* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Annual Monitoring for Patients on Persistent Medications
Survey
Document related concepts
Compounding wikipedia , lookup
Polysubstance dependence wikipedia , lookup
Pharmacognosy wikipedia , lookup
Drug design wikipedia , lookup
Neuropharmacology wikipedia , lookup
Drug discovery wikipedia , lookup
Discovery and development of ACE inhibitors wikipedia , lookup
Drug interaction wikipedia , lookup
Pharmaceutical industry wikipedia , lookup
Theralizumab wikipedia , lookup
Prescription drug prices in the United States wikipedia , lookup
Adherence (medicine) wikipedia , lookup
Prescription costs wikipedia , lookup
Pharmacokinetics wikipedia , lookup
Transcript
Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 1 Proposed Changes to Existing Measure for HEDIS®1 2015: Annual Monitoring for Patients on Persistent Medications (MPM) NCQA seeks comments on proposed modifications to the Annual Monitoring for Patients on Persistent Medications measure. This measure assesses the percentage of individuals on selected persistent medications (angiotensin converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARB], digoxin, diuretics or anticonvulsants) who received a therapeutic monitoring event in the measurement year. We propose the following changes to the measure: Retire the anticonvulsant rate. Revise the numerator for ACE inhibitors or ARBs, digoxin and diuretics rates to no longer allow a blood urea nitrogen therapeutic monitoring test to count as evidence of annual monitoring of kidney function. Revise the numerator for the digoxin rate to add monitoring of serum digoxin level. The proposed changes would bring the measure in line with current evidence. In fall 2013, NCQA contracted with a team of researchers at the Johns Hopkins Hospital Center for Medication Quality and Outcomes to review the current evidence for annual monitoring of adults using these medications. The review supports the proposed changes: Evidence demonstrates no benefit to routine drug concentration monitoring for patients on anticonvulsants who are responding to therapy. For monitoring patients with persistent use of ACE inhibitors or ARBs, diuretics or digoxin, evidence supports annual monitoring of serum creatinine and serum potassium to reduce potentially fatal risks associated with the use of these medications. There is no evidence on the utility of using blood urea nitrogen to monitor renal function. For monitoring patients with persistent use of digoxin, evidence from multiple clinical trials supports annual monitoring of serum digoxin concentration level, to avoid potential digoxin toxicity. Supporting documents for the proposed measure include the draft measure specification, recent performance data, and the evidence work-up which contains a detailed description of the findings from the evidence review. NCQA acknowledges the contributions of the Geriatric Measurement Advisory Panel. 1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 2 Annual Monitoring for Patients on Persistent Medications (MPM) SUMMARY OF CHANGES TO HEDIS® 2015 Revised the numerator for the ACE Inhibitors and ARB, digoxin and diuretics rates to no longer allow a blood urea nitrogen therapeutic monitoring test to count as evidence of annual monitoring. Revised the numerator for the digoxin rate to add monitoring of serum digoxin level. Retired the indicator for anticonvulsants. Description The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report each of the four three rates separately and as a total rate. Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Annual monitoring for members on digoxin. Annual monitoring for members on diuretics. Annual monitoring for members on anticonvulsants. Total rate (the sum of the four three numerators divided by the sum of the four three denominators). Eligible Population Product lines Commercial, Medicaid, Medicare (report each product line separately). Ages 18 years and older as of December 31 of the measurement year. Continuous enrollment The measurement year. Allowable gap No more than one gap in enrollment of up to 45 days during the measurement year each year of continuous enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled). Anchor date December 31 of the measurement year. Benefits Medical and pharmacy. Event/ diagnosis Members on persistent medications (i.e., members who received at least 180 treatment days of ambulatory medication in the measurement year). Refer to Additional Eligible Population Criteria for each rate. Treatment days are the actual number of calendar days covered with prescriptions within the measurement year (i.e., a prescription of 90 days supply dispensed on December 1 of the measurement year counts as 30 treatment days). Sum the days supply for all medications and subtract any days supply that extends beyond December 31 of the measurement year. Note: Medications dispensed in the year prior to the measurement year must be counted toward the 180 treatment days. ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 3 Administrative Specification For each product line, report each of the three four rates separately and as a combined rate. The total rate is the sum of the three four numerators divided by the sum of the three four denominators. Rate 1: Annual Monitoring for Members on ACE Inhibitors or ARBs Additional eligible population criteria Members who received at least 180 treatment days of ACE inhibitors or ARBs, during the measurement year. Refer to Table CDC-L to identify ACE inhibitors and ARBs. Numerator At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. Any of the following during the measurement year meet criteria: Note: Members may switch therapy with any medication listed in Table CDC-L during the measurement year and have the days supply for those medications count toward the total 180 treatment days (i.e., a member who received 90 days of ACE inhibitors and 90 days of ARBs meets the denominator definition for rate 1). A lab panel test (Lab Panel Value Set). A serum potassium test (Serum Potassium Value Set) and a serum creatinine test (Serum Creatinine Value Set). A serum potassium test (Serum Potassium Value Set) and a blood urea nitrogen test (Blood Urea Nitrogen Value Set). Note: The tests do not need to occur on the same service date, only within the measurement year. Rate 2: Annual Monitoring for Members on Digoxin Additional eligible population criteria Members who received at least 180 treatment days of digoxin (Table MPM-B) during the measurement year. Table MPM-B: Drugs to Identify Members on Digoxin Description Inotropic agents Prescription Digoxin Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 1, 2013. Numerator At least one serum potassium, at least one and either a serum creatinine, and at least one serum digoxin or a blood urea nitrogen therapeutic monitoring test in the measurement year. Any of the following during the measurement year meet criteria: A lab panel test (Lab Panel Value Set) and serum digoxin test (Digoxin Level Value Set). A serum potassium test (Serum Potassium Value Set) and a serum creatinine test (Serum Creatinine Value Set) and serum digoxin test (Digoxin Level Value Set). A serum potassium test (Serum Potassium Value Set) and a blood urea nitrogen test (Blood Urea Nitrogen Value Set). ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 4 Note: The tests do not need to occur on the same service date, only within the measurement year. Rate 3: Annual Monitoring for Members on Diuretics Members who received at least 180 treatment days of a diuretic (Table MPM-C), during the measurement year. Additional eligible population criteria Note: Members may switch therapy with any medication listed in Table MPM-C during the measurement year and have the days supply for those medications count toward the total 180 treatment days. Table MPM-C: Drugs to Identify Members on Diuretics Description Antihypertensive combinations Loop diuretics Potassium-sparing diuretics Thiazide diuretics Prescription Aliskiren-hydrochlorothiazide Fosinopril-hydrochlorothiazide Aliskiren-hydrochlorothiazide-amlodipine Hydrochlorothiazide-irbesartan Amiloride-hydrochlorothiazide Hydrochlorothiazide-lisinopril Amlodipine-hydrochlorothiazide-olmesartan Hydrochlorothiazide-losartan Amlodipine-hydrochlorothiazide-valsartan Hydrochlorothiazide-methyldopa Atenolol-chlorthalidone Hydrochlorothiazide-metoprolol Benazepril-hydrochlorothiazide Hydrochlorothiazide-moexipril Bendroflumethiazide-nadolol Hydrochlorothiazide-olmesartan Bisoprolol-hydrochlorothiazide Hydrochlorothiazide-propranolol Candesartan-hydrochlorothiazide Hydrochlorothiazide-quinapril Captopril-hydrochlorothiazide Hydrochlorothiazide-spironolactone Chlorthalidone-clonidine Hydrochlorothiazide-telmisartan Enalapril-hydrochlorothiazide Hydrochlorothiazide-triamterene Eprosartan-hydrochlorothiazide Hydrochlorothiazide-valsartan Bumetanide Furosemide Ethacrynic acid Torsemide Amiloride Spironolactone Triamterene Eplerenone Chlorothiazide Hydrochlorothiazide Methyclothiazide Chlorthalidone Indapamide Metolazone Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 1, 2014. Numerator At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. Any of the following during the measurement year meet criteria: A lab panel test (Lab Panel Value Set). A serum potassium test (Serum Potassium Value Set) and a serum creatinine test (Serum Creatinine Value Set). A serum potassium test (Serum Potassium Value Set) and a blood urea nitrogen test (Blood Urea Nitrogen Value Set). Note: The tests do not need to occur on the same service date, only within the measurement year. ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 5 Rate 4: Annual Monitoring for Members on Anticonvulsants Additional eligible population criteria Members who received at least 180 treatment days for an anticonvulsant (Table MPM-D) during the measurement year. Note: Members who are on multiple anticonvulsant drugs count toward the denominator multiple times if they meet the persistent medications criteria for each drug taken during the measurement year (i.e., a member who received at least 180 days of phenytoin and 180 days of valproic acid is counted twice in the denominator for Rate 4, once for each drug). Table MPM-D: Drugs to Identify Members on Anticonvulsants Description Barbiturate anticonvulsants Dibenzazepine anticonvulsants Hydantoin anticonvulsants Miscellaneous anticonvulsants Drugs Phenobarbital Carbamazepine Phenytoin Divalproex sodium Valproic acid Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 1, 2013. Numerator At least one drug serum concentration level monitoring test for the prescribed drug during the measurement year as identified by the following value sets: Members prescribed phenobarbital must have at least one drug serum concentration for phenobarbital (Phenobarbital Level Value Set). Members prescribed carbamazepine must have at least one drug serum concentration for carbamazepine (Carbamazepine Level Value Set). Members prescribed phenytoin must have at least one drug serum concentration for phenytoin (Phenytoin Level Value Set). Members prescribed valproic acid or divalproex sodium must have at least one drug serum concentration for valproic acid (Valproic Acid Level Value Set). If a member received only one type of anticonvulsant, the drug serum concentration level test must be for the specific drug taken as a persistent medication (i.e., a member on phenytoin received a drug serum test for phenytoin). If a member persistently received multiple types of anticonvulsants, each anticonvulsant medication and drug monitoring test combination is counted as a unique event (i.e., a member on both phenytoin and valproic acid with at least 180 treatment days for each drug in the measurement year must separately show evidence of receiving drug serum concentration tests for each drug to be considered numerator-compliant for each drug). Exclusion (optional) Exclude members from each eligible population rate who had an inpatient (acute or nonacute) claim/ encounter during the measurement year. ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 Data Elements for Reporting Organizations that submit HEDIS data to NCQA must provide the following data elements. Table MPM-1/2/3: Data Elements for Annual Monitoring for Patients on Persistent Medications Administrative Measurement year Data collection methodology (Administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval For each of the 3 rates and total For each of the 3 rates and total For each of the 3 rates and total For each of the 3 rates and total For each of the 3 rates and total ©2014 National Committee for Quality Assurance 6 Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 7 Annual Monitoring for Patients on Persistent Medications (MPM) Measure Work-up Measure Description This measure assesses the percentage of members 18 years of age and older who received a least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report each of the four rates separately and as a total rate. Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. Digoxin: At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. Any of the following during the measurement year meet criteria: – Diuretics: At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year. – Anticonvulsants: At least one drug serum concentration level monitoring test for the prescribed drug during the measurement year. Total rate (the sum of the four numerators divided by the sum of the four denominators) Topic Overview Importance and Prevalence Prevalence In a given week, an average of 82 percent of adults in the U.S. take at least one medication (prescription or nonprescription drug, vitamin/mineral, herbal/natural supplement); 29 percent take five or more (Slone Survey, 2006). While the prevalence of medication use has not increased dramatically since 2000, polypharmacy has increased from 23 percent to 29 percent for use of five or more medications, and from 6.3 percent to 12 percent for use of at least five prescription drugs (Slone Survey, 2006). Prescription medication use is highest among older adults. A 2005–2006 survey of adults aged 57–85 found that 81 percent of older adults reported using at least one prescription medication and 29 percent of survey respondents used at least five prescription medications concurrently. Use of at least five prescription medications was highest among men (37.1 percent) and