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Public listing of 2019 CUHSM Non-Program measures - CUHSM.ORG
| 2019 QCDR Measure IDs | Measure Title (REQUIRED) | Measure Description (REQUIRED) | Denominator (REQUIRED) | Numerator (REQUIRED) | Denominator Exclusions (REQUIRED) | Denominator Exceptions (REQUIRED) | Numerator Exclusions (REQUIRED) |
Data Source Used for the Measure (REQUIRED) (Administrative clinical data, Facility discharge data, Chronic condition data warehouse (CCW), Claims, CROWNWeb, EHR (enter relevant parts), Hybrid, IRF-PAI, LTCH CARE data set, National Healthcare Safety Network |
If applicable, please enter additional information regarding the data source used | Provide a concise summary of evidence of a performance gap, in addition to any study citation (citations should be the most current available or within 5 years) (REQUIRED) | Is there a variance in the measure rate? If yes, indicate if the variance is within your registry and/or from another source. If another source, please cite the source. | QCDR Measure Type (REQUIRED) | If this is an existing measure with changes, do the changes impact the intent of the measure? | Please indicate what has changed to the existing measure and how the change impacts the intent of the 2018 version | Can the measure be benchmarked against the previous performance year's data? | If applicable, please Indicate why the 2018 benchmark cannot be used | Does this measure belong to another entity/organization? (REQUIRED) | If applicable, please indicate you have the appropriate documentation to use the measure | NQF ID Number (if applicable) | Is the QCDR measure a high priority measure? (REQUIRED) | High Priority Type (REQUIRED) | Measure Type (REQUIRED) | NQS Domain (REQUIRED) | What one meaningful measure area applies to this measure? (REQUIRED) | Meaningful Measure Area Rationale (REQUIRED) | Inverse Measure (REQUIRED) | Proportional Measure (REQUIRED) | Continuous Variable Measure (REQUIRED) | Ratio Measure (REQUIRED) |
If Continuous Variable and/or Ratio is chosen, what
would be the range of the score(s)? (if not continuous variable and/or ratio measure enter N/A) |
Number of performance rates to be calculated and submitted in the XML (Enter the # of performance rates or N/A. If only one rate is calculated, enter “1”. Also, provide the name for each performance rate, if there is more than one performance rate calcula |
Indicate an Overall Performance Rate if more than 1 performance rate is to be submitted. Specify which of the submitted rates will represent an overall performance rate for the measure or how an overall performance rate could be calculated based on the da | Risk-Adjusted (REQUIRED) | If risk-adjusted, indicate which score is risk-adjusted (REQUIRED) | Please provide any test data on reliability/validity. | Provide current clinical guideline the measure is derived from (REQUIRED) | Please indicate which specialty/specialties this measure applies to (REQUIRED) (i.e., Anesthesiology, Neurology, Urology, etc.) | Preferred measure published clinical category (REQUIRED) (i.e., Diabetes, Substance Use/Management) | What is the measure funding source? |
Vendor Organization Staff (enter vendor organization JIRA users who are stakeholders regarding this issue) |
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| CUHSM3 | CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys) |
•Adult Primary Care Survey: 37 core and 64 supplemental question survey
of adult outpatient primary care patients. Pediatric Care Survey: 36 core and 16 supplemental question survey of outpatient pediatric care patients. Specialist Care Survey: 37 core and 20 supplemental question survey of adult outpatients specialist care patients. Level of analysis for each of the 3 surveys: group practices, sites of care, and/or individual clinicians |
The measure’s denominator is the number of survey respondents. The target populations for the surveys are patients who have had at least one visit to the selected provider in the target 12-month time frame. This time frame is also known as the look back period. The sampling frame is a person-level list and not a visit-level list. | The top box numerator for the Overall Rating of Provider is the number of respondents who answered 9 or 10 for the item, with 10 indicating “Best provider possible”. |
The following are excluded when constructing the sampling frame: • Patients that had another member of their household already sampled. • Patients who are institutionalized (put in the care of a specialized institution) or deceased. |
None | None | Survey | Data provided by CAHPS vendors | N/A | N/A | Existing Approved QCDR Measure With No Changes | Yes | N/A | No | N/A | N/A | Yes | Outcome | Patient Reported Outcome (PRO) | Person and Caregiver Centered Experience and Outcomes | Patient’s Experience of Care | As designated by NQF | No | Yes | No | No | N/A | 1 | 1st Performance Rate | Yes | #1 | See AHRQ website | Designated by AHRQ (measure steward) | Survey | AHRQ | Mike Smith | |||||
