1. Monthly Metrics Forum February 2014 Appropriate Testing for Children With Pharyngitis And Appropriate Treatment for Children With Upper Respiratory Infection Judith.rosen.1.ctr@us.af.mil

2. Overview Appropriate testing for children with Pharyngitis Appropriate treatment for children with Upper Respiratory Infection Other Metrics major specification changes for 2014

3. Measurement Year Both measures look at a rolling 12 month period that ends 6 months prior to the metrics date Examples: – Metrics for 31 Dec 2013 look at episodes of care from 1 July 2012 – 30 Jun 2013 – Metrics for 31 Oct 2013 look at episodes of care from 1 May 2012-30 Apr 2013

4. APPROPRIATE TESTING FOR CHILDREN WITH PHARYNGITIS

5. Appropriate Testing Definition In the 12 month measurement period, the percentage of children 2–18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test by 3 days after the encounter. A higher rate represents better performance (i.e., appropriate testing). 5

6. HEDIS Percentile Benchmarks Year 10th25th50th75th90th for 2014 65.4175.2182.5188.6592.28 for 2013 67.2676.1282.0387.592.08

7. Denominator Children age 2-18 who had an Outpatient or Emergency Department (ED) encounter in the last year for pharyngitis and were dispensed antibiotic medications on or up to 3 days after this episode of care date Patient must be continuously enrolled from 30 days prior to Episode date through 3 days after episode date 7

8. Denominator Exclusions Excludes encounters with any additional diagnoses Excludes patients who received antibiotics in the last 30 days Excludes patients who received antibiotics more than 30 days prior, but the script was still active on episode date Only patient’s earliest episode in measurement year counts

9. Age Clarification 2 years old by start date of measurement year Less than 19 by last date of measurement year So, if they child had an episode of care when they were 18, but turned 19 prior to the end of the measurement year, none of their episodes of care will be included

10. Qualifying encounters DescriptionCPT/E&M Codes Outpatient 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99382-99385, 99341-99345, 99392-99395, 99401-99404, 99411,99412, 99420, 99429 Emergency Dept99281-99285 (*Do not include ED visits that result in an inpatient admission) DescriptionICD-9-CM Diagnosis Acute pharyngitis462 Acute tonsillitis463 Streptococcal sore throat034.0

11. NUMERATOR Of the denominator patients, the patients who had a streptococcus test in the 7 day period from 3 days prior to the episode through 3 days after Also pull by lab test name in CHCS CPT Codes Group A Streptococcus Tests 87070, 87071, 87081, 87430, 87650-87652, 87880

12. Patient list Will be a historical list that is not actionable, similar to Appropriate imaging with Low Back Pain

13. Children with Pharyngitis Metric Summary Only includes 2-18 yr olds’ outpatient/ED encounters with just 1 diagnosis AND had Antibiotics dispensed within 3 days after Compliance=patient has strep test Excludes kids already on antibiotics Only child’s first visit in the 12 month measurement period will count To improve: provider education on proper coding and treatment. Ensure coding compliance of testing.

14. Top Performing DMISs

15. APPROPRIATE TREATMENT FOR CHILDREN WITH UPPER RESPIRATORY INFECTION (URI)

16. Definition In the 12 month measurement period, the percentage of children 3 months–18 years of age who were given a diagnosis of upper respiratory infection (URI) and were NOT dispensed an antibiotic prescription on or 3 days after the visit.

17. CRITICAL UNDERSTANDING The calculation of this measure is reported as an inverted rate [1 – (numerator/eligible population)] A higher rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed).

18. HEDIS Percentile Benchmarks Year 10th25th50th75th90th for 2014 72.5480.2585.4790.5194.32 for 2013 72.0379.8785.3490.1894.22

19. Denominator Children age 3 months-18yo who had an Outpatient or ED encounter in the last year for URI Patient must be continuously enrolled from 30 days prior to Episode date through 3 days after episode date 19

20. Denominator Exclusions Excludes encounters with any additional diagnoses Exclude encounters where patient had a competing diagnosis on or 3 days after the episode date Excludes patients who received antibiotics in the last 30 days Excludes patients who received antibiotics more than 30 days prior, but the script was still active on episode date Only patient’s earliest episode in measurement year counts

21. Age Clarification 3 months old by start date of measurement year Less than 19 by last date of measurement year So, if they child had an episode of care when they were 18, but turned 19 prior to the end of the measurement year, none of their episodes of care will be included

22. Qualifying encounters DescriptionCPT/E&M Codes Outpatient 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99382-99385, 99341-99345, 99392-99395, 99401-99404, 99411,99412, 99420, 99429 Emergency Dept99281-99285 (*Do not include ED visits that result in an inpatient admission) DescriptionICD-9-CM Diagnosis Acute nasopharyngitis (common cold) 460 URI465

23. Competing Diagnoses

24. NUMERATOR Of the denominator patients, identify the patients who were dispensed an antibiotic on the episode date or in the 3 days after Metric is an inverse calculation with higher score is better: 1 – (numerator/denominator)=score

25. Patient list Will be a historical list that is not actionable, similar to Appropriate imaging with Low Back Pain

26. Children with URI Treatment Metric Summary Only includes 3 months-18 yr olds’ outpatient/ED encounters with just 1 diagnosis Compliance= NO Antibiotics prescribed on episode date or the 3 days after Excludes patients already on antibiotics Excludes if competing diagnosis w/in 3 days after Counts only child’s 1st episode in measurement year To improve: provider education on proper coding and treatment

27. Top DMIS Performers

28. Significant 2014 HEDIS changes Cervical Cancer Screening – Women over 30 can have pap + HPV on same date every 5 yrs or pap every 3yrs Breast Cancer Screening – Age group 52-74 with mammo – Metric looks for mammo in last 27 months not 24 Asthma changes how to count inhaler medication dispensing events – All inhaled meds dispensed on same date count as single dispensing event – 2013 counted each inhaler as a dispensing event – 4 dispensing events is a criteria that could place patient in denominator – Impact should be fewer non-asthmatics on metric/lists

29. Antidepressant Medication Management 2014 changes 2013 Same ICD9 codes Start with Earliest dx in 12 month identification period (IP) Initial Dispensing occur within 30 before to 14 days after initial dx Must have at least 1 er, 1 inpt or 2 outpt major depression dx in 12mon IP Negative med history of 90 days prior to 1st dispensing in IP Continuous enrollment of 90 days prior to 1st dispensing through 231 days after 2014 Same diagnoses Start with earliest antidepressant dispensing DX occur within 60 days before to 60 days after 1 st dispensing 1 outpt, er or inpt dx around 1 st dispensing will suffice Negative med history of 105 days prior to 1 st dispensing in IP Continuous enrollment of 105 days prior to 1 st dispensing through 231 days after Impact should be more accurate capture of initial dispensing event for patient (and not falsely identify as “newly treated” a patient several months into therapy who picked up refill a 1-2 weeks late)

30. Benchmarks 2014 Health Plan Measures MHSPHP Data Timeperiod 20132014 Percentile10th25th50th75th90th10th25th50th75th90th Breast Cancer Screening 63.666.4270.3374.6279.03 63.0465.7870.1574.7678.67 Cervical Cancer Screening 69.974.3777.1379.682.92 69.1972.8975.6878.5581.94 Colorectal Cancer Screening 49.8855.9963.2968.8673.72 50.8556.9364.1569.8275 Comprehensive Diabetes Care Hemoglobin A1c (HbA1c testing) 85.5187.5790.3392.8894.69 85.6487.5990.5492.8894.92 LDL-C screening 80.058385.4288.1490.88 79.7482.7585.6988.3291.01 LDL-C control <100 mg/dL 38.1943.9547.935358.39 36.944.1348.5953.0359.12 HbA1c <=9.0% 60.6767.6773.578.4781.8260.6766.4373.1878.7281.82 HbA1c Control <8% 51.0457.4162.7767.6470.8 50.9457.3862.6367.471.43 <7% for a selected population 33.8638.2143.2247.6949.76 35.2740.0944.147.8151.32 Use of Appropriate Medications for People with Asthma 88.8990.9192.3193.8795.24 87.590.0691.3693.0194.55 Chlamydia Screening in Women 31.9637.3143.950.5960.32 32.8637.6143.5851.3261.08 Cholesterol Management for Patients with Cardiovascular Conditions LDL-C screening 82.2485.988.7890.9193.79 83.6886.3288.7890.9192.98 LDL-C is controlled (<100mg/dL) 47.7555.1660.867.5373.06 46.9554.7460.9866.9173.06 Antidepressant Medication Management Effective Acute Phase Treatment 57.8661.1465.3870.0473.43 60.4964.3768.8873.7278.32 Effective Continuation Phase Treatment 41.0744.1849.0954.0557.75 44.0348.5652.9658.3662.65 Mental Health Follow-up After Hospitalization in 7 days 41.6250.7959.4669.0176.21 39.3948.7758.968.9675.44 in 30 days 61.6271.4777.7284.2989.21 61.9570.3178.0284.2188 Well Child Visits <15 months (six or more well-child visits) 64.5371.8880.685.5390.59 65.2573.1181.3485.9991.29 Appropriate Testing for Children With Pharyngitis 65.4175.2182.5188.6592.28 Appropriate Treatment for Children With Upper Respiratory Infection 72.5480.2585.4790.5194.32 LBP 2013 Benchmarks: 90 th = 82.21% 75 th = 79.15% 2014: 90 th = 82.73% 75 th = 79.66%

31. Next month: 2014 updates Judith.rosen.ctr.1@us.af.mil