women (36.0 percent) aged 75–85 years (Qato et al., 2008). The same national survey of older adults found that the most commonly used prescription or over-the-counter medications were cardiovascular agents. Aspirin was the most commonly used medication (28 percent of respondents), followed by hydrochlorothiazide (diuretic used by 15.6 percent of patients during the measurement year.) The ACE-inhibitor lisinopril use was 12.2 percent of respondents and the angiotensin receptor blockers amlodipine and valsartan were used by 8.3 percent and 4.6 percent of respondents, respectively (Qato et al., 2008). Health importance Approximately 1.5 million preventable adverse drug events occur in the United States each year (Institute of Medicine, 2007). Some result from a lack of appropriate monitoring. Appropriate monitoring is critical for detecting potentially harmful effects of a medication and adjusting the dosage (Steinman et al., 2011). A cohort study of 30,397 Medicare enrollees that examined drug-related incidents in ambulatory clinical settings found that 60.8 percent of identified preventable adverse drug events occurred due to errors in monitoring, and inadequate laboratory monitoring of drug therapies accounted for errors in 36.1 percent of these preventable adverse drug ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 events. Diuretics as a drug class accounted for 22.1 percent of all preventable adverse drug events, second only to cardiovascular agents, which accounted for 24.5 percent (Gurwitz et al., 2003). Although the majority of research on adverse drug events has focused primarily on older adults, adverse drug events are not exclusive to older adults. Younger adults taking persistent medications are at risk for the same adverse drug events if appropriate monitoring is not provided. The most severe adverse drug events can result in hospitalization. From 2007–2009, there were an estimated 99,628 emergency hospitalizations for adverse drug events in adults 65 years of age or older. The medications in this measure were all listed among the 13 most commonly implicated medications in emergency hospitalization for adverse drug event: Digoxin (3.5 percent). Renin-angiotensin inhibitors (2.9 percent). Anticonvulsants (1.7 percent). Diuretics (1.1 percent). Digoxin was also the medication most likely to result in hospitalization after an ED visit (80 percent of ED visits for individuals on digoxin results in hospitalization). The four most commonly implicated medications or medication classes were warfarin (33.3 percent), insulin (13.9 percent), oral antiplatelet agents (13.3 percent) and oral hypoglycemic agents (10.7 percent) (Budnitz et al., 2011). Financial importance and cost effectiveness The exact financial cost of not monitoring individuals on persistent medications is unknown, but the resource use and cost associated with adverse drug events can shed light on the financial impact. A recent estimation revealed that in the U.S., the cost of problems linked to drug use in the ambulatory setting exceeded $177 billion in 2000 (Rodriguez et al., 2003). A retrospective cohort study of Medicare enrollees found that for all adverse drug events, the increase in post-event costs over the preevent period was $1,310 greater for those experiencing an adverse drug event than a comparison group, after controlling for age, sex, comorbidity, number of scheduled medications and hospitalization during the pre-event period. For preventable adverse drug events, the post-event health care costs were $1,983 greater. The national annual costs were estimated to be $887 million in 2000 (Field et al., 2005). Several studies have found that in both hospital and ambulatory settings, adverse drug events that result in more serious patient outcomes (e.g., life threatening or fatal) are more likely to be preventable than less serious adverse drug events (Gurwitz et al., 2003; Bates et al., 1995; Gurwitz et al., 2000). Adverse drug events are generally considered preventable when they are due to error that could have been avoided. For individuals on persistent medications, appropriate monitoring will reduce the number of preventable adverse drug events, thereby improving patient safety and outcomes while decreasing health care costs. ©2014 National Committee for Quality Assurance 8 Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 9 Supporting Evidence for Annual Monitoring To help re-evaluate this measure, NCQA contracted with a team of researchers at the Johns Hopkins Hospital Center for Medication Quality and Outcomes to review the current evidence for annual monitoring for adults using these medications. The initial search strategy included evidence- and consensus-based guidelines, meta-analyses and systematic reviews. Upon review, the search strategy was broadened to