| CUHSM4 | CAHPS Health Plan Survey v 4.0 - Adult questionnaire | 30-question core survey of adult health plan members that assesses the quality of care and services they receive. Level of analysis: health plan – HMO, PPO, Medicare, Medicaid, commercial | The measure’s denominator is the number of survey respondents who answered the question. The target population for the survey includes all individuals who have been enrolled in a health plan for at least 6 (Medicaid) or 12 (Commercial) months with no more than one 30-day break in enrollment. Denominators will vary by item and composite. | The top box numerator for each of the four Overall Ratings items is the number of respondents who answered 9 or 10 for the item; with a 10 indicating the “Best possible.” |
Individuals are excluded from the survey target population if: 1) They were not continuously enrolled in the health plan (excepting an allowable enrollment lapse of less than 30 days). 2) Their primary health coverage is not through the plan. 3) Another member of their household has already been sampled. 4) They have been institutionalized (put in the care of a specialized institution) or are deceased. |
None | None | Survey | Data provided by CAHPS vendors | N/A | N/A | Existing Approved QCDR Measure With No Changes | Yes | N/A | No | N/A | N/A | Yes | Outcome | Patient Reported Outcome (PRO) | Person and Caregiver Centered Experience and Outcomes | Patient’s Experience of Care | As designated by NQF | No | Yes | No | No | N/A | 1 | 1st Performance Rate | Yes | #1 | See AHRQ website | Designated by AHRQ (measure steward) | Survey | AHRQ | Mike Smith | |||||
| CUHSM6 | Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder | Percentage of individuals at least 18 years of age as of the beginning of the measurement period with bipolar I disorder who had at least two prescription drug claims for mood stabilizer medications and had a Proportion of Days Covered (PDC) of at least 0.8 for mood stabilizer medications during the measurement period (12 consecutive months). | Individuals at least 18 years of age as of the beginning of the measurement period with bipolar I disorder and at least two prescription drug claims for mood stabilizer medications during the measurement period (12 consecutive months). | Individuals with bipolar I disorder who had at least two prescription drug claims for mood stabilizer medications and have a PDC of at least 0.8 for mood stabilizer medications. | None | None | None | Administrative clinical data | Prescription Drug Event Data Elements | N/A | N/A | Existing Approved QCDR Measure With No Changes | Yes | N/A | No | N/A | 1880 | Yes | Outcome | Intermediate Outcome | Patient Safety | Medication Management | As designated by NQF | No | Yes | No | No | N/A | 1 | 1st Performance Rate | Yes | #1 | See NCQA Website | Designated by NCQA (measure steward) | Mental/Behavior Disorders | NCQA | Mike Smith | |||||
| CUHSM8 | Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications | The percentage of individuals 25 to 75 years of age with schizophrenia or bipolar disorder who were prescribed any antipsychotic medication and who received a cardiovascular health screening during the measurement year. | Individuals ages 25 to 75 years of age by the end of the measurement year with a diagnosis of schizophrenia or bipolar disorder who were prescribed any antipsychotic medication during the measurement year. | Individuals who had one or more LDL-C screening during the performance period, and if abnormal LDL-C result (<70mg/dL OR >190 mg/dL) recorded as the highest fasting or direct laboratory test result in the measurement year, a clinical action plan which includes treatment and/or follow-up. |
Individuals are excluded from the denominator if: a) they were discharged alive for a coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) (these events may occur in the measurement year or year prior to the measurement year), OR b) they were diagnosed with ischemic vascular disease (IVD) (this diagnosis must appear in both the measurement year and the year prior to the measurement year), chronic heart failure, OR c) they had a prior myocardial infarction (identified in the measurement year or as far back as possible) |
None | None | Administrative clinical data | Prescription Drug Event Data Elements | N/A | N/A | Existing Approved QCDR Measure With No Changes | Yes | N/A | No | N/A | N/A | Yes | Patient Safety | Process | Patient Safety | Medication Management | As designated by NQF | No | Yes | No | No | N/A | 1 | 1st Performance Rate | Yes | #1 | See CMS Website | Designated by CMS (measure steward) | Mental/Behavior Disorders | CMS | Mike Smith |