol and Other Drug Dependence Treatment—Initiation
45.4
41.1
4.3
Fall Risk Management—Discussion
31.3
38.9
-7.6
Fall Risk Management—Management
59.1
64.3
-5.2
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
10.6
18.4
-7.8
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
27.5
33.9
-6.4
Potentially Harmful Drug-Disease Interactions in the Elderly—
Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
16.6
19.5
-2.9
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
22.2
27.7
-5.4
Use of High-Risk Medications in the Elderly—At Least One Medication*
21.2
26.1
-4.9
Measures Targeted Toward Older Adults
Use of High-Risk Medications in the Elderly—At Least Two Medications*
4.8
6.7
-2.0
Management of Urinary Incontinence—Discussion
57.8
60.3
-2.5
Management of Urinary Incontinence—Treatment
36.0
36.0
-0.1
Physical Activity in Older Adults—Advice
47.8
48.6
-0.9
Physical Activity in Older Adults—Discussion
52.8
50.6
2.2
Osteoporosis Testing in Older Women
69.8
63.2
6.6
Osteoporosis Management in Women Who Had a Fracture
21.6
15.9
5.7
Glaucoma Screening in Older Adults
65.0
58.5
6.5
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
163
Appendix 9B: Public ly R eporting vs . No npub licly
Reporting Plans: 2010 M edicare PPOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
MEDICARE PPO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
372.3
428.3
-56.0
Adult BMI Assessment
37.7
27.2
10.6
Breast Cancer Screening
65.8
65.7
0.0
Colorectal Cancer Screening
41.3
38.9
2.4
Persistence of Beta-Blocker Treatment After a Heart Attack
83.2
78.7
4.5
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
57.2
43.5
13.7
Comprehensive Diabetes Care—Eye Exams
63.0
57.0
5.9
Comprehensive Diabetes Care—HbA1c Screening
90.9
87.9
3.1
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
59.1
43.8
15.3
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
33.1
51.0
-17.9
Comprehensive Diabetes Care—LDL Cholesterol Screening
86.5
84.6
1.9
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
46.6
40.3
6.3
Comprehensive Diabetes Care—Medical Attention for Nephropathy
87.4
87.1
0.3
Controlling High Blood Pressure
56.2
51.2
5.0
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
87.1
87.3
-0.2
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
51.3
43.9
7.4
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
78.1
75.9
2.2
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
35.3
34.7
0.6
Pharmacotherapy Management of COPD—Bronchodilators
76.7
71.5
5.2
Pharmacotherapy Management of COPD—Systemic Corticosteroids
70.1
66.3
3.8
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
90.8
90.8
0.0
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
69.2
67.6
1.6
Annual Monitoring for Patients on Persistent Medications—Digoxin
92.8
91.4
1.5
Annual Monitoring for Patients on Persistent Medications—Diuretics
91.2
91.2
0.1
Annual Monitoring for Patients on Persistent Medications—Combined
90.6
90.6
0.0
Antidepressant Medication Management—Acute Phase
67.2
68.5
-1.3
Safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months
Wellness and Prevention
Chronic Disease Management
Antidepressant Medication Management—Continuation Phase
55.5
56.9
-1.4
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
40.7
28.6
12.2
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
62.3
54.2
8.1
164
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�HEDIS EFFECTIVENESS OF CARE MEASURES
PUBLICLY REPORTING VS. NONPUBLICLY REPORTING PLANS:
MEDICARE PPO AVERAGES—2010
MEASURE
PUBLIC
NONPUBLIC
DIFFERENCE
Alcohol and Other Drug Dependence Treatment—Engagement
4.6
6.2
-1.6
Alcohol and Other Drug Dependence Treatment—Initiation
57.8
53.3
4.5
Fall Risk Management—Discussion
31.0
31.6
-0.6
Fall Risk Management—Management
55.5
54.2
1.3
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
10.8
19.1
-8.3
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
27.0
29.9
-2.9
Potentially Harmful Drug-Disease Interactions in the Elderly—
Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
16.1
18.0
-1.9
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
21.4
25.6
-4.2
Use of High-Risk Medications in the Elderly—At Least One Medication*
21.8
22.1
-0.2
Measures Targeted Toward Older Adults
Use of High-Risk Medications in the Elderly—At Least Two Medications*
5.0
5.3
-0.3
Management of Urinary Incontinence—Discussion
58.1
56.3
1.8
Management of Urinary Incontinence—Treatment
36.6
34.3
2.3
Physical Activity in Older Adults—Advice
47.5
48.7
-1.3
Physical Activity in Older Adults—Discussion
54.1
52.0
2.1
Osteoporosis Testing in Older Women
73.5
73.2
0.2
Osteoporosis Management in Women Who Had a Fracture
18.7
16.7
2.0
Glaucoma Screening in Older Adults
65.0
66.2
-1.3
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
165
Appendix 10: HMOs vs. PPOs , Commercial Plans
�HEDIS EFFECTIVENESS OF CARE MEASURES
HMOS VS. PPOS: COMMERCIAL AVERAGES—2010
MEASURE
HMO
PPO
DIFFERENCE
Safety and Potential Waste
Imaging Studies for Low Back Pain
74.2
73.3
-0.9
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
22.5
21.3
-1.2
Ambulatory Care—ED Visits per 1,000 Member Months
187.4
174
-13.4
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
76.7
71.7
-5.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
45.0
39.0
-6.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
52.4
47.2
-5.1
Wellness and Prevention
Flu Shots for Adults
52.5
51.6
-0.9
Breast Cancer Screening
70.8
67.0
-3.8
Cervical Cancer Screening
77.0
74.5
-2.4
Chlamydia Screening in Women—16–20 Years
40.8
38.1
-2.7
Chlamydia Screening in Women—21–24 Years
45.7
41.9
-3.8
Chlamydia Screening in Women—Total Rate
43.1
40.0
-3.1
Chronic Disease Management
Persistence of Beta-Blocker Treatment After a Heart Attack
75.5
71.3
-4.2
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
87.7
87.0
-0.7
Use of Appropriate Medications for People With Asthma—5–11 Years
96.7
97.0
0.4
Use of Appropriate Medications for People With Asthma—12–50 Years
91.8
91.8
0.0
Use of Appropriate Medications for People With Asthma—Overall Rate
92.9
93.0
0.2
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
41.7
40.2
-1.5
Pharmacotherapy Management of COPD—Bronchodilators
77.8
73.5
-4.3
Pharmacotherapy Management of COPD—Systemic Corticosteroids
69.8
66.2
-3.7
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
81.6
78.4
-3.2
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
60.4
57.9
-2.5
Annual Monitoring for Patients on Persistent Medications—Digoxin
84.6
79.1
-5.5
Annual Monitoring for Patients on Persistent Medications—Diuretics
81.0
78.1
-2.9
Annual Monitoring for Patients on Persistent Medications—Combined
80.9
77.8
-3.1
Antidepressant Medication Management—Acute Phase
64.7
64.3
-0.4
Antidepressant Medication Management—Continuation Phase
48.3
48.1
-0.3
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
59.7
54.2
-5.6
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
77.4
74.1
-3.2
Alcohol and Other Drug Dependence Treatment—Engagement
15.6
16.0
0.3
166
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�HEDIS EFFECTIVENESS OF CARE MEASURES
HMOS VS. PPOS: COMMERCIAL AVERAGES—2010
MEASURE
HMO
PPO
DIFFERENCE
Alcohol and Other Drug Dependence Treatment—Initiation
42.7
40.8
-1.9
Appropriate Testing for Children With Pharyngitis
77.6
76.6
-0.9
Appropriate Testing for Children With Upper Respiratory Infection
85.1
83.7
-1.4
Measures Targeted Toward Children and Adolescents
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
38.8
38.1
-0.7
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
43.4
43.3
-0.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
1.6
2.9
1.4
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
1.1
1.5
0.5
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
1.3
1.7
0.4
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
2.2
2.7
0.5
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
4.9
5.3
0.4
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
12.8
13.0
0.2
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
76.3
72.8
-3.6
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
71.6
67.8
-3.8
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
42.7
39.2
-3.5
Children and Adolescents’ Access to Primary Care Practitioners—Children 12–24 Months
97.5
96.9
-0.6
Children and Adolescents’ Access to Primary Care Practitioners—Children 25 Months–6 Years
91.2
89.1
-2.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
91.6
89.4
-2.2
Children and Adolescents’ Access to Primary Care Practitioners—Adolescents 12–19 Years
89.2
86.8
-2.4
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
167
Appendix 11: HMOs vs. PPOs , M edicare Plans
�HEDIS EFFECTIVENESS OF CARE MEASURES
HMOS VS. PPOS: MEDICARE AVERAGES—2010
MEASURE
HMO
PPO
DIFFERENCE
450.3
379
-71.2
68.5
65.8
-2.7
83.1
82.5
-0.6
Safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months
Wellness and Prevention
Breast Cancer Screening
Chronic Disease Management
Persistence of Beta-Blocker Treatment After a Heart Attack
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
72.8
77.8
5.1
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
33.9
35.3
1.4
Pharmacotherapy Management of COPD—Bronchodilators
78.2
76.1
-2.2
Pharmacotherapy Management of COPD—Systemic Corticosteroids
66.6
69.6
3.0
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
90.7
90.8
0.1
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
68.2
69.1
0.9
Annual Monitoring for Patients on Persistent Medications—Digoxin
93.1
92.7
-0.5
Annual Monitoring for Patients on Persistent Medications—Diuretics
90.9
91.2
0.4
Annual Monitoring for Patients on Persistent Medications—Combined
90.2
90.6
0.5
Antidepressant Medication Management—Acute Phase
65.0
67.4
2.4
Antidepressant Medication Management—Continuation Phase
51.9
55.7
3.8
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
37.4
39.1
1.6
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
55.4
61.2
5.8
Alcohol and Other Drug Dependence Treatment—Engagement
3.7
4.8
1.0
Alcohol and Other Drug Dependence Treatment—Initiation
44.6
57.4
12.8
Measures Targeted Toward Older Adults
Fall Risk Management—Discussion
32.8
31.1
-1.8
Fall Risk Management—Management
60.1
55.3
-4.8
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
11.6
11.7
0.1
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
28.7
27.3
-1.4
Potentially Harmful Drug-Disease Interactions in the Elderly—
Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
17.1
16.3
-0.9
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
23.3
21.8
-1.4
Use of High-Risk Medications in the Elderly—At Least One Medication*
22.1
21.9
-0.2
Use of High-Risk Medications in the Elderly—At Least Two Medications*
5.1
5.1
-0.1
Management of Urinary Incontinence—Discussion
58.2
57.9
-0.4
Management of Urinary Incontinence—Treatment
36.0
36.3
0.4
Physical Activity in Older Adults—Advice
47.9
47.6
-0.3
168
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�HEDIS EFFECTIVENESS OF CARE MEASURES
HMOS VS. PPOS: MEDICARE AVERAGES—2010
MEASURE
HMO
PPO
DIFFERENCE
Physical Activity in Older Adults—Discussion
52.3
53.9
1.5
Osteoporosis Testing in Older Women
68.5
73.4
4.9
Osteoporosis Management in Women Who Had a Fracture
20.7
18.5
-2.2
Glaucoma Screening in Older Adults
63.8
65.1
1.3
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
169
Appendix 12: HMOs vs. PPOs , Commercial Plans
�CAHPS MEMBER SATISFACTION MEASURES
HMOS VS. PPOS: COMMERCIAL AVERAGES—2010
MEASURE
HMO
PPO
DIFFERENCE
Consumer and Patient Engagement and Experience
Rating of Health Plan—Rating of 8, 9 or 10
64.2
58.6
-5.6
Rating of Health Plan—Rating of 9 or 10
40.3
33.7
-6.6
Rating of Health Care—Rating of 8, 9 or 10
76.6
75.6
-1.0
Rating of Health Care—Rating of 9 or 10
50.7
48.1
-2.6
Getting Needed Care—Usually or Always
86.2
86.6
0.4
Getting Needed Care—Always
53.9
53.9
0.0
Getting Care Quickly—Usually or Always
86.5
87.1
0.7
Getting Care Quickly—Always
58.2
57.7
-0.5
How Well Doctors Communicate—Usually or Always
93.9
94.6
0.7
How Well Doctors Communicate—Always
73.5
73.5
0.0
Rating of Personal Doctor—Rating of 8, 9 or 10
83.2
82.8
-0.4
Rating of Personal Doctor—Rating of 9 or 10
65.0
62.8
-2.2
Rating of Specialist—Rating of 8, 9 or 10
82.3
81.6
-0.7
Rating of Specialist—Rating of 9 or 10
64.1
61.9
-2.2
Customer Service—Usually or Always
84.5
83.0
-1.4
Customer Service—Always
59.4
55.5
-3.9
Claims Processing—Usually or Always
88.6
87.8
-0.8
Claims Processing—Always
55.5
50.7
-4.7
170
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Appendi x 13: HMOs vs. PPOs , M edicare Plans
�CAHPS MEMBER SATISFACTION MEASURES
HMOS VS. PPOS: MEDICARE AVERAGES—2010
MEASURE
HMO
PPO
DIFFERENCE
Consumer and Patient Engagement and Experience
Information not available for the October 2011 pre-publication edition of this report. Information will appear in the November 2011 final edition.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
171
Appendix 14A: Variation in Plan Performance: The 90th
Percentile vs. The 10th Percentile: Commercial HMOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
COMMERCIAL HMO STATISTICS—2010
MEASURE
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
82.0
66.4
15.6
Safety and Potential Waste
Imaging Studies for Low Back Pain
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
31.6
15.0
16.6
Ambulatory Care—ED Visits per 1,000 Member Months
231.8
139.9
91.8
Adult BMI Assessment
76.9
1.2
75.7
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
85.2
67.2
18.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
59.0
33.6
25.4
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
63.2
42.6
20.5
Flu Shots for Adults
62.4
43.9
18.6
Prenatal and Postpartum Care—Timeliness of Prenatal Care
97.8
81.3
16.5
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
90.7
66.7
24.0
Breast Cancer Screening
79.5
63.3
16.2
Cervical Cancer Screening
83.2
71.0
12.2
Colorectal Cancer Screening
74.2
48.9
25.3
Chlamydia Screening in Women—16–20 Years
53.9
29.3
24.5
Chlamydia Screening in Women—21–24 Years
61.4
32.6
28.9
Chlamydia Screening in Women—Total Rate
56.7
30.6
26.1
Persistence of Beta-Blocker Treatment After a Heart Attack
87.5
64.1
23.4
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
75.9
52.4
23.5
Comprehensive Diabetes Care—Eye Exams
75.3
40.4
34.9
Comprehensive Diabetes Care—HbA1c Screening
94.2
85.6
8.5
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
51.0
34.3
16.7
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
72.0
52.3
19.7
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
16.8
37.8
-21.0
Comprehensive Diabetes Care—LDL Cholesterol Screening
91.0
80.0
11.0
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
57.2
37.2
20.0
Comprehensive Diabetes Care—Medical Attention for Nephropathy
89.6
76.9
12.6
Controlling High Blood Pressure
74.1
51.3
22.8
Wellness and Prevention
Chronic Disease Management
172
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�HEDIS EFFECTIVENESS OF CARE MEASURES
COMMERCIAL HMO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
93.7
84.7
9.0
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
72.0
48.1
23.9
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
93.7
81.4
12.2
Use of Appropriate Medications for People With Asthma—5–11 Years
99.2
94.1
5.1
Use of Appropriate Medications for People With Asthma—12–50 Years
95.0
88.1
6.9
Use of Appropriate Medications for People With Asthma—Overall Rate
95.7
89.9
5.8
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
52.2
31.2
21.0
Pharmacotherapy Management of COPD—Bronchodilators
86.5
67.5
19.0
Pharmacotherapy Management of COPD—Systemic Corticosteroids
78.4
60.0
18.4
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
86.5
77.0
9.6
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
70.0
52.4
17.6
Annual Monitoring for Patients on Persistent Medications—Digoxin
92.9
75.0
17.9
Annual Monitoring for Patients on Persistent Medications—Diuretics
86.1
76.0
10.1
Annual Monitoring for Patients on Persistent Medications—Combined
85.9
76.0
9.9
Antidepressant Medication Management—Acute Phase
73.5
56.3
17.3
Antidepressant Medication Management—Continuation Phase
56.7
39.1
17.6
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
75.0
43.7
31.3
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
88.5
66.2
22.3
Alcohol and Other Drug Dependence Treatment—Engagement
22.8
8.3
14.5
Alcohol and Other Drug Dependence Treatment—Initiation
52.9
32.0
20.8
Appropriate Testing for Children With Pharyngitis
90.5
62.8
27.7
Appropriate Testing for Children With Upper Respiratory Infection
94.5
75.4
19.1
Childhood Immunization Status—DTaP/DT
92.5
80.5
12.0
Childhood Immunization Status—Hepatitis B
95.9
84.9
11.0
Childhood Immunization Status—HiB
97.8
90.9
6.9
Childhood Immunization Status—IPV
96.4
87.4
9.1
Childhood Immunization Status—MMR
94.9
86.7
8.3
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
92.0
79.8
12.2
Childhood Immunization Status—VZV
94.6
87.4
7.3
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
86.6
69.9
16.7
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
84.9
65.2
19.7
MEASURE
Measures Targeted Toward Children and Adolescents
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
173
�HEDIS EFFECTIVENESS OF CARE MEASURES
COMMERCIAL HMO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Childhood Immunization Status—Hepatitis A
54.6
20.0
34.6
Childhood Immunization Status—Rotavirus
78.8
47.0
31.8
Childhood Immunization Status—Influenza
70.1
41.8
28.2
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
30.9
8.3
22.6
Immunizations for Adolescents—Meningococcal
77.7
35.9
41.7
Immunizations for Adolescents—Tdap/Td
91.9
46.1
45.8
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
75.2
30.6
44.6
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
49.0
30.7
18.4
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
55.6
31.3
24.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
75.9
0.2
75.7
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
74.1
0.2
73.9
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
70.1
0.0
70.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
3.6
0.0
3.6
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
2.0
0.0
2.0
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
2.5
0.0
2.5
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
3.9
0.4
3.5
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
8.3
1.9
6.4
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
21.7
5.9
15.9
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
89.6
61.1
28.6
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
84.5
56.9
27.7
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
60.2
28.5
31.7
Children and Adolescents' Access to Primary Care Practitioners—
Children 12–24 Months
99.4
95.4
4.0
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
95.7
86.2
9.4
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 Years
96.7
86.8
9.9
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
95.1
83.5
11.6
MEASURE
*Lower rates signify better performance.
174
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Appendix 14B: Variation in Plan Performance: The 90th
Percentile vs. The 10th Percentile: Commercial PPOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
COMMERCIAL PPO STATISTICS—2010
MEASURE
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
80.6
65.4
15.2
Safety and Potential Waste
Imaging Studies for Low Back Pain
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
27.1
15.9
11.2
Ambulatory Care—ED Visits per 1,000 Member Months
208.8
133.3
75.6
Adult BMI Assessment
47.3
0.8
46.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
79.8
65.3
14.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
47.0
32.6
14.4
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
55.6
38.8
16.7
Flu Shots for Adults
57.9
45.3
12.6
Prenatal and Postpartum Care—Timeliness of Prenatal Care
96.0
41.6
54.4
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
87.1
36.2
50.9
Breast Cancer Screening
72.5
62.2
10.3
Cervical Cancer Screening
79.0
69.2
9.8
Colorectal Cancer Screening
55.3
41.1
14.2
Chlamydia Screening in Women—16–20 Years
48.2
29.5
18.7
Chlamydia Screening in Women—21–24 Years
55.2
30.6
24.6
Chlamydia Screening in Women—Total Rate
51.0
29.9
21.0
Persistence of Beta-Blocker Treatment After a Heart Attack
79.9
62.3
17.6
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
71.3
0.8
70.5
Comprehensive Diabetes Care—Eye Exams
59.0
31.5
27.4
Comprehensive Diabetes Care—HbA1c Screening
91.0
77.4
13.6
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
45.0
4.5
40.4
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
67.2
12.5
54.7
Wellness and Prevention
Chronic Disease Management
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
23.8
92.7
-68.8
Comprehensive Diabetes Care—LDL Cholesterol Screening
87.1
70.2
16.9
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
50.7
11.7
39.0
Comprehensive Diabetes Care—Medical Attention for Nephropathy
84.4
57.6
26.8
Controlling High Blood Pressure
67.6
42.6
25.1
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
89.9
68.2
21.7
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
175
�HEDIS EFFECTIVENESS OF CARE MEASURES
COMMERCIAL PPO STATISTICS—2010
MEASURE
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
64.5
9.8
54.7
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
91.8
81.0
10.8
Use of Appropriate Medications for People With Asthma—5–11 Years
99.0
95.0
4.0
Use of Appropriate Medications for People With Asthma—12–50 Years
94.0
88.9
5.1
Use of Appropriate Medications for People With Asthma—Overall Rate
95.4
90.6
4.7
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
48.5
32.8
15.7
Pharmacotherapy Management of COPD—Bronchodilators
84.4
63.6
20.7
Pharmacotherapy Management of COPD—Systemic Corticosteroids
78.7
52.5
26.1
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
83.0
73.0
10.0
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
64.5
50.8
13.8
Annual Monitoring for Patients on Persistent Medications—Digoxin
85.9
71.0
14.9
Annual Monitoring for Patients on Persistent Medications—Diuretics
83.1
72.9
10.2
Annual Monitoring for Patients on Persistent Medications—Combined
82.6
72.5
10.1
Antidepressant Medication Management—Acute Phase
69.6
59.6
10.0
Antidepressant Medication Management—Continuation Phase
54.8
42.2
12.5
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
68.0
40.1
28.0
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
84.2
63.3
20.9
Alcohol and Other Drug Dependence Treatment—Engagement
21.6
10.8
10.9
Alcohol and Other Drug Dependence Treatment—Initiation
47.0
33.8
13.2
Appropriate Testing for Children With Pharyngitis
88.3
63.4
24.9
Appropriate Testing for Children With Upper Respiratory Infection
92.1
74.1
18.0
Childhood Immunization Status—DTaP/DT
86.6
38.8
47.8
Childhood Immunization Status—Hepatitis B
91.0
24.6
66.4
Childhood Immunization Status—HiB
95.4
53.3
42.1
Childhood Immunization Status—IPV
92.2
46.6
45.6
Childhood Immunization Status—MMR
91.5
70.6
20.8
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
86.9
41.2
45.7
Childhood Immunization Status—VZV
91.9
70.2
21.7
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
78.5
18.5
59.9
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
75.0
17.2
57.8
Childhood Immunization Status—Hepatitis A
37.9
17.7
20.2
Measures Targeted Toward Children and Adolescents
176
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�HEDIS EFFECTIVENESS OF CARE MEASURES
COMMERCIAL PPO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Childhood Immunization Status—Rotavirus
70.6
33.6
37.0
Childhood Immunization Status—Influenza
65.2
35.4
29.8
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
19.9
3.3
16.5
Immunizations for Adolescents—Meningococcal
63.7
26.6
37.1
Immunizations for Adolescents—Tdap/Td
77.0
37.6
39.4
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
58.4
24.5
33.8
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
44.9
31.7
13.2
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
52.7
34.4
18.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
46.3
0.1
46.2
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
54.3
0.2
54.0
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
48.2
0.0
48.2
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
5.3
0.9
4.3
MEASURE
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
2.6
0.5
2.0
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
2.8
0.7
2.1
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
4.3
1.3
3.0
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
7.5
2.7
4.9
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
18.1
7.8
10.3
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
82.7
60.1
22.6
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
82.5
51.9
30.6
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
57.7
24.4
33.2
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
98.7
94.8
3.9
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
94.3
83.1
11.2
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
95.4
81.6
13.8
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
93.7
80.4
13.3
*Lower rates signify better performance.
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
177
Appendix 15: Variation in Plan Performance: The 90th
Percentile vs. The 10th Percentile: Medicaid HMOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
MEDICAID HMO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Imaging Studies for Low Back Pain
82.3
67.0
15.2
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
31.6
15.1
16.5
Ambulatory Care—ED Visits per 1,000 Member Months
76.6
44.4
32.2
Adult BMI Assessment
70.5
3.2
67.2
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
80.8
64.7
16.1
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
48.5
30.0
18.4
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
55.0
30.2
24.7
Prenatal and Postpartum Care—Timeliness of Prenatal Care
93.3
71.4
21.9
Prenatal and Postpartum Care—Postpartum Visit Between 21 and 56 Days After Delivery
75.2
53.7
21.5
Breast Cancer Screening
62.9
38.7
24.3
Cervical Cancer Screening
78.7
53.0
25.6
Chlamydia Screening in Women—16–20 Years
66.7
42.9
23.8
Chlamydia Screening in Women—21–24 Years
72.2
50.5
21.6
Chlamydia Screening in Women—Total Rate
69.1
46.0
23.0
Persistence of Beta-Blocker Treatment After a Heart Attack
88.6
61.0
27.5
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
76.0
43.8
32.2
Comprehensive Diabetes Care—Eye Exams
70.6
34.0
36.7
Comprehensive Diabetes Care—HbA1c Screening
90.9
73.6
17.3
Comprehensive Diabetes Care—Good Glycemic Control
(HbA1c <7% for a Selected Population)
44.4
23.6
20.8
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
59.1
33.8
25.4
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
29.1
60.4
-31.2
Comprehensive Diabetes Care—LDL Cholesterol Screening
84.2
63.7
20.5
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
45.9
21.5
24.4
Comprehensive Diabetes Care—Medical Attention for Nephropathy
86.9
68.1
18.7
Controlling High Blood Pressure
67.6
42.1
25.5
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
89.1
74.4
14.6
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
57.1
28.9
28.3
MEASURE
Safety and Potential Waste
Wellness and Prevention
Chronic Disease Management
178
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�HEDIS EFFECTIVENESS OF CARE MEASURES
MEDICAID HMO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
83.2
53.3
29.8
Use of Appropriate Medications for People With Asthma—5–11 Years
96.0
87.5
8.5
Use of Appropriate Medications for People With Asthma—12–50 Years
91.3
79.8
11.4
Use of Appropriate Medications for People With Asthma—Overall Rate
93.2
83.6
9.6
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
47.2
19.1
28.0
Pharmacotherapy Management of COPD—Bronchodilators
89.3
71.1
18.2
Pharmacotherapy Management of COPD—Systemic Corticosteroids
76.8
46.5
30.3
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
90.6
79.9
10.7
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
76.6
57.6
19.0
Annual Monitoring for Patients on Persistent Medications—Digoxin
95.5
80.4
15.1
Annual Monitoring for Patients on Persistent Medications—Diuretics
90.7
79.3
11.3
Annual Monitoring for Patients on Persistent Medications—Combined
88.1
78.3
9.9
Antidepressant Medication Management—Acute Phase
59.9
43.0
16.9
Antidepressant Medication Management—Continuation Phase
44.2
25.7
18.5
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
68.3
23.0
45.3
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
82.6
36.0
46.6
Alcohol and Other Drug Dependence Treatment—Engagement
25.9
2.0
23.9
Alcohol and Other Drug Dependence Treatment—Initiation
60.7
30.0
30.7
Appropriate Testing for Children With Pharyngitis
83.0
45.1
37.9
Appropriate Testing for Children With Upper Respiratory Infection
94.8
79.2
15.6
Childhood Immunization Status—DTaP/DT
88.5
70.8
17.7
Childhood Immunization Status—Hepatitis B
95.9
82.9
13.0
Childhood Immunization Status—HiB
96.1
84.3
11.8
Childhood Immunization Status—IPV
95.9
85.6
10.2
Childhood Immunization Status—MMR
95.4
86.1
9.3
Childhood Immunization Status—Pneumococcal Conjugate (PCV)
88.8
68.8
20.0
Childhood Immunization Status—VZV
95.1
85.4
9.7
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, HiB, Hepatitis B and VZV)
85.8
62.3
23.6
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV)
82.6
56.8
25.8
Childhood Immunization Status—Hepatitis A
48.7
24.3
24.4
Childhood Immunization Status—Rotavirus
72.2
43.6
28.7
Childhood Immunization Status—Influenza
60.3
22.0
38.3
MEASURE
Measures Targeted Toward Children and Adolescents
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
179
�HEDIS EFFECTIVENESS OF CARE MEASURES
MEDICAID HMO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza)
23.6
6.3
17.3
Immunizations for Adolescents—Meningococcal
79.7
38.0
41.7
Immunizations for Adolescents—Tdap/Td
87.8
45.3
42.5
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td)
75.5
33.8
41.7
Follow-Up Care for Children Prescribed ADHD Medication—Initiation
50.7
24.9
25.8
Follow-Up Care for Children Prescribed ADHD Medication—Continuation
62.5
23.0
39.5
Lead Screening in Children
87.6
34.6
53.0
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—BMI Percentile (Overall)
69.8
0.7
69.1
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (Overall)
72.0
0.7
71.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (Overall)
60.6
0.0
60.5
Frequency of Prenatal Care Visits—<21% of Expected Visits
19.1
1.8
17.3
Frequency of Prenatal Care Visits—21–40% of Expected Visits
13.8
1.9
11.9
Frequency of Prenatal Care Visits—41–60% of Expected Visits
14.2
4.0
10.3
Frequency of Prenatal Care Visits—61–80% of Expected Visits
19.7
7.1
12.7
Frequency of Prenatal Care Visits—>80% of Expected Visits
81.8
34.7
47.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits
4.4
0.5
3.9
Well-Child Visits: Ages 0–15 Months—One Well-Child Visit
4.1
0.7
3.4
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits
6.1
1.1
5.0
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits
9.3
2.7
6.6
Well-Child Visits: Ages 0–15 Months—Four Well-Child Visits
15.6
5.3
10.3
Well-Child Visits: Ages 0–15 Months—Five Well-Child Visits
21.9
8.3
13.6
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits
77.1
41.9
35.2
Well-Child Visits: Ages 3–6 Years—One or More Well-Child Visits
82.9
60.9
22.0
Adolescent Well-Care Visits—At Least One Comprehensive Well-Care Visit
64.1
35.0
29.1
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
98.6
92.6
6.0
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 Years
92.7
82.0
10.7
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 Years
94.7
85.2
9.5
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 Years
93.4
81.1
12.4
MEASURE
*Lower rates signify better performance.
180
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Appendix 16A: Variation in Plan Performance: The
90th Percentile vs. The 10th Percentile: Medicare HMOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
MEDICARE HMO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
782.1
248.3
533.8
Adult BMI Assessment
80.2
16.8
63.4
Breast Cancer Screening
80.9
55.5
25.4
Colorectal Cancer Screening
75.6
40.0
35.5
Persistence of Beta-Blocker Treatment After a Heart Attack
91.6
72.4
19.2
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
75.1
48.5
26.6
Comprehensive Diabetes Care—Eye Exams
79.3
49.7
29.6
Comprehensive Diabetes Care—HbA1c Screening
95.9
84.0
12.0
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
80.2
47.8
32.4
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
11.3
45.0
-33.7
Comprehensive Diabetes Care—LDL Cholesterol Screening
94.1
81.3
12.8
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
65.4
37.0
28.4
Comprehensive Diabetes Care—Medical Attention for Nephropathy
93.9
84.7
9.2
Controlling High Blood Pressure
74.4
47.7
26.7
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
94.4
81.2
13.2
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
72.2
40.6
31.5
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
85.0
58.4
26.6
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
46.9
20.5
26.4
Pharmacotherapy Management of COPD—Bronchodilators
87.2
67.5
19.7
Pharmacotherapy Management of COPD—Systemic Corticosteroids
76.8
53.6
23.2
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
94.9
86.1
8.8
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
81.3
56.4
24.8
Annual Monitoring for Patients on Persistent Medications—Digoxin
97.0
88.4
8.6
Annual Monitoring for Patients on Persistent Medications—Diuretics
95.1
86.2
8.8
Annual Monitoring for Patients on Persistent Medications—Combined
94.5
85.9
8.6
Antidepressant Medication Management—Acute Phase
77.4
51.8
25.7
Antidepressant Medication Management—Continuation Phase
65.6
35.8
29.8
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
66.0
13.5
52.5
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
80.2
25.3
55.0
MEASURE
Safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months
Wellness and Prevention
Chronic Disease Management
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
181
�HEDIS EFFECTIVENESS OF CARE MEASURES
MEDICARE HMO STATISTICS—2010
MEASURE
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Alcohol and Other Drug Dependence Treatment—Engagement
7.9
0.4
7.5
Alcohol and Other Drug Dependence Treatment—Initiation
63.3
25.0
38.3
Fall Risk Management—Discussion
44.4
25.8
18.7
Fall Risk Management—Management
69.8
51.6
18.2
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
5.0
23.0
-18.0
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
18.8
41.3
-22.5
Potentially Harmful Drug-Disease Interactions in the Elderly—
Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
11.9
23.4
-11.5
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
15.8
32.4
-16.6
Use of High-Risk Medications in the Elderly—At Least One Medication*
13.2
33.1
-19.8
Use of High-Risk Medications in the Elderly—At Least Two Medications*
1.6
9.8
-8.1
Management of Urinary Incontinence—Discussion
64.3
50.9
13.4
Management of Urinary Incontinence—Treatment
41.1
30.7
10.3
Physical Activity in Older Adults—Advice
54.5
41.7
12.8
Physical Activity in Older Adults—Discussion
60.3
44.7
15.6
Osteoporosis Testing in Older Women
80.6
54.4
26.2
Osteoporosis Management in Women Who Had a Fracture
29.8
12.0
17.9
Glaucoma Screening in Older Adults
77.9
48.0
29.9
Measures Targeted Toward Older Adults
*Lower rates signify better performance.
182
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Appendix 16B: Variation in Plan Performance: The
90th Percentile vs. The 10th Percentile: Medicare PPOs
�HEDIS EFFECTIVENESS OF CARE MEASURES
MEDICARE PPO STATISTICS—2010
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
506.7
266.8
239.9
Adult BMI Assessment
64.0
2.8
61.2
Breast Cancer Screening
77.5
54.1
23.4
Colorectal Cancer Screening
53.4
31.1
22.3
Persistence of Beta-Blocker Treatment After a Heart Attack
89.9
72.1
17.8
Comprehensive Diabetes Care—Blood Pressure Control (<140/90 mm Hg)
70.6
39.4
31.2
Comprehensive Diabetes Care—Eye Exams
75.8
49.6
26.2
Comprehensive Diabetes Care—HbA1c Screening
94.9
85.9
9.0
Comprehensive Diabetes Care—Good Glycemic Control (HbA1c <8%)
76.1
31.7
44.4
Comprehensive Diabetes Care—Poor Glycemic Control (HbA1c >9%)*
15.3
63.5
-48.2
Comprehensive Diabetes Care—LDL Cholesterol Screening
92.0
80.8
11.2
Comprehensive Diabetes Care—LDL Cholesterol Control (<100 mg/dL)
60.3
29.0
31.4
Comprehensive Diabetes Care—Medical Attention for Nephropathy
91.2
83.5
7.7
Controlling High Blood Pressure
69.0
41.6
27.4
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Cholesterol Screening
92.5
81.1
11.4
Cholesterol Management for Patients With Cardiovascular Conditions—
LDL Control (<100 mg/dL)
65.2
34.9
30.3
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
85.7
67.9
17.7
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
45.8
23.7
22.1
Pharmacotherapy Management of COPD—Bronchodilators
84.4
67.2
17.3
Pharmacotherapy Management of COPD—Systemic Corticosteroids
79.0
60.9
18.2
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARBs
93.6
87.6
6.0
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants
83.6
57.6
25.9
Annual Monitoring for Patients on Persistent Medications—Digoxin
96.8
89.3
7.5
Annual Monitoring for Patients on Persistent Medications—Diuretics
94.0
87.9
6.2
Annual Monitoring for Patients on Persistent Medications—Combined
93.3
87.4
5.9
Antidepressant Medication Management—Acute Phase
77.6
55.6
22.1
Antidepressant Medication Management—Continuation Phase
66.3
42.7
23.6
Follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge
63.8
21.1
42.8
Follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge
78.7
47.2
31.6
MEASURE
Safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months
Wellness and Prevention
Chronic Disease Management
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • A P P E N D I C E S
183
�HEDIS EFFECTIVENESS OF CARE MEASURES
MEDICARE PPO STATISTICS—2010
MEASURE
90TH
PERCENTILE
10TH
PERCENTILE
DIFFERENCE
Alcohol and Other Drug Dependence Treatment—Engagement
8.7
1.3
7.4
Alcohol and Other Drug Dependence Treatment—Initiation
80.7
35.5
45.2
Fall Risk Management—Discussion
39.9
25.2
14.6
Fall Risk Management—Management
65.9
46.6
19.3
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS*
4.3
20.0
-15.7
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
17.7
38.3
-20.5
Potentially Harmful Drug-Disease Interactions in the Elderly—
Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
10.5
22.2
-11.7
Potentially Harmful Drug-Disease Interactions in the Elderly—Overall Rate*
15.0
29.8
-14.8
Use of High-Risk Medications in the Elderly—At Least One Medication*
14.9
30.4
-15.5
Use of High-Risk Medications in the Elderly—At Least Two Medications*
1.9
8.4
-6.5
Management of Urinary Incontinence—Discussion
65.6
51.5
14.1
Management of Urinary Incontinence—Treatment
42.1
31.1
10.9
Physical Activity in Older Adults—Advice
52.7
41.6
11.1
Physical Activity in Older Adults—Discussion
59.6
47.1
12.5
Osteoporosis Testing in Older Women
82.8
62.0
20.8
Osteoporosis Management in Women Who Had a Fracture
25.7
10.3
15.5
Glaucoma Screening in Older Adults
76.1
53.8
22.3
Measures Targeted Toward Older Adults
*Lower rates signify better performance.
184
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Re ferences
AVOIDANCE OF ANTIBIOTIC TREATMENT IN ADULTS WITH ACUTE BRONCHITIS
1. Grijalva C.G., J.P. Nuorti, M. Griffin. 2009. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings.
JAMA. 302: 758–66.
2. Gonzales, R., et al. 2001. Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis: Background. Ann
Intern Med. 134:521–9.
3. Irwin, R.S., et al. 2006. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 1S–292S.
4. Evertsen, J., D.J. Baumgardner, A. Regnery, I. Banerjee. 2010. Diagnosis and management of pneumonia and bronchitis in outpatient
primary care practices. Prim Care Respir J. 19(3):237–41.
5. Centers for Disease Control and Prevention. 2010. Appropriate Antibiotic Use – Saves lives, saves money, makes sense.
http://www.cdc.gov/getsmart/healthcare/resources/factsheets/pdf/antibiotic-use.pdf (May 27, 2011)
6. Tan, T., et al. 2008. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ.
337:a437.
7. Steinman, M.A., A. Sauaia, J.H. Maselli, P.M. Houck, R. Gonzales. 2004. Office evaluation and treatment of elderly patients with acute
bronchitis. J Am Geriatr Soc. 52(6):875–9.
8. Braman, S.S. 2006. Diagnosis and management of cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 129:1S–23S.
USE OF IMAGING STUDIES FOR LOWER BACK PAIN
1. American Association of Neurological Surgeons. June 2006. Low Back Pain. http://www.aans.org/Patient%20Information/
Conditions%20and%20Treatments/Low%20Back%20Pain.aspx (May 2011)
2. National Institute of Arthritis and Musculoskeletal and Skin Disease. July 2010. Back Pain. http://www.niams.nih.gov/Health_Info/
Back_Pain/default.asp (May 2011)
3. Manek, N.J., A.J. MacGregor. 2005. Epidemiology of Back Disorders: Prevalence, Risk Factors, and Prognosis. Current Opinion in
Rheumatology, 17(2): 134–40.
4. Koes, B.W., M.W. van Tulder, S. Thomas. 2006. Diagnosis and Treatment of Low Back Pain. BMJ 332(7555):1430–434.
5. Jarvik, J.G., W. Hollingworth, B. Martin, S.S. Emerson, D.T. Gray, T.S. Overman, et al. 2003. Rapid Magnetic Resonance Imaging vs
Radiographs for Patients with Low Back Pain: a Randomized Controlled Trial. JAMA 289(21):2810–18.
6. ARHQ, U.S. Department of Health and Human Services, 2008. Medical Expenditure Panel Survey (MEPS).
http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&tableSeries=2&year=1&SearchMethod=1&Action=Search. (May 2011).
7. Chou, R., A. Qaseem, D.K. Owens, P. Shekelle. 2011. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From
the American College of Physicians. Annals of Internal Medicine 154: 181–9.
8. Ivanova, J. I., H. G. Birnbaum, M. Schiller, E. Kantor, B.M. Johnstone, R.W. Swindle. May 19, 2011. Real-world Practice Patterns,
Health-care Utilization, and Cost in Patients with Low Back Pain: The Long Road to Guideline-concordant Care. Spine Journal.
ADULT BMI ASSESSMENT
1. American Medical Association. 2011. Promoting Healthy Lifestyles: Obesity. http://www.ama-assn.org/ama/pub/physician-resources/
public-health/promoting-healthy-lifestyles/obesity.page (June 13, 2011)
2. Centers for Disease Control and Prevention. 2010. Overweight and Obesity: Defining Overweight and Obesity. http://www.cdc.gov/
obesity/defining.html (July 13, 2011)
3. National Heart Lung and Blood Institute. 2011. Assessing Your Weight and Health Risk. http://www.nhlbi.nih.gov/health/public/heart/
obesity/lose_wt/risk.htm (June 13, 2011)
4. Weight-control Information Network. 2010. Statistics Related to Overweight and Obesity. NIDDK and NIH. http://win.niddk.nih.gov/
statistics/index.htm (June 13, 2011)
5. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Causes and Consequences. http://www.cdc.gov/obesity/
causes/index.html (June 13, 2011)
6. RTI International. 2011. About RTI. http://www.rti.org/page.cfm/About_RTI (June 22, 2011)
7. Finkelstein, E.A., J.G. Trogdon, J.W. Cohen and W. Dietz. Annual Medical Spending Attributable to Obesity: Payer and Service-Specific
Estimates. 2009. Health Affairs. 28(5); w822–w831.
8. Weight-control Information Network. 2008. Understanding Adult Obesity. NIDDK and NIH. http://win.niddk.nih.gov/publications/
understanding.htm#consequences (June 13, 2011).
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • R e f erences
185
FLU SHOTS FOR ADULTS
1. Centers for Disease Control and Prevention. Seasonal Influence (Flu). Updated September 15, 2010. http://www.cdc.gov/flu/about/qa/
disease.htm (May 2011)
2. Centers for Disease Control and Prevention. Seasonal Flu Shot. Updated February 8, 2011. http://www.cdc.gov/flu/about/qa/flushot.
htm#whoshould (July 2011)
3. Centers for Disease Control and Prevention. 2008. Prevention and Control of Influenza Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 57:1–60
4. Centers for Disease Control and Prevention. Key Facts About Influenza (Flu) & Flu Vaccine. Updated September 15, 2010.
http://www.cdc.gov/flu/keyfacts.htm#preventingseasonal (May, 2011)
5. Nichol, K.L. 2003. The efficacy, effectiveness and cost-effectiveness of inactivated influenza virus vaccines. Vaccine 21(16):1769–75.
6. Centers for Disease Control and Prevention. National Immunization Survey: Summer 2007. http://www.cdc.gov/vaccines/stats-surv/nis/
downloads/nis-adult-summer-2007.pdf (May 2011)
7. Centers for Disease Control and Prevention. 2009. Influenza Vaccination Coverage Among Children and Adults—United States,
2008–2009 Influenza Season. MMWR Morb Mortal Wkly Rep 58(39): 1091–5.
8. National Foundation for Infectious Diseases. Facts About Influenza for Adults. Updated January 2010. http://www.nfid.org/pdf/
factsheets/influadult.pdf (May 2011)
9. Maciosek, M.V., L.I. Solberg, A.B. Coffield, N.M. Edwards, M.J. Goodman. Influenza vaccination health impact and cost effectiveness
among adults aged 50 to 64 and 65 and older. Am J Prev Med 2006; 31(1):72–9.
10. Akazawa, M., J.L. Sindelar, A.D. Paltiel. 2003. Economic costs of influenza-related work absenteeism. Value Health 6(2):107–15.
PRENATAL AND POSTpARTUM CARE & FREQUENCY OF ONGOING PRENATAL CARE
1. Agency for Healthcare Research and Quality (AHRQ). 2011. Complicating Conditions of Pregnancy and Childbirth, 2008: Statistical
Brief. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.pdf (June 6, 2011)
2. Centers for Disease Control and Prevention. Reproductive Health: Data and Statistics. http://www.cdc.gov/reproductivehealth/Data_
Stats/index.htm (June 6, 2011)
3. Health Resources and Services Administration. Maternal Morbidity and Risk Factors in Pregnancy. http://mchb.hrsa.gov/whusa10/hstat/
mh/pages/236mmrfp.html (June 6, 2011)
4. Collins, J.L., J. Lehnherr, S.F. Posner, K.E. Toomey. 2009.Ties That Bind: Maternal and Child Health and Chronic Disease Prevention at the
Centers for Disease Control and Prevention. http://www.cdc.gov/pcd/issues/2009/jan/08_0233.htm (June 6, 2011)
5. Weir, S., H.E. Posner, J. Zhang, G. Willis, J.D. Baxter, R.E. Clark. Predictors of Prenatal and Postpartum Care Adequacy in a Medicaid
Managed Care Population. http://www.sciencedirect.com/science/article/pii/S1049386711000454 (June 6, 2011)
6. Dietz P.M., K.K. Vesco, W.M. Callaghan, D.J. Bachman, F.C. Bruce, C.J. Berg, et al. 2008. Postpartum screening for diabetes after a
gestational diabetes mellitus-affected pregnancy. Obstetrics & Gynecology 112(4):868–74.
7. Deave, T., J. Heron, J. Evans, A. Emond. 2008. The impact of maternal depression in pregnancy on early child development. International
Journal of Obstetrics and Gynaecology 115(8):1043–51.
8. Vintzileos, A., C. Ananth, J.C. Smulian, W.E. Scorza, R.A. Knuppel. 2002. The Impact of Prenatal Care on Post-Neonatal Deaths in the
Presence and Absence of Antenatal High-risk Conditions. American Journal of Obstetrics and Gynecology; 187(5): 1258–62.
9. March of Dimes Foundation. PeriStats: Distribution of Prenatal Care Adequacy Categories. http://www.marchofdimes.com/peristats/
(June 2011)
10. Agency for Healthcare Research and Quality. Health Care Innovations Exchange: Group Visits Focused on Prenatal Care and Parenting
Improve Birth Outcomes and Provider Efficiency. http://www.innovations.ahrq.gov/content.aspx?id=1909 (June 2011)
BREAST CANCER SCREENING
1. BreastCancer.org. 2011. U.S. Breast Cancer Statistics. http://www.breastcancer.org/symptoms/understand_bc/statistics.jsp (June 10,
2011)
2. American Cancer Society. 2011. Cancer Facts & Figures 2011. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/
documents/document/acspc-026238.pdf (May 29, 2011)
3. Mandelblatt J.S., K.A. Cronin, S. Bailey, D.A. Berry, H.J. de Koning, G. Draisma, et al. 2009. Effects of mammography screening under
different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. 151:738–47.
4. BreastCancer.org. 2011. Facts and Figures about Breast Cancer http://www.breastcancer.org/about_us/press_room/facts_figures.jsp
(June 10, 2011)
5. National Business Group on Health. 2011. Pathways to Managing Cancer in the Workplace. http://www.businessgrouphealth.org/pdfs/
FINAL_Pathways_Managing_Cancer_2011.pdf (June 10, 2011)
6. Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force. 2009. Annals of Internal Medicine.151:738–47.
http://www.annals.org/content/151/10/727.full.pdf+html (May 29, 2011)
7. American Cancer Society. 2010. Breast cancer facts and figures 2010-2011. http://www.cancer.org/acs/groups/content/@nho/
documents/document/f861009final90809pdf.pdf (May 29, 2011)
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CERVICAL CANCER SCREENING
1. American Cancer Society. 2011. Cancer Prevention & Early Detection Facts & Figures 2011. http://www.cancer.org/acs/groups/
content/@epidemiologysurveilance/documents/document/acspc-029459.pdf (May 29, 2011)
2. Myers, E. 2008. The current and future role of screening in the era of HPV vaccination. Gynecologic Oncology 109.2.S31.
3. National Cervical Cancer Collation. Early Detection. http://www.nccc-online.org/health_news/early_detection.html (June 10, 2011)
4. Centers for Disease Control and Prevention. 2010. Cervical Cancer. http://www.cdc.gov/cancer/cervical/pdf/Cervical_FS_0510.pdf
(June 10, 2011)
COLORECTAL CANCER SCREENING
1. National Cancer Institute. SEER Statistical Fact Sheets: Colon and Rectum. http://seer.cancer.gov/statfacts/html/colorect.html (May 2011)
2. American Cancer Society. Cancer Facts and Figures 2010. http://www.cancer.org/acs/groups/content/@nho/documents/document/
acspc-024113.pdf (May 2011)
3. U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement.
AHRQ Publication 08-05124-EF-3, October 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm
4. Redaelli, A., C.W. Cranor, G.J. Okano, P.R. Reese. 2003. Screening, prevention and socioeconomic costs associated with the treatment of
colorectal cancer. Pharmacoeconomics 21(17):1213–38.
5. American Cancer Society. Colorectal Cancer. What are the survival rates for colorectal cancer by state? http://www.cancer.org/Cancer/
ColonandRectumCancer/DetailedGuide/colorectal-cancer-survival-rates (May 2011)
6. American Cancer Society. Colorectal Cancer. What are the risk factors for colorectal cancer? http://www.cancer.org/Cancer/
ColonandRectumCancer/DetailedGuide/colorectal-cancer-risk-factors. (May 2011)
7. Centers for Disease Control and Prevention. National Health Interview Survey. http://www.cdc.gov/nchs/nhis.htm (May 2011)
8. Whitlock, E.P., J.S. Lin, E. Liles, et al. 2008. Screening for colorectal cancer: A targeted, updated systematic review for the U.S. Preventive
Services Task Force. Annals 149: 638–58.
9. Rozen, P. 2004. Cancer of the gastrointestinal tract: early detection or early prevention? Eur J Cancer Prev 13(1):71–5.
10. National Cancer Institute. A Snapshot of Colorectal Cancer. http://www.cancer.gov/aboutnci/servingpeople/snapshots/colorectal.pdf
(May 2011)
11. Centers for Disease Control and Prevention. Vital Signs: Colorectal Cancer Screening, Incidence, and Mortality—United States,
2002—2010. July 8, 2011. Morbidity and Mortality Weekly Report (MMWR) 60(26): 844–89. http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm6026a4.htm?s_cid=mm6026a4_w (July 2011)
12. Frazier, A., G.A. Colditz, C.S. Fuchs, K.M. Kuntz. 2000. Cost-effectiveness of screening for colorectal cancer in the general population.
Journal of the American Medical Association, 284(15): 1954–61.
13. Beydoun, H.A., M.A. Beydoun. 2008. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United
States. Cancer Causes Control 19:339–59.
CHLAMYDIA SCREENING IN WOMEN
1. Centers for Disease Control and Prevention. 2011. Sexually Transmitted Diseases: Chlamydia—CDC Fact Sheet. http://www.cdc.gov/std/
chlamydia/stdfact-chlamydia.htm (June 2, 2011)
2. National Chlamydia Coalition. 2010. Research Briefs: Developments in STD Screening: Chlamydia Testing. 2010 Series, No.1.
http://www.prevent.org/data/files/ncc/research%20brief%201%20std%20testing.pdf (June 2, 2011)
3. Centers for Disease Control and Prevention. 2010. Public Health Grand Rounds. Presentation: Chlamydia Prevention: Challenges and
Strategies for Reducing Disease Burden. http://www.cdc.gov/about/grand-rounds/archives/2010/05-May.htm (June 2, 2011)
4. U.S. Preventive Services Task Force. June 2007. Screening for Chlamydia Infection. http://www.uspreventiveservicestaskforce.org/uspstf/
uspschlm.htm (June 2, 2011)
5. Centers for Disease Control and Prevention. 2011. Sexually Transmitted Diseases: Pelvic Inflammatory Disease (PID)—CDC Fact Sheet.
http://www.cdc.gov/std/PID/STDFact-PID.htm (June 27, 2011)
6. National Business Group on Health. 2011. Chlamydia (Screening). http://www.businessgrouphealth.org/preventive/topics/chlamydia.
cfm (June 6, 2011)
7. Centers for Disease Control and Prevention. 2010. Sexually Transmitted Diseases (STDs): Chlamydia Treatment. http://www.cdc.gov/std/
chlamydia/treatment.htm (June 6, 2011)
8. The American Congress of Obstetricians and Gynecologists (ACOG). 2007. Spotlight on Chlamydia: Annual Screenings a Must for Young
Women. http://www.acog.org/from_home/publications/press_releases/nr05-08-07-1.cfm (June 2, 2011)
T he S tate o f H ea l th C are Q ua l it y 2 0 1 1 • R e f erences
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MEDICAL ASSISTANCE WITH SMOKING AND TOBACCO USE CESSATION
1. Centers for Disease Control and Prevention. 2008. Smoking Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—
United States, 2000-2004. MMWR 57(45): 1226–228. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm#tab
2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: Nationwide 2009 Data. Adults Who Are Current
Smokers. http://apps.nccd.cdc.gov/brfss/page.asp?cat=TU&yr=2009&state=UB#TU (May 2011)
3. Office of the Surgeon General. 2004. The Health Consequences of Smoking: A Report of the Surgeon General. Department of Health and
Human Services. Updated 2004. http://www.cdc.gov/tobacco/data_statistics/sgr/2004/complete_report/index.htm (March 17, 2010)
4. American Lung Association. General Smoking Facts. Updated February 2010 http://www.lungusa.org/stop-smoking/about-smoking/
facts-figures/general-smoking-facts.html (May 2011)
5. Pierce, J.P., K. Messer, M.M. White, D.W. Cowling, D.P. Thomas. 2011. Prevalence of Heavy Smoking in California and the United States,
1965-2007. JAMA 305(20): 2037–130.
6. Connolly, G.N., H.R. Alpert. 2008. Trends in the Use of Cigarettes and Other Tobacco Products, 2000–2007. JAMA 299(22):2629–30.
7. American Lung Association. Tobacco Policy Trend Report. Helping Smoker Quit: State Cessation Coverage. Updated February 2009.
http://www.lungusa.org/stop-smoking/tobacco-control-advocacy/reports-resources/tobacco-policy-trend-reports/ (May 2011)
8. Fiore, M.C., C.R. Jaen, W.C. Bailey. Clinical Practice Guideline. Treating Tobacco Use and Dependence: 2008. Update. US Department of
Health and Human Services. Updated 2008. http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf (March 17, 2010)
9. Maciosek, M.V., A.B. Coffield, N.M. Edwards, T.J. Flottemesch, M.J. Goodman, L.I. Solberg. 2006. Priorities among effective clinical
preventive services. Results of a systemic review and analysis. Am J Prev Med 31(1):52–61.
10. Tobacco Cessation Leadership Network. Trends in Delivery and Reimbursement of Tobacco Dependence Treatment. Updated 2006.
http://www.tcln.org/reports/pdfs/Trends_in_Delivery_and_Reimbursement_final.pdf (May 2011)
11. Steinberg, M.B., A. Akincigil, C.D. Delnevo, S. Crystal, J. L. Carson. 2006. Gender and Age Disparities for Smoking-Cessation Treatment.
American Journal of Preventive Medicine, 30(5): 405–12.
12. Centers for Disease Control and Prevention. 2005. Annual smoking-attributable mortality, years of potential life lost, and productively
losses—United States, 1997–2000. MMWR 54(25):625–8.
AMBULATORY CARE: EMERGENCY DEPARTMENT VISITS
1. Carlo, M.E., J.S. Powers. 2010. Ambulatory Care Sensitive Emergency Department Use Among Low-cost Medical Home Patients. Tenn
Med. 103(1): 31–3.
2. Centers for Disease Control and Prevention. National Health Statistics Report—National Hospital Ambulatory Medical Care Survey: 2007
Emergency Department Summary. http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf (June 2011)
3. Institute for Healthcare Improvement. Primary Care Access. http://www.ihi.org/IHI/Topics/OfficePractices/Access/ (June 2011)
4. Institute of Medicine. 2003. The Future of Emergency Care in the United States Health System.
5. American Hospital Association. 2007. The 2007 State of America’s Hospitals—Taking the Pulse: Finding from the 2007 AHA Survey of
Hospital Leaders. www.aha.org/aha/content/2007/PowerPoint/StateofHospitalsChartPack2007.ppt (June 2011)
6. Trzeciak, S., E.P. Rivers. 2003. Emergency Department Overcrowding in the United States: An Emerging Threat to Patient Safety and
Public Health. Emergency Med J. 20(5): 402–5.
7. Bourdreauz, E.D., J. Friedman, M.E. Chansky, B.M. Baumann. 2004. Emergency Department Patient Satisfaction: Examining the Role of
Acuity. Academy of Emergency Medicine. 11(2): 162–8.
PERSISTENCE OF BETA-BLOCKER TREATMENT AFTER A HEART ATTACK
1. Mayo Clinic. Heart Attack Basics. http://www.mayoclinic.com/health/heart-attack/DS00094 (June 2011)
2. Centers for Disease Control and Prevention. Heart Disease Facts. Updated 2010. http://www.cdc.gov/heartdisease/facts.htm (May 2011)
3. Bangalore, S., F.H. Messerli, J.B. Kostis, C.J. Pepine. 2007. Cardiovascular Protection Using Beta-Blockers: A Critical Review of the
Evidence. Journal of the American College of Cardiologists 50: 563–72.
4. American Heart Association. 2006. Heart Disease and Stroke Statistics- 2011 Update. http://circ.ahajournals.org/cgi/content/
full/123/4/e18 (May 2011)
5. Bradford, W.D., J. Chen, H. M. Krumholz. 1999. Under-utilization of Beta-Blocker After Acute Myocardial Infarction: Pharmacoeconomic
Implications. Pharmacoeconomics 15(3): 257–68.
6. Mayo Clinic. 2010. Beta-Blockers. http://www.mayoclinic.com/health/beta-blockers/HI00059 (May 2011)
7. Hernandez, A. F., et al. 2009. Clinical Effectiveness of Beta-Blockers in Heart Failure: Findings from the OPTIMIZE-HF (Organized
Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) Registry. Journal of American College of Cardiology
53: 184–92.
8. Kramer, J.M., et al., 2006. Nation Evaluation of Adherence to Beta-Blocker Therapy for 1 Year After Acute Myocardial Infarction in
Patients With Commercial Health Insurance. American Heart Journal 152: 454.1e–454.8e.
9. Ho, P.M., et al., 2006. Impact of Medication Therapy Discontinuation on Mortality After Myocardial Infarction. Archive of Internal
Medicine 166: 1842–47.
10. Phillips, K.A., M.G. Shlipk, P. Coxson, P.A. Heidenreich, M.G. Hunink, P.A. Goldman, et al., 2000. Health and Economic Benefits of
Increased Beta-Blocker Use Following Myocardial Infarction. JAMA 284(21): 2748–54.
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11. The Commonwealth Fund. Heart Treatment is the Hospital. Updated 2006. http://www.commonwealthfund.org/Content/PerformanceSnapshots/Hospital-Treatment/Heart-Attack-Treatment-in-the-Hospital.aspx (May 2010)
12. Levy, C.R., T.A. Radcliff, E.H. Williams, E. Hutt. January 2009. Acute Myocardial Infarction in Nursing Home Residents: Adherence to
Treatment Guidelines Reduces Mortality, But Why is Adherence So Low? Journal of the American Medical Directors Association; 10(1): 56–61.
COMPREHENSIVE DIABETES CARE
1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.
pdf (June 2011)
2. American Heart Association. Heart Disease and Stroke Statistics—2011 Update: A Report From the American Heart Association.
http://circ.ahajournals.org/cgi/content/full/123/4/e18 (June 2011)
3. National Institute of Diabetes and Digestive and Kidney Diseases. Kidney Disease of Diabetes. http://kidney.niddk.nih.gov/kudiseases/
pubs/kdd/index.htm#1 (June 2011)
4. Vermeer S.E., W. Sandee, A. Algra, P.J. Koudstaal, L.J. Kappelle, D.W. Dippel. 2006. Dutch TIA Trial Study Group. Impaired Glucose
Tolerance Increases Stroke Risk in Nondiabetic Patients with Transient Ischemic Attack or Minor Ischemic Stroke. Stroke; 37:1413–1417.
5. Centers for Disease Control and Prevention. September 2009. Number (in Thousands) of Hospital Discharges with Diabetes As Any-Listed
Diagnosis, United States, 1980-2006. http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm (June 2011)
6. Agency for Healthcare Research and Quality. 2009. HCUP Nationwide Inpatient Sample. http://hcupnet.ahrq.gov/HCUPnet.jsp (June 2011)
7. Asche, C., J. LaFleur, C. Conner. 2011 A Review of Diabetes Treatment Adherence and the Association with Clinical and Economic
Outcomes. Clinical Therapeutics; 33(1): 74–109.
8. Anderson, R.T., K.M. Narayan, et al., April 2011. Effect of Intensive Glycemic Lowering on Health-related Quality of Life in Type 2
Diabetes: ACCORD Trial. Diabetes Care; 34(4): 807–12.
9. Saatci, E., G. Tahmiscioglu, N. Bozdemir, et al., July 2010. The Well-being and Treatment Satisfaction of Diabetic patients in Primary
Care. Health Quality of Life Outcomes; 8:67.
CONTROLLING HIGH BLOOD PRESSURE
1. Mayo Clinic. High Blood Pressure (Hypertension). http://www.mayoclinic.com/health/high-blood-pressure/DS00100 (June 2011)
2. American Heart Association. December 15, 2010. Heart Disease and Stroke Statistics 2011 Update: A Report From the American Heart
Association. Circulation: Journal of the American Heart Association http://circ.ahajournals.org/cgi/reprint/CIR.0b013e3182009701
(June 1, 2011)
3. Wang, T.J., and R.S. Vasan. 2005. Epidemiology of Uncontrolled Hypertension in the United States. Circulation 112(11):1651–62.
4. Seshadri, S., A. Beiser, M. Kelly-Hayes, C.S. Kase, R. Au, W.B. Kannel, et al. 2006. The Lifetime Risk of Stroke: Estimates From the
Framingham Study. Stroke 37(2):345–50.
5. Vasan, R.S., A. Beiser, S. Seshadri, M.G. Larson, W.B. Kannel, R.B. D’Agostino, D. Levy. 2002. Residual lifetime risk for developing
hypertension in middle-aged women and men: the Framingham Heart Study. JAMA 287:1003–10.
6. Nguyen, Q.C., J.W. Tabor, P.P. Entzel, Y. Lau, C. Suchindran, J.M. Hussey, C.T. Halpern, K.M. Harris, E.A.Whitsel. May 23, 2011.
Discordance in National Estimates of Hypertension Among Young Adults. Epidemiology.
7. Vasan, R.S., A. Beiser, S. Seshadri, M.G. Larson, W.B. Kannel, R.B. D’Agostino, D. Levy. 2002. Residual lifetime risk for developing
hypertension in middle-aged women and men: the Framingham Heart Study. JAMA 287:1003–10.
8. Schappert, S.M., E.A. Rechsteiner. 2008. Ambulatory Medical Care Utilization Estimates. National Health Statistics Report, 6:1–29.
9. Franco, O.H., A. Peeters, L. Bonneux, C. de Laet. 2005. Blood pressure in adulthood and life expectancy with cardiovascular disease in
men and women: life course analysis. Hypertension 46(2):280–6.
10. Whelton, P.K., J. He, L.J. Appel, J.A. Cutler, S. Havas, T.A. Kotchen, et al. 2002. Primary Prevention of Hypertension: Clinical and Public
Health Advisory from The National High Blood Pressure Education Program. JAMA 288:1882–8.
11. Egan, B.M., Y. Whoa, R. N. Axon. 2010. US Trends in Prevalence, Awareness, Treatment, and Control of Hypertension, 1988-2008.
Journal of the American Medical Association, 303(20): 2043–50.
12. Centers for Disease Control and Prevention. 2010. Health, United States, 2010: With Special Features of Death and Dying.
http://www.cdc.gov/nchs/data/hus/hus10.pdf#066 (June 2011)
CHOLESTEROL MANAGEMENT FOR PATIENTS WITH CARDIOVASCULAR CONDITIONS
1. Mayo Clinic. 2011. High Cholesterol Basics. http://www.mayoclinic.com/health/high-blood-cholesterol/DS00178/
DSECTION=symptoms (June 2011)
2. Centers for Disease Control and Prevention. 2010. Cholesterol. http://www.cdc.gov/cholesterol/about.htm (June 2011)
3. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. 2011. Heart Disease and Stroke Statistics—2011
Update. Circulation; 123(4), e18. http://circ.ahajournals.org/cgi/reprint/CIR.0b013e3182009701 (June 2011)
4. Centers for Disease Control and Prevention. 2011. Leading Causes of Death. http://www.cdc.gov/nchs/fastats/lcod.htm (June 2011)
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5. American Heart Association. American Heart Association Defines ‘Ideal’ Cardiovascular Health, Sets New Goal to Focus on Improving
Health Factors and Lifestyle Behaviors. January 20, 2010. http://americanheart.mediaroom.com/index.php?s=43&item=931 (March 16,
2010)
6. Nicholls, S.J., et al. 2007. Statins, High-density Lipoprotein Cholesterol, and Regression of Coronary Atherosclerosis. JAMA 297(5):
499–508.
7. Heidenreich, P.A., J.G. Trogdon, et al., 2011. Forecasting the Future of Cardiovascular Disease in the United States: A Policy Statement
from the American Heart Association. Circulation; 123(8): 933–44.
8. National Cholesterol Education Program. High Blood Cholesterol: What You Need to Know. http://www.nhlbi.nih.gov/health/public/
heart/chol/wyntk.pdf (June 2011)
9. Lin, Y., S.S. Mousa, N. Elshourbagy, S.A. Mousa. 2010. Current Status and Future Directions in Lipid Management: Emphasizing LowDensity Lipoproteins, High-Density Lipoproteins, and Triglycerides as Targets for Therapy. Vascular Health Risk Management; 6:73–85.
DISEASE MODIFYING ANTI-RHEUMATIC DRUG THERAPY IN RHEUMATOID ARTHRITIS
1. Mayo Clinic. Rheumatoid Arthritis Basics. http://www.mayoclinic.com/health/rheumatoid-arthritis/DS00020 (June 2011)
2. The Arthritis Foundation. 2008. Rheumatoid arthritis fact sheet. http://www.arthritis.org/media/newsroom/media-kits/Rheumatoid_
Arthritis_Fact_Sheet.pdf (June 2011)
3. Helmick, C., D. Felson, R. Lawrence, S. Gabriel, et al., 2008. Estimates of the Prevalence of Arthritis and Other Rheumatic Conditions in
the United States. Arthritis & Rheumatism, 58(1): 15–25.
4. Siegel, J. 2008. Comparative effectiveness of treatments for rheumatoid arthritis. Ann Int Med. 142(2): 162–3.
5. Goodson, N., J. Marks, M. Lunt, D. Symmons. 2005. Cardiovascular Admissions and Mortality in an inception Cohort of Patients with
Rheumatoid Arthritis with Onset in the 1980s and 1990s. Ann Rheum Dis. 64:1595–601.
6. Centers for Disease Control and Prevention. 2005. Prevalence and Most Common Causes of Disability Among Adults—United States.
MMWR Weekly. 58(16):421–6. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5816a2.htm (June 2011)
7. Donahue et al. 2008. Systematic review: comparative effectiveness and harms of disease-modifying medications for rheumatoid arthritis.
Ann Int Med. 142(2):124–34.
8. Centers for Disease Control and Prevention. Arthritis: At a Glance 2011. http://www.cdc.gov/chronicdisease/resources/publications/
AAG/arthritis.htm (June 2011)
9. Agency for Healthcare Research and Quality. 2009 H-CUP: Patient and Hospital Characteristics for ICD-9-CM principle diagnosis
codes(s) 714.0–714.9. http://hcup.ahrq.gov/HCUPnet.asp. (June 2011)
10. Pincus, T., L.F. Callahan. What is the natural history of rheumatoid arthritis? Rheum Dis Clin North Am. 1993; 19(1):123–51.
USE OF APPROPRIATE MEDICATIONS FOR PEOPLE WITH ASTHMA
1. Centers for Disease Control and Prevention. 2009. Asthma—Basic Information. http://www.cdc.gov/asthma/faqs.htm (June 1, 2011)
2. Akinbami, L.J., J.E. Moorman, X. Liu. 2011. Asthma prevalence, health care use, and mortality: United States, 2005–2009. National
Health Statistics Reports. 32: 1–15.
3. Columbia University. 2010. Best Practice Asthma Program Saves the US Healthcare System More than $4500 a Year per Child. http://
www.mailman.columbia.edu/news/best-practice-asthma-program-saves-us-healthcare-system-more-4500-year-child (May 26, 2011)
4. Asthma Regional Council. 2010. Living with Asthma in New England: Results from the 2006 BRFSS and Call-back Survey.
http://www.asthmaregionalcouncil.org/uploads/Surveillance/BRFSS%20-%20Living%20with%20Asthma%20in%20New%20England%20
February%202010.pdf (May 26, 2011)
5. Barnett, S.B., T.A. Nurmagambetov. 2011. Costs of asthma in the United States: 2002–2007. Journal of Allergy and Clinical Immunology.
127(1): 145–52.
6. Centers for Disease Control and Prevention. 2011. Vital Signs: Asthma Prevalence, Disease Characteristics, and Self-Management
Education—United States, 2001–2009. Morbidity and Mortality Weekly Report (MMWR). 60(17): 547–52. http://www.cdc.gov/mmwr/
preview/mmwrhtml/mm6017a4.htm (May 26, 2011)
USE OF SPIROMETRY TESTING IN THE ASSESSMENT AND DIAGNOSIS OF COPD
1. American Lung Association. 2010. Trends in COPD (Chronic Bronchitis and Emphysema): Morbidity and Mortality. http://www.lungusa.
org/finding-cures/our-research/trend-reports/copd-trend-report.pdf (May 31, 2011).
2. Hanania, N. COPD 2010. http://www.chestnet.org/accp/chestsoundings/copd-2010 (May 31, 2011)
3. Global Initiative for Chronic Obstructive Lung Disease. 2010. Global strategy for the diagnosis, management, and prevention of COPD.
www.goldcopd.com. (May 27, 2011)
4. Schneider, et al. 2009. Diagnostic accuracy of spirometry in primary care.BMC Pulmonary Medicine 9:31.
5. Anecchino, C., E. Rossi, C. Fanizza, et al. 2007. Prevalence of chronic obstructive pulmonary disease and pattern of comorbidities in a
general population. Int J Chron Obstruct Pulmon Dis 2 567–74.
6. Joo, M.J., D.H. Au, T.A. Lee. 2009. Use of Spirometry in the Diagnosis of COPD and Efforts to Improve Quality of Care. Transl Res 154:103–10.
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7. Lin, K., B. Watkins, T. Johnson, J.A. Rodriguez, M.B. Barton. 2008. Screening for chronic obstructive pulmonary disease using spirometry:
summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 148:535–43.
8. U.S. Preventive Services Task Force. 2008. Screening for chronic obstructive pulmonary disease. Ann Intern Med 148:529–34.
PHARMACOTHERAPY MANAGEMENT OF COPD EXACERBATION
1. American Lung Association. 2010. Trends in COPD (Chronic Bronchitis and Emphysema): Morbidity and Mortality. http://www.lungusa.
org/finding-cures/our-research/trend-reports/copd-trend-report.pdf (May 27, 2011)
2. Anzueto, A. 2010. Impact of exacerbations on COPD. Eur Respir Rev 19:116 113–18.
3. Menzin J., L. Boulanger, J. Marton, L. Guadagno, H. Dastani, R. Dirani, A. Phillips, H. Shah. 2008. The economic burden of chronic
obstructive pulmonary disease (COPD) in a U.S. Medicare population. Respir Med 102(9):1248–56.
4. Willsie, S.K. Following the GOLD Standard. Treating COPD in Primary Care. Presented at American College of Osteopathic Family
Physicians 47th Annual Convention and Scientific Seminars. March 18–21, 2010. Las Vegas, Nevada.
5. Negro, R.D. 2008. Optimizing economic outcomes in the management of COPD. Int J Chron Obstruct Pulmon Dis 3(1): 1–10.
6. National Committee on Quality Assurance. 2009. Insights for Improvement: Advancing COPD Care Through Quality Measurement.
http://www.ncqa.org/portals/0/publications/NCQA_Insights_Improvement_FINAL.pdf (May 27, 2011)
7. Global Initiative for chronic obstructive lung disease. 2010. Global strategy for the diagnosis, management, and prevention of COPD.
www.goldcopd.com (May 27, 2011)
ANNUAL MONITORING FOR PATIENTS ON PERSISTENT MEDICATIONS
1.
2.
3.
4.
Center for Disease Control and Prevention. 2008. Medication Safety Basics. http://www.cdc.gov/MedicationSafety/basics.html (June 1, 2011)
Avorn, J., 2010. Medication Use in Older Patients: Better Policy Could Encourage Better Practice. JAMA 304(14):1606–7.
Budnitz, D., et al., 2006. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296:1858–66.
U.S. Food and Drug Administration. 2010. Safe Use Initiative Fact Sheet. http://www.fda.gov/Drugs/DrugSafety/ucm188760.htm (June
1, 2011)
5. Slone Epidemiology Center at Boston University. 2006. Patterns of medication use in the United States. http://www.bu.edu/slone/
SloneSurvey/AnnualRpt/SloneSurveyWebReport2006.pdf (June 1, 2011)
6. Classen D.C., et al., 2010. Adverse drug events among hospitalized Medicare patients: Epidemiology and national estimates from a new
approach to surveillance. Jt Comm J Qual Patient Saf 36:12–21.
7. Hohl, C.M., B. Nosyk, L. Kuramoto, et al., 2011. Outcomes of emergency department patients presenting with adverse drug events. Ann
Emerg Med DOI:10.1016/j.annemergmed.2011.01.003
Antidepressant Medication Management
1. The National Alliance on Mental Illness. 2009. Major Depression Fact Sheet. http://www.nami.org/Template.cfm?Section=Depression&Te
mplate=/ContentManagement/ContentDisplay.cfm&ContentID=88956 (May 31, 2011)
2. Department of Veteran Affairs, Department of Defense. 2009. VA/DoD clinical practice guideline for management of major depressive
disorder (MDD). http://www.healthquality.va.gov/MDD_FULL_3c.pdf (May 31, 2011)
3. Institute for Clinical Systems Improvement (ICSI). 2010. Major depression in adults in primary care. http://www.guideline.gov/content.as
px?id=23857&search=major+depression (May 31, 2011)
4. McIntyre, R.S., S. Liauw, V.H. Taylor. 2011. Depression in the workforce: the intermediary effect of medical comorbidity. Journal of
Affective Disorders. 128(1):S29–S36.
5. Smith, J.P., G.C. Smith. 2010. Long-term economic costs of psychological problems during childhood. Social Science and Medicine.
71(1):110–15.
6. Johnston, K., W. Westerfield, S. Momim, R. Phillipi. 2009. The direct and indirect costs of employee depression, anxiety, and emotional
disorders—An employer case study. J of Occ and Envt Med. 51(5):564–77.
7. Birnbaum, H.G., Kessler, R.C., Kelley, D., Ben-Hamadi, R., Joish, V.N., Greenberg, P.E. 2010. Employer burden of mild, moderate, and
severe major depressive disorder: mental health services utilization and costs, and work performance. Depression and Anxiety. 27(1):78–89.
8. Wang, J., N. Schmitz N. 2010. Does job strain interact with psychosocial factors outside of the workplace in relation to the risk of major
depression? The Canadian National Population Health Survey. Soc. Psychiatry. [Epub ahead of print].
9. American Psychiatric Association. 2010 Practice guideline for the treatment of patients with major depressive disorder. Third edition.
http://www.guideline.gov/content.aspx?id=24158 (May 31, 2011)
10. Lauber, C., J.L. Bowen. 2010. Low mood and employment: when affective disorders are intertwined with the workplace—a UK
perspective. Int. Rev. Psychiatry. 22(2):173–82.
11. Hunot, V.M., R. Horne, M.N. Leese, R.C. Churchill. 2007. A cohort study of adherence to antidepressants in primary care: the influence of
antidepressant concerns and treatment preferences. Prim Care Companion J Clin Psychiatry. 9:91–9.
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FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS
1. Kessler R.C., W.T. Chiu, O. Demler, E.E. Walters. 2005. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the
National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry 62(6):617–27.
2. The Substance Abuse and Mental Health Services Administration. 2008. Serious Mental Illness Among Adults http://oas.samhsa.
gov/2k2/SMI/SMI.cfm (June 10, 2011)
3. Mental Health: A Report of the Surgeon General Chapter 1: Introduction and Themes. http://www.surgeongeneral.gov/library/
mentalhealth/chapter1/sec1.html (June 10, 2011)
4. National Alliance on Mental Illness. 2011. What is Mental Illness: Mental Illness Facts. http://www.nami.org/template.
cfm?section=about_mental_illness (June 10, 2011)
5. Larkin, G.L., R.P. Smith, A.L. Beautrais. 2008. Trends in U.S. emergency department visits for suicide attempts, 1992–2001. Crisis 29(2):73–80.
6. Cougnard, A., M. Parrot, S. Grolleau, E. Kalmi, A. Desage, D. Misdarhi, et al. 2006. Pattern of health service utilization and predictors of
readmission after a first admission for psychosis: a 2-year-follow-up study. Acta Psychiatr Scand 113(4):340–9.
7. Insel, Thomas R. 2008. Assessing the Economic Costs of Serious Mental Illness. The Am J Psychiat http://ajp.psychiatryonline.org/cgi/
reprint/165/6/663 (June 10, 2011)
8. National Alliance on Mental Illness. 2011. The Impact and Cost of Mental Illness: The Case of Depression. http://www.nami.org/
Template.cfm?Section=Policymakers_Toolkit&Template=/ContentManagement/ContentDisplay.cfm&ContentID=19043 (June 10, 2011)
9. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2008. Results from the 2008 National Survey on
Drug Use and Health: National Finding. NSDUH Series H-34, DHHS Publication No. SMA 08-4343. Rockville, MD.
http://oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf (June 10, 2011)
10. DeFrances, C.J., M.J. Hall. 2007. National Hospital Discharge Survey. Advance data from vital and health statistics. No. 385. http://
www.cdc.gov/nchs/data/ad/ad385.pdf (June 10, 2011)
INITIATION AND ENGAGEMENT OF ALCOHOL AND OTHER DRUG DEPENDENCE TREATMENT
1. Substance Abuse and Mental Health Services Administration (SAMHSA). 2009. Results from the 2009 National Survey on Drug Use and
Health. http://oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm (June 10, 2011)
2. National Institute on Drug Abuse (NIDA). 2011. NIDA InfoFacts: Nationwide Trends. http://www.drugabuse.gov/pdf/infofacts/
NationTrends.pdf (June 10, 2011)
3. Frederic, C.B., S.J. Bartels, L.M. Brockmann, A.D. Van Citters. 2010. Evidence-Based Practices for Preventing Substance Abuse and
Mental Health Problems in Older Adults. Excerpt: Prevention of Substance Misuse Problems: Alcohol Misuse. www.public-health.uiowa.
edu/icmha/.../Evidence-basedCareForAlcohol.DOC (June 10, 2011)
4. National Institute on Drug Abuse. 2010. Monitoring the Future: National results on adolescent drug use. http://monitoringthefuture.org/
pubs/monographs/mtf-overview2010.pdf
5. Keyes, K.M., M.L. Hatzenbuehler, K.A. McLaughlin, B. Link, M. Olfson, B.F. Grant. 2010. Stigma and Treatment for Alcohol Disorders in
the United States. American Journal of Epidemiology 172 (12): 1364–72.
6. National Institute on Drug Abuse. 2010. Comorbidity: Addiction and Other Mental Illnesses. http://www.drugabuse.gov/PDF/
RRComorbidity.pdf (June 10, 2010)
7. Substance Abuse and Mental Health Services Administration (SAMHSA). 2006. Report to Congress: Addictions Treatment Workforce
Development. http://www.pfr.samhsa.gov/docs/Report_to_Congress.pdf (June 10, 2010)
APPROPRIATE TESTING FOR CHILDREN WITH PHARYNGITIS
1. Wisconsin Department of Health Services. 2010. Disease Fact Sheet Series: Streptococcal Pharyngitis. http://www.dhs.wisconsin.gov/
communicable/FactSheets/StreptococcalPharyngitis.htm (May 31, 2011)
2. Huhtala, T.A. 2011. Updates on Sinusitis, Pharyngitis and UTI. February 27–March 4, Salt Lake City, Utah.
3. Wessels, M.R. 2011. Streptococcal Pharyngitis. New England Journal of Medicine 364: 648–55.
4. Gerber, M.A., R.S. Baltimore, C.B. Eaton, M. Gewitz, A.H. Rowley, S.T. Shulman, K.A. Taubert. 2009. Prevention of Rheumatic Fever and
Diagnosis and Treatment of Acute Streptococcal Pharyngitis: A Scientific Statement From the American Heart Association Rheumatic Fever,
Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on
Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed
by the American Academy of Pediatrics. Circulation 119: 1541–51.
5. Lee, G.M., J.A. Salomon, C. Gay, J.K. Hammitt. 2010. Preferences for health outcomes associated with Group A Streptococcal disease
and vaccination. Health and Quality of Life Outcomes 8:28.
6. Undeland, D.K., T.J. Kowalski, W.L. Berth, J.D. Gundrum. 2010. Appropriately Prescribing Antibiotics for Patients with Pharyngitis: A
Physician-Based Approach vs a Nurse-Only Triage and Treatment Algorithm. Mayo Clin Proc 85(11): 1011–15.
7. Pfoh, E., M.R. Wessels, D. Goldmann, G.M. Lee. 2008. Burden and Economic Cost of Group A Streptococcal Pharyngitis. Pediatrics
121(2): 229–34.
8. Ayanruoh, S., M. Waseem, Frances Quee, Alyssa Humphrey, Toussaint Reynolds. 2009. Impact of Rapid Streptococcal Test on Antibiotic
Use in a Pediatric Emergency Department. Pediatric Emergency Care 25(11): 748–50.
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WELL-CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE AND IN THE THIRD, FOURTH, FIFTH AND SIXTH YEARS OF LIFE
1. Child Trends Data Bank. 2010. Well-Child Visits. http://www.childtrendsdatabank.org/?q=node/85 (June 2011)
2. Brown, B., M. Weitzman, et al., The Commonwealth Fund. Early Child Development in Social Context: A Chartbook.
http://www.commonwealthfund.org/Content/Publications/Chartbooks/2004/Sep/Early-Child-Development-in-Social-Context--AChartbook.aspx (June 2011)
3. National Institutes of Health Medline Plus. Well-child Visits. Updated January 17, 2011. http://www.nlm.nih.gov/medlineplus/ency/
article/001928.htm (June 2011)
4. Chung, P.J., T.C. Lee, J.L. Morrison, M.A. Schuster. 2006. Preventive Care for Children in the United States: Quality and Barriers. Annual
Review of Public Health; 27: 491–515.
5. National Survey of Children’s Health. NSCH 2007. Child and Adolescent Health measurement Initiative, Data Resource Center for Child
and Adolescent Health. http://nschdata.org (June 2011)
6. Hakim, R.B., D.S. Ronsaville. 2002. Effect of Compliance with Health Supervision Guidelines Among U.S. Infants on Emergency
Department Visits. Archives of Pediatric and Adolescent Medicine; 156: 1015–20.
7. Rosenberg, S.A., D. Zhang, C.C. Robinson. 2008. Prevalence of Developmental Delays and participation in Early Intervention Services for
Young Children. Pediatrics; 121(6): e1503–e1509.
8. Sice, L. The Commonwealth Fund. 2007. Developmental Screening in Primary Care: The Effectiveness of Current Practice and
Recommendations for Improvement. http://www.commonwealthfund.org/usr_doc/1082_Sices_developmental_screening_primary_care.
pdf?section=4039 (June 2011)
9. Honeycutt, A.A., S.D. Grosse, L.J. Dunlap et al. 2003. Economic Costs of Mental Retardation, Cerebral Palsy, Hearing Loss, and Vision
Impairment. In B.M. Altman, S.N. Barnett, G.E. Hendershot, S.A. Larson, eds., Using Survey Data to Study Disability: Results from the
National Health Interview Survey on Disability, Vol. 3. Amsterdam: Elsevier, 207–28.
ADOLESCENT WELL-CARE VISITS
1. National Quality Measures Clearinghouse. Adolescent Well-care Visits. http://www.qualitymeasures.ahrq.gov/content.aspx?id=15051
(June 2011)
2. American Medical Association. Guidelines for Adolescent Preventive Services: Recommendations Monograph. http://www.ama-assn.
org//resources/doc/ad-hlth/gapsmono.pdf (June 2011)
3. American Academy of Pediatrics. 2008. Achieving Quality Health Services for Adolescents. Pediatrics. 121(6):1263–270.
4. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance: Tobacco Use. http://apps.nccd.cdc.gov/youthonline/App/
Default.aspx (June 2011)
5. National Institutes of Health. PubMed Health: Obesity. Updated October 12, 2010. http://www.ncbi.nlm.nih.gov/pubmedhealth/
PMH0004552/ (June 2011)
6. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
http://brightfutures.aap.org/pdfs/Preventive%20Services%20PDFs/Forward%20and%20Introduction.pdf (June 2011)
7. Irwin, C.E., Jr., S.H. Adams, M.J. Park, P.W. Newacheck. 2009. Preventive Care For Adolescents: Few Get Visits and Fewer Get Services.
Pediatrics. 123(4): e565–72.
8. Finkelstein, E.A., P.S. Corso, T.R. Miller. 2006. Incidence and Economic Burden of Injuries in the United States. New York: Oxford
University Press
9. Park, M.J., T.M. Macdonald, E.M. Ozer, et al., 2001. Investing in Clinical Preventive Health Services for Adolescents. University of
California, San Francisco
10. Health Resources and Services Administration. Child Health USA 2010. http://www.mchb.hrsa.gov/chusa10/hstat/hsa/pages/200hsa.
html (June 2011)
CHILDREN AND ADOLESCENTS’ ACCESS TO PRIMARY CARE PRACTITIONERS
1. American Academy of Pediatrics. Scope of Health Care Benefits for Children From Birth Through Age 21. http://aappolicy.
aappublications.org/cgi/reprint/pediatrics;117/3/979.pdf (June 2011)
2. Hensley-Quinn, M., E. Osius. National Academy for State Health Policy. 2008. SCHIP and Adolescents: An Overview and Opportunities
for States. http://www.nashp.org/sites/default/files/shpbriefing_adolescents.pdf (June 2011)
3. Starfield, B., L. Shi, J. Macinko. 2005. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly. 83(3): 457–502.
4. Chung, P.J., T.C. Lee, J.L. Morrison, M.A. Schuster. 2006. Preventive Care for Children in the United States: Quality and Barriers. Annual
Review of Public Health. 27: 491–515.
5. National Survey of Children’s Health (NSCH). 2007. Child and Adolescent Health Measurement Initiative, Data Resource Center for Child
and Adolescent Health. http://nschdata.org (June 2011)
6. Chipman, S.A., J. Lan, C. Chang, D.C. Goodman. 2010. Geographic Maldistribution of Primary Care for Children. Pediatrics. 127(6): e1626.
7. Friedberg, M.W., P.S. Hussey, E.C. Schneider. 2010. Primary Care: A Critical Review of the Evidence on Quality and Costs of Health
Care. Health Affairs. 29(5): 766–72.
8. Bodenheimer and Fernandez. 2005. High and Rising Health Care Costs. Part 4: Can Costs Be Controlled While Preserving Quality? Ann
Intern Med. 143:26–31.
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9. American Academy of Pediatrics. 2008. Achieving Quality Health Services for Adolescents. Pediatrics. 121(6):1263–270.
10. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd Edition.
http://brightfutures.aap.org/pdfs/Preventive%20Services%20PDFs/Forward%20and%20Introduction.pdf (June 2011)
FOLLOW-UP CARE FOR CHILDREN PRESCRIBED ADHD MEDICATION
1. Visser, S.N., R.H. Bitsko, M.L. Danielson, R. Perou, S.J. Blumberg. 2010. Increasing Prevalence of Parent-Reported Attention-Deficit/
Hyperactivity Disorder Among Children - United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44):1439–43.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w (June 10, 2011)
2. Centers for Disease Control and Prevention. 2010. Attention-Deficit / Hyperactivity Disorder (ADHD) Symptoms and Diagnosis.
http://www.cdc.gov/ncbddd/adhd/diagnosis.html (June 10, 2011)
3. Centers for Disease Control and Prevention. 2010. Attention-Deficit / Hyperactivity Disorder (ADHD) Other Concerns & Conditions.
http://www.cdc.gov/ncbddd/adhd/conditions.html (June 10, 2011)
4. Guevara, J., P. Lozano, T. Wickizer, L. Mell, H. Gephart. 2002. Psychotropic medication use in a population of children who have
attention-deficit/hyperactivity disorder. Pediatrics. 109(5):733–9.
5. National Institutes of Health Fact Sheet. 2011. Attention Deficit Hyperactivity Disorder (ADHD). http://report.nih.gov/NIHfactsheets/
ViewFactSheet.aspx?csid=25&key=A#A (June 10, 2011)
6. Pelham, W.E, E.M. Foster, J.A. Robb. 2007. The economic impact of attention-deficit/hyperactivity disorder in children and adolescents. J
Pediatr Psychol. 32(6):711–27.
7. Matza, L.S., C. Paramore, M. Prasad. 2005. A review of the economic burden of ADHD. Cost Eff Resour Alloc. 3:5.
8. Brown, R.T., R.W. Amler, W.S. Freeman, J.M. Perrin, M.T. Stein, H.M. Feldman, K. Pierce, M.L. Wolraich. 2005. Treatment of AttentionDeficit/Hyperactivity Disorder: Overview of the Evidence. Pediatrics. 115(6):e749–57.
APPROPRIATE TREATMENT FOR CHILDREN WITH UPPER RESPIRATORY INFECTION
1. Hart, A.M. 2007. An Evidence-Based Approach to the Diagnosis and Management of Acute Respiratory Infections. Journal for Nursing
Practitioners 3(9): 607–11.
2. Lucile Packard Children’s Hospital at Stanford. 2011. Upper Respiratory Infection (URI, or Common Cold). http://www.lpch.org/
DiseaseHealthInfo/HealthLibrary/respire/uricold.html (June 1, 2011)
3. Wong, D.M., D.A. Blumberg, L.G. Lowe. 2006. Guidelines for the Use of Antibiotics in Acute Upper Respiratory Tract Infections. Am Fam
Physician 74(6): 956–66.
4. Centers for Disease Control and Prevention. 2011. Get Smart: Know When Antibiotics Work. Facts About Antibiotic Resistance. http://
www.cdc.gov/getsmart/antibiotic-use/fast-facts.html#ref2 (May 26, 2011)
5. Ong, S., J. Nakase, G.J. Moran, D.J. Karras, M.J. Kuehnert, D.A. Talan. 2007. Antibiotic Use for Emergency Department Patients with
Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction. Ann Emerg Med 50: 213–20.
6. Fendrick, A.M., A.S. Monto, B. Nightengale, M. Sarnes. 2003. The Economic Burden of Non-Influenza-Related Viral Respiratory Tract
Infection in the United States. Arch Intern Med 163: 487–94.
7. Linder, J.A. 2007. Improving Care for Acute Respiratory Infections: Better Systems, Not Better Microbiology. Clin Infect Dis 45(9): 1189–91.
8. Friedman, B., D. Schwabe-Warf, R. Goldman. 2011. Reducing inappropriate antibiotic use among children with influenza infection. Can
Fam Physician 57(1): 42–4.
CHILDHOOD IMMUNIZATION STATUS
1. Centers for Disease Control and Prevention. 2009. Vaccines & Immunizations: How Vaccines Prevent Disease. http://www.cdc.gov/
vaccines/vac-gen/howvpd.htm (June 1, 2011)
2. Centers for Disease Control and Prevention. 2011. Vaccines & Immunizations: Infants and Toddlers. http://www.cdc.gov/vaccines/specgrps/infants-toddlers.htm (June 1, 2011)
3. Centers for Disease Control and Prevention. 2010. Vaccines & Immunizations: 10 Things You Need to Know About Immunizations. http://
www.cdc.gov/vaccines/vac-gen/10-shouldknow.htm (June 6, 2011)
4. Centers for Disease Control and Prevention. 2011. General Recommendations on Immunization: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (MMWR). January 28, 2011. 60(RR02);1–60.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm?s_cid=rr6002a1_e
5. American Academy of Pediatrics. Children’s Health Topics: Immunizations/Vaccines. http://www.aap.org/healthtopics/immunizations.
cfm (June 6, 2011)
6. HealthyChildren. American Academy of Pediatrics. 2011. Safety & Prevention: Why Immunize Your Child. http://www.healthychildren.
org/english/safety-prevention/immunizations/Pages/Why-Immunize-Your-Child.aspx?nfstatus=401&nftoken=00000000-0000-00000000-000000000000&nfstatusdescription=ERROR%3a+No+local+token (June 1, 2011)
7. Immunization Action Coalition. 2010. Vaccines work! CDC statistics demonstrate dramatic declines in vaccine-preventable diseases when
compared with the pre-vaccine era. http://www.immunize.org/catg.d/p4037.pdf (June 6, 2011)
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8. Zhou, F. Updated economic evaluation of the routine childhood immunization schedule in the United States. Presented at the 45th National
Immunization Conference. Washington, DC; March 28–31, 2011.
9. Centers for Disease Control and Prevention. 2011. Ten Great Public Health Achievements—United States, 2001—2010. MMWR
Morbidity and Mortality Weekly Report May 20, 2011. 60(19):619-623.
10. Kennedy, A., M. Basket, K. Sheedy. 2011. Identifying and Addressing Vaccine-Safety Concerns Among Parents: Vaccine Attitudes,
Concerns, and Information Sources Reported by Parents of Young Children: Results From the 2009 HealthStyles Survey. Pediatrics 2011;
127 (Suppl 1):S92–S99.
11. Centers for Disease Control and Prevention. 2011. Vaccines & Immunizations. Statistics and Surveillance: U.S. Vaccination Coverage
Reported via NIS. http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nis (July 12, 2011)
12. U.S. National Library of Medicine. MedlinePlus. 2011. Childhood Immunization. http://www.nlm.nih.gov/medlineplus/
childhoodimmunization.html (June 6, 2011)
IMMUNIZATIONS FOR ADOLESCENTS
1. American Medical Association. 2008. Improving Adolescent Immunizations. http://www.ama-assn.org/resources/doc/public-health/
ad_immunizations_mon.pdf (June 8, 2011)
2. Centers for Disease Control and Prevention. 2011. Preteen and Teen Vaccines: For Parents. http://www.cdc.gov/vaccines/who/teens/
for-parents.html (June 7, 2011)
3. Centers for Disease Control and Prevention. 2011. Preteen and Teen Vaccines: Tdap Vaccine for Preteens and Teens. http://www.cdc.
gov/vaccines/who/teens/vaccines/tdap.html (June 8, 2011)
4. Immunization Action Coalition. 2010. Vaccines work! CDC statistics demonstrate dramatic declines in vaccine-preventable diseases when
compared with the pre-vaccine era. http://www.immunize.org/catg.d/p4037.pdf (June 6, 2011)
5. National Foundation for Infectious Diseases. 2009. Adolescent Vaccination. 10 Reasons To Be Vaccinated. http://www.adolescentvaccination.
org/ten_reasons.htm (June 9, 2011)
6. Broder, K.R., A.C. Cohn, B. Schwartz, J.D. Klein, M.M. Fisher, D.B. Fishbein, C. Mijalski, G.B. Burstein, M.E. Vernon-Smiley, M.M.
McCauley, C.J. Wibbelsman. 2008. Adolescent Immunizations and Other Clinical Preventive Services: A Needle and a Hook? Pediatrics
121(Suppl 1):S25–S34.
7. Lee, G.M., S.A. Lorick, E. Pfoh, K. Kleinman, D. Fishbein. Adolescent Immunizations: Missed Opportunities for Prevention. 2008.
Pediatrics 122(4):711–17.
Lead Screening in Children
1. Needleman, H.L. 2004. Lead poisoning. Annual Review of Medicine 55:209–22.
2. Environmental Protection Agency. Lead in Paint, Dust, and Soil: Health effects of lead. http://www.epa.gov/lead/pubs/leadinfo.
htm#health (May 2011)
3. General Lead Information. National Center for Environmental Health http://www.cdc.gov/nceh/lead/ (May, 2011)
4. United States Preventive Services Task Force (USPSTF). 1996. Chapter 23, Screening for Elevated Lead Levels in Childhood and
Pregnancy. Guide to Clinical Preventive Services. Second Edition. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hscps2ed1996&
part=A12872 (March 9, 2009)
5. Lustberg, M., E. Silbergeld. Blood lead levels and mortality. 2002. Arch Intern Med Nov 25;162(21):2443–9.
6. Lead: Prevention Tips. National Center for Environmental Health. Updated June 2009. http://www.cdc.gov/nceh/Lead/tips.htm (May 2011)
7. Trasande, L., Y. Liu. Reducing The Staggering Costs of Environmental Disease in Children. 2011. Health Affairs, 30(5): 863–70.
8. Jones, et al. 2009. Trends in Blood Lead Levels and Blood Lead Testing Among US Children Aged 1 to 5 Years, 1988–2004. Pediatrics
March; 123(3):e376–85.
WEIGHT ASSESSMENT AND COUNSELING FOR NUTRITION AND PHYSICAL ACTIVITY FOR CHILDREN/ADOLESCENTS
1. American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity: About Childhood Obesity.
http://www.aap.org/obesity/about.html (June 9, 2011)
2. National Child Care Information and Technical Assistance Center. 2010. Childhood Obesity Prevention. http://nccic.acf.hhs.gov/
poptopics/childobesity.html (June 9, 2011)
3. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Data and Statistics. http://www.cdc.gov/obesity/
childhood/data.html (June 9, 2011)
4. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Causes and Consequences. http://www.cdc.gov/obesity/
causes/index.html (June 9, 2011)
5. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Basics About Childhood Obesity. http://www.cdc.gov/
obesity/childhood/basics.html (June 9, 2011)
6. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Economic Consequences. http://www.cdc.gov/obesity/
causes/economics.html (July 12, 2011)
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7. Finkelstein, E.A., J.G. Trogdon, J.W. Cohen, W. Dietz. 2009. Annual medical spending attributable to obesity: Payer- and service-specific
estimates. Health Affairs 28(5): w822–w831.
8. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Basics About Childhood Obesity. http://www.cdc.gov/
obesity/childhood/basics.html (June 9, 2011)
FALL RISK MANAGEMENT
1. American Occupational Therapy Association. 2010. Analysis of Medicare Policy in Relation to Preventing Falls Among Older Adults.
http://www.aota.org/Practitioners/PracticeAreas/Aging/Falls/Key/Analysis.aspx (May 27, 2011)
2. American Geriatrics Society. 2010. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice
Guideline for Prevention of Falls in Older Persons. http://www.americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.
Guidelines.pdf. (May 27, 2011)
3. Centers for Disease Control and Prevention. 2010. Falls Among Older Adults: An Overview. http://www.cdc.gov/
HomeandRecreationalSafety/Falls/adultfalls.html (May 27, 2011)
4. Centers for Disease Control and Prevention. 2008. Self-Reported Falls and Fall-Related Injuries Among Persons Aged >65 Years—United
States. Morb Mortal Wkly Rep 57(09);225–9.
5. Business Group on Health. 2011. Injuries from Falls: Fact Sheet. http://www.businessgrouphealth.org/pdfs/04811%20NBGH%20
InjuryPrevnt%20FactSheet_FALLS.pdf (May 27, 2011)
6. Centers for Disease Control and Prevention. 2011. Cost of Fall Injuries in Older Persons in the United States. http://www.cdc.gov/
HomeandRecreationalSafety/falls/data/cost-estimates.html (May 27, 2011)
7. Centers for Disease Control and Prevention. 2011. Cost of Fall Injuries in Older Persons in the United States. http://www.cdc.gov/
HomeandRecreationalSafety/falls/data/cost-estimates.html (May 27, 2011)
MEDICATION IN THE ELDERLY
1.
2.
3.
4.
5.
6.
Budnitz, D., et al. 2006. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296:1858–66.
Zhan, C., et al. 2001. Potentially inappropriate medication use in the community-dwelling elderly. JAMA 286(22):2823–68.
Beers, M.H. 1997. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 157:1531–6.
Rothberg, M.B., P.S. Pekow, F. Liu, et al. 2008. Potentially inappropriate medication use in hospitalized elders. J Hosp Med 3(2):91–102.
Fick, D.M., et al. 2003. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med 163:2716–24.
Fick, D.M., L.C. Mion, M.H. Beers, J.L. Waller. 2008. Health Outcomes Associated With Potentially Inappropriate Medication Use in
Older Adults. Res Nurs Health 31(1):42–51.
7. Fu, A.Z., J.A. Jiang, J.H. Reeves, J.E. Fincham, G.G. Liu, M. Perri. 2007. Potentially inappropriate medication use and healthcare
expenditures in the US community-dwelling elderly. Med Care 45:472–476.
8. Jano, E., R. Aparaus. 2007. Healthcare Outcomes Associated with Beers’ Criteria: A Systematic Review. Ann Pharmacother 41:438–48.
9. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS). Panel on the Clinical Practice Guideline for the Prevention of
Falls in Older Persons. Clinical practice guideline: Prevention of falls in older persons. http://www.americangeriatrics.org/health_care_
professionals/clinical_practice/clinical_guidelines_recommendations/2010/ (June 2, 2011)
10. Flores, E.K., R. Henry, D.W. Stewart. 2011. Pharmacist’s Role in an Interdisciplinary Falls Clinic. SouthMed J 104(2):143–6.
11. Hilmer, S.N., D.E. Mager, E.M. Simonsick, Y. Cao, S.M. Ling, G. Windham, T.B. Harris, J.T. Hanlon, S.M. Rubin, R.L. Shorr, et al. 2007. A
drug burden index to define the functional burden of medications in older people. Arch Intern Med 167:781–7.
MANAGEMENT OF URINARY INCONTINENCE IN OLDER ADULTS
1. DuBeau, C.E., G.A. Kuchel, T. Johnson, et al. 2009. Incontinence in the Frail Elderly. In: Incontinence, 4th ed. P. Abrams, L. Cardozo, S.
Khoury, A. Wein. 961–1024. Plymouth, UK: Health Publication Ltd.
2. Morrison, A., R. Levy. 2006. Fraction of nursing home admissions attributable to urinary incontinence. Value Health 9(4):272.
3. Holroyd-Leduc, J.M., S.E. Straus. 2004. Management of Urinary Incontinence in Women. JAMA 291(8):996–9.
4. Koch, L.H. 2006. Help-seeking behaviors of women with urinary incontinence: an integrative literature review. J Midwifery Women’s
Health 51(6):39–44.
5. Gomelsky, A., R.R. Dmochowski. 2011. Urinary Incontinence in the Aging Female: Etiology Pathophysiology and Treatment Options.
Aging health 7(1):79–88.
6. Buckley, B.S., M.C. Lapitan. 2010. Prevalence of urinary incontinence in men, women, and children—current evidence: findings of the
Fourth International Consultation on Incontinence. Urology 76:265.
7. Levy, R., N. Muller. 2006. Urinary incontinence: economic burden and new choices in pharmaceutical treatment. Adv Ther 23(4):556–73.
8. Thum, L.P., A. Wagg. 2009. Management of urinary incontinence in the elderly. Aging Health 5(5), 647–53.
9. Society of Obstetricians and Gynaecologists of Canada (SOGC). 2006. Conservative management of urinary incontinence. J Obstet
Gynaecol Can 28(12):1113–8.
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PHYSICAL ACTIVITY IN OLDER ADULTS
1. Ashe, M.C., W.C. Miller, J.J. Eng, L. Noreau. 2009. Older adults, chronic disease and leisure-time physical activity. Gerontology 55(1) 64–72.
2. Elsawy, B., K.E. Higgins. 2010. Physical Activity Guidelines for Older Adults. American Family Physician. 81(1):55–9.
3. Centers for Disease Control and Prevention (CDC). 2008. Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical
Activity. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf (May 27, 2011)
4. Centers for Disease Control and Prevention (CDC). 2011. Healthy Aging. Helping People To Live Long and Productive Lives and Enjoy a
Good Quality Of Life. http://www.cdc.gov/chronicdisease/resources/publications/AAG/aging.htm (May 27, 2011)
5. Ackermann, R.T., B., Williams, H.Q. Nguyen, E.M. Berke, et al. 2008. Healthcare Cost Differences with Participation in a Community
Based Group Physical Activity Benefit for Medicare Managed Care Health Plan Members. Journal of the American Geriatrics Society;
56(8): 1459–65.
6. Chodzko-Zajko, W.J., D. Proctor, F.M. Singh, C.T. Minson, et al. 2009. Exercise and Physical Activity for Older Adults. Medicine &
Science in Sports & Exercise 41(7) 1510–30.
7. Nelson, M.E., J. Rejeski, S.N. Blair, P.W. Duncan, P.W., et al. Physical Activity and Public Health in Older Adults: Recommendation from
the American College of Sports Medicine and the American Heart Association. http://www.acsm.org/AM/Template.cfm?Section=home_
page&Template=/CM/ContentDisplay.cfm&ContentID=7789 (May 27, 2011)
GLAUCOMA SCREENING IN OLDER ADULTS
1. Goldberg, L.D. 2008. The Case for Glaucoma Screening: A look at the effect of early detection on healthcare costs. Ophthalmology
Management. Available at http://www.ophmanagement.com/article.aspx?article=101274 (May 27, 2011)
2. The Foundation of the American Academy of Ophthalmology. 2007. Glaucoma. Eye Care America. http://eyecareamerica.org/
eyecare/conditions/glaucoma/index.cfm (May 27, 2011)
3. National Eye Institute. 2010. Facts about Glaucoma. http://www.nei.nih.gov/health/glaucoma/glaucoma_facts.asp (May 27, 2011)
4. Centers for Medicare & Medicaid Services. 2010. Medicare Preventive Services: Glaucoma. https://www.cms.gov/MLNProducts/
downloads/glaucoma.pdf (May 27, 2011)
5. National Eye Institute. Vision Problems in the U.S. http://www.preventblindness.org/vpus/2008_update/VPUS_2008_update.pdf (May 27, 2011)
6. Fiscella, R.G., J. Lee, E. Davis, J. Walt. 2009. Cost of Illness of Glaucoma: A Critical and Systematic Review. Pharmaco Economics 27 (3)
189–98.
7. McKinnon, S.J., L.D. Goldberg, P. Peeples, J.G. Walt, T.J. Bramley. 2008. Current Management of Glaucoma and the Need for Complete
Therapy. American Journal of Managed Care 14: S20–S27.
OSTEOPOROSIS MANAGEMENT IN WOMEN WHO HAD A FRACTURE
1. Mayo Clinic. Osteoporosis Basics. http://www.mayoclinic.com/health/osteoporosis/DS00128 (June 2011)
2. Vondracek, S.F., S.A. Linnebur. 2009. Diagnosis and management of osteoporosis in the older senior. Clin Interv Aging 4:121–39.
3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Once is Enough: A Guide to Preventing Future Fractures. Updated
2009. http://my.clevelandclinic.org/Documents/rheumatology_immunology/oa01.pdf (June 2011).
4. U.S. Preventive Services Task Force. January 18, 2011. Screening for Osteoporosis: U.S. Preventive Service Task Force Recommendation
Statement. Annals of Internal Medicine; 154: 356–64.
5. Singh, S., R. Foster, K.M. Khan. 2011. Accident or Osteoporosis? Survey of Community Follow-up After Low-Trauma Fracture. Canadian
Family Physician; 57(4): e128–33.
6. Lewiecki, E.M. 2008. Prevention and Treatment of Postmenopausal Osteoporosis. Obstetrics and Gynecology Clinics of North America;
35(2): 301–15.
7. The Joint Commission. 2008. Improving and Measuring Osteoporosis Management. http://www.jointcommission.org/assets/1/18/
OsteoMono_REVFinal_31208.pdf (June 2011)
8. Burge, R.T., B. Dawson-Hughes, A.B. King, et al., 2007. Incidence and Economic Burden of osteoporosis Related Fractures in the United
States, 2005–2025. Journal of Bone Mineral Research; 22(3): 465–75.
9. U.S. Department of Health and Human Services. Bone Health and Osteoporosis (A Report of the Surgeon General). 2004. Rockville, MD:
US Dept of Health and Human Services, Public Health Service, Office of the Surgeon General.
10. Majumadr, S.R. 2008. Recent Trends in Osteoporosis Treatment After Hip Fracture: Improving but Wholly Inadequate. Journal of
Rheumatology 35(2): 190–1902.
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OSTEOPOROSIS TESTING IN OLDER WOMEN
1. National Osteoporosis Foundation. 2008. Fact Sheet. http://216.247.61.108/professionals/NOF_Fact_Sheet.pdf (June 6, 2011)
2. Bone Health Learning Center. Osteoporosis in 2011. http://www.healthline.com/health-feature/osteoporosis-2011 (June 8, 2011)
3. Burge, R., B. Dawson-Hughes, D.H. Solomon, J.B. Wong, A. King, A. Tosteson. 2007. Incidence and economic burden of osteoporosisrelated fractures in the United States, 2005–2025. Journal of Bone and Mineral Research 22(3):465–75.
4. Blume, S.W., J.R. Curtis. 2011. Medical costs of osteoporosis in the elderly Medicare population. Osteoporosis International 22(6):1835–44.
5. Becker, D.J., M.L. Kilgore, M.A. Morrisey. 2010. The societal burden of osteoporosis. Current Rheumatology Report 12(3):186–91.
6. Saag, S.G., P. Geusens. Progress in Osteoporosis and Fracture Prevention: Focus on Postmenopausal Women. 2009. Arthritis Research &
Therapy 11(5):251.
7. Ioannidis, G., A. Papaioannou, L. Thabane, A. Gafni, A. Hodsman, B. Kvern, A. Walsh, F. Jiwa, J.D. Adachi. 2009. Family physicians’
personal and practice characteristics that are associated with improved utilization of bone mineral density testing and osteoporosis
medication prescribing. Population Health Management 12(3):131–8.
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Acknowledgments
Health Plans
The 2011 State of Health Care Quality Report would not be possible without the public reporting
of performance results by the 740 HMO and POS plans and 302 PPO plans this report analyzes.
Those plans collectively cover more than 118 million Americans, and are to be commended for
their commitment to quality improvement.
Staff
NCQA employees who helped create this report include:
Communications
Performance Measurement
Ashley Carter
Dawn Alayon, MPH, CPH
Paul Cotton
Sepheen C. Byron, MHS
Andy Reynolds, MBA
Jennifer Chemi
Apoorva Stull, MA
Mohua Choudhury
Sarah Thomas, MS
Jeremy Gottlich
Candice Groseclose
Data Collection Operations
Benjamin Hamlin, MPH
Garcene Duckett
Mallory L. N. Johnson, MPA
Felicia Fridie
Divya Pamnani, MHSA
Robin Gant
Milesh M. Patel, MS
Carla Pacheco
Bob Rehm, MBA
Michele Taylor
Dana T. Rey, MPH
Careema Yusuf, MPH
Information Systems
Bob Chisholm
Publications
Jonathan Cook
Carolyn Moeller, MHS
Paul Jackovich
Judy Jiao
Policy
Bing Li
Judy Lacourciere
Bhuvaneshwari Maruthac
Raghav Seshadri
Quality Solutions Group
Subra Shanmugam
Phyllis Torda, MA
Helen Zhang
The State of Health Care Quality Continuous Improvement and the Expansion of Quality Measurement www.ncqa.org
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2011
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T h e S tat e o f H e a lt h C a r e Q u a l i t y 2 0 1 1