include randomized, controlled trials and cohort studies, in addition to relevant studies listed in the selected articles. Two independent reviewers evaluated all selected articles to ensure quality. Where evidence included at least one large, high-quality, randomized controlled trial, the researchers rated the evidence “sufficient.” Their conclusions for each medication class included in this measure were as follows: ACE Inhibitors or ARBs ACE inhibitors and ARBs are commonly used medications to treat hypertension. There is sufficient evidence from several retrospective cohort studies (Miao 2011; Hurley 2005; Coleman 2010; Raebel 2007), and the Reduction in Endpoints with the Angiotensin Antagonist Losartan (RENAAL) trial that that ACE inhibitors or ARBs can increase serum potassium concentrations (Brenner 2000). High serum potassium, known as hyperkalemia, is a potentially fatal condition that can alter heart function and cause arrhythmias. Additionally, ACE inhibitors and ARBs can decrease renal function, for which serum creatinine is a commonly used clinical marker (Gottlieb 1992; Packer 1987; Burnier 1989; Hurley 2005; Coleman 2010; Raebel 2007). Therefore, serum potassium and serum creatinine are clinically useful monitoring parameters for these potentially serious safety concerns associated with the use of these drugs. Typically, if hyperkalemia or decreased renal function are observed, more frequent monitoring may be conducted or ACE inhibitor or ARB therapy may be withdrawn. Frequency of monitoring depends on the amount of time an individual has been taking the medication, but annual monitoring is the minimum appropriate frequency (McDowell 2013). There is less evidence of the utility of using blood urea nitrogen to monitor renal function for patients taking ACE inhibitors or ARBs; however, serum creatinine will be available in virtually all cases where a blood urea nitrogen is reported. There is insufficient evidence to justify using serum sodium or serum urea as a monitoring parameter for patients taking ACE inhibitors or ARBs. Digoxin Digoxin is used to treat heart failure and abnormal heart rhythms. Evidence from multiple RCTs supports using an annual serum digoxin concentration measurement as a monitoring parameter (Uretsky 1993; Packer 1993; Garg 1997; Young 1998; Krum 1995; Hurley 2005). Digoxin toxicity is known to be a serious (potentially fatal) safety concern and there are a number of factors (e.g., decreased renal function or changes in serum electrolyte concentrations) that may precipitate toxicity, even in the setting of a stable dose over time. Although we recommend monitoring serum potassium and serum creatinine during digoxin therapy, the clinical evidence to support this recommendation is less strong. However, it is generally accepted and agreed on that hypokalemia poses a serious and potentially fatal risk to patients taking digoxin and diuretics (Hurley 2005; Pinkerman 2013; Hunt 2009). Additionally, digoxin is excreted renally; therefore, monitoring serum creatinine is critical for determining if digoxin is affecting renal function. The utility of blood urea nitrogen monitoring has been studied less. Diuretics Diuretics are used to treat a number of heart-related conditions, including high blood pressure; heart failure; kidney and liver problems; and glaucoma. Evidence from the Randomized Aldactone Evaluation Study (RALES) trial (Pitt 1999), the Eplerenome Post-AHI Heart Failure Efficacy and Survival Study (EPHESUS) trial (Pitt 2003) and other evidence and consensus based guidelines (Lindenfeld 2010; Hunt 2009; McDowell 2013) supports using serum creatinine and serum potassium as annual ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 monitoring parameters for patients taking diuretics. Hypokalemia (decreased potassium level) is a common adverse effect of treatment with diuretics and may cause fatal arrhythmias and increase the risk of digitalis (digoxin) toxicity. Hyperkalemia (increased potassium levels) may complicate therapy with ACE inhibitors, ARBs, and potassium-sparing diuretics (aldosterone antagonists) (Hunt 2009; Juurlink 2003; Juurlink 2004; Scensson 2004). There is less evidence of the utility of using blood urea nitrogen to monitor renal function for patients taking diuretics. Anticonvulsants Gaps in care Although monitoring the concentration of antiepileptic medications is common in clinical practice, the best evidence demonstrates no advantage to annual drug concentration monitoring, compared with using clinical response to therapy (Tomson 2007; Jannuzzi 2000). Some lower forms of evidence (reviews and FDA labels) suggest that serum concentration monitoring may be useful in revealing drug interactions and in patients taking multiple antiepileptic medications (Patsalos 2008; Johannessen 2010; Eadie 2001). Recent data from the HEDIS® Health Plan measure set show overall high rates of annual monitoring for patients using ACE inhibitors or ARBs, digoxin or diuretics (79 percent–93 percent across all product types). Rates of monitoring for patients using anticonvulsants have remained relatively flat and low (56 percent–70 percent of patients receiving annual monitoring) across all plans since 2007. Medicare plans have consistently had higher rates of performance, compared with commercial and Medicaid plans. The gap between the 10th and 90th percentile for the total monitoring rate is approximately 10 percentage points for commercial plans and approximately 6 percentage points for Medicaid and Medicare plans. Health care disparities Several studies have examined racial and gender disparities in the use of medications by older adults and have found differences in rates of medication-related problems (Gaskin et al., 2006; Lewey et al., 2013; Qato et al., 2010; Roth et al., 2011). Medication monitoring may therefore be particularly relevant to those populations who experience higher rates of medication-related problems. ©2014 National Committee for Quality Assurance 10 Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 11 Selected Guidelines Table 1: Monitoring for Patients on ACE Inhibitors or ARBs Reference FDA Label (FDAa, 2012) FDA Label (FDAb, 2013) Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (Chobanian 2003) Medication ACE Inhibitors—Lotensin® (benazepril) ARB—Cozaar® (losartan potassium) ACE Inhibitor ARB Monitoring Parameter Renal function: serum creatinine or blood urea nitrogen Population Hypertensive patients with impaired renal function Monitoring Frequency Within first few weeks of therapy Rationale Treatment associated with increases in blood urea nitrogen and serum creatinine. Serum potassium Patients using an ACE Inhibitor and potassium supplements or potassiumsparing diuretics Monitor frequently Hyperkalemia occurred in approximately 1% of hypertensive patients Serum creatinine Serum potassium Patients with type 2 diabetes with nephropathy Endpoint: doubling of serum creatinine Based on the RENAAL study, treatment associated with reduction in the occurrence of sustained doubling of serum creatinine3 Incidence of hyperkalemia was higher in active treatment group than placebo but few patients discontinued treatment Serum creatinine Blood urea nitrogen Patients with unilateral or bilateral renal artery stenosis Serum potassium Patients with heart failure and using an aldosterone antagonist Patients with renal disease or renal transplantation Serum creatinine Serum potassium ©2014 National Committee for Quality Assurance Treatment associated with increases in serum creatinine or blood urea nitrogen 1–2 weeks following initiation or escalation in therapy 1–2 weeks following initiation or escalation in therapy Risk of hyperkalemia Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 Reference American College of Cardiology and the American Heart Association (Hunt 2009) Medication ACE Inhibitor ARB Monitoring Parameter Serum potassium Population Patients with heart failure Monitoring Frequency Serial monitoring Renal function Serum potassium Patients using an ACE Inhibitor and potassiumsparing diuretic (aldosterone antagonist) ACE Inhibitor Renal function Serum creatinine Institute for Clinical Systems Improvement (Pinkerman 2013) ACE Inhibitor ARB Serum creatinine Blood urea nitrogen Serum potassium Patients with bilateral renal artery stenosis or using an nonsteroid anti-inflammatory drug Patients age 18 years or older with heart failure Renal Function: monthly for first 3 months and then every 3 months Potassium: within 3 days and again at 1 week Renal function: monthly for first 3 months and then every 3 months Best practice in primary care pathology/ European Task Force Guidelines (Smellie 2007; Burden 2005; Swedberg 2005) ACE Inhibitor ARB Serum creatinine Serum electrolytes Low-risk patients with heart failure using ACE Inhibitors, ARBs, and diuretics High-risk patients with heart failure using potassiumsparing diuretics or combination therapy or with existing renal dysfunction ©2014 National Committee for Quality Assurance 1–4 weeks after initiation/dose increase then 1–2 times per year If elderly: 1–2 weeks after initiation/dose increase, then 1–2 times per year 1–2 weeks after each dose increase/relevant drug addition 5–7 days after each dose increase/relevant drug addition 12 Rationale Hyperkalemia may complicate therapy and cause cardiac conduction disturbances Increases risk for hyperkalemia Increases serum creatinine level To assess deterioration in kidney function associated with use of ACEIs or ARBs (patients with kidney disease and/or heart failure) Based on the European Taskforce guideline Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 13 Table 2: Monitoring for Patients on Digoxin Reference Heart Failure Society of America (Lindenfeld 2010) Medication Digoxin Monitoring Parameter Serum digoxin (0.7– 0.9 ng/mL) Population Majority of patients except the elderly or those with impaired renal function Frequency Monitoring in specific situations (see rationale) Rationale Serum digoxin concentration <1.0 ng/mL were associated with favorable outcomes whereas those >1.2 ng/mL were associated with harm (B): Monitoring considered when: A significant change in renal function occurs A potentially interacting drug is added or discontinued Confirmation of suspected digoxin toxicity FDA Label (FDAc, 2013) Institute for Clinical Systems Improvement (Pinkerman 2013) American College of Cardiology and the American Heart Association (Hunt 2009) Digoxin (Lanoxin) Digoxin Digoxin Serum digoxin Adults with mild to moderate heart failure and for the control of resting ventricular rate in patients with chronic atrial fibrillation Sample just before next scheduled dose of drug Blood tests will be necessary to ensure digoxin dose is appropriate (therapeutic and toxic effect) Serum digoxin Elderly or renal-impaired patient with heart failure Monitor at 1–2 weeks after initiation Monitor to avoid digoxin toxicity: serum digoxin levels do not always correlate to symptoms of toxicity Serum digoxin Patients age 18 years or older with heart failure 5- to 7-days after initiation/dose change Monitoring also recommended for: suspected toxicity, suspected non-adherence, new or existing renal dysfunction, determination of therapeutic range Serum creatinine Electrolytes Patients age 18 years or older with heart failure Baseline and periodically thereafter Serum potassium Patients with heart failure and using a diuretic Serial monitoring Dose of digoxin should be based on clinical grounds but serum digoxin concentration can be helpful to the clinician in determining the adequacy of digoxin therapy and in assigning certain probabilities to the likelihood of digoxin intoxication. ©2014 National Committee for Quality Assurance Hypokalemia may cause fatal arrhythmias and increase the risk of digoxin toxicity Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 14 Table 3: Monitoring for Patients on Diuretics Monitoring Parameter Serum potassium Population Patients with heart failure Aldosterone Antagonist (Potassium-Sparing Diuretic) Serum potassium Patients with heart failure Varied with RCT RALES Trial: Serum potassium was monitored every 4 weeks for 12 weeks, every 3 months up to a year, and every 6 months after the first year during Potassium-Sparing Diuretic therapy in patients with diabetes or renal insufficiency or in those taking ACE Inhibitors or ARBs. EPHESUS Trial: Serum potassium was monitored at 48 hours, at 4–5 weeks, and then every 3 months during Potassium-Sparing Diuretic therapy in patients taking a large number of concomitant medications. Spironolactone Serum potassium Serum creatinine Patients with heart failure Within first few weeks of the treatment See rationale above. Eplerenone Electrolytes, especially serum potassium Patients with heart failure and with eGFR <60 ml/min, baseline serum potassium >4.3 mEq/L, diabetes mellitus, and prior use of antiarrhythmic drugs Not specified See rationale above. Reference Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. (Chobanian 2003) Medication Potassium-Sparing Diuretic Heart Failure Society of America (Lindenfeld 2010) Frequency ©2014 National Committee for Quality Assurance Rationale Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 Reference American College of Cardiology and the American Heart Association (Hunt 2009) 15 Medication Diuretics Monitoring Parameter Serum potassium Population Patients with heart failure Frequency Not specified Rationale Hypokalemia is a common adverse effect of treatment with Diuretics and may cause fatal arrhythmias and increase the risk of digitalis (digoxin) toxicity, whereas hyperkalemia may complicate therapy with ACE Inhibitors, ARBs, and Potassium-Sparing Diuretics (Aldosterone Antagonists) Potassium-Sparing Diuretic (Aldosterone Antagonist) Serum potassium Renal function Patients with heart failure 3 days, 1 week, 3 months, and then 3 month intervals Subsequent monitoring should be dictated by the general clinical stability of renal function and fluid status The addition or an increase in dosage of ACE Inhibitors or ARBs should trigger a new cycle of monitoring Potassium-Sparing Diuretic (Aldosterone Antagonists) Serum potassium Renal function Patients with heart failure Not recommended Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of the therapy in patients with current or prior symptoms of heart failure Institute for Clinical Systems Improvement (ICSI)36 ACE Inhibitor ARB Diuretic Potassium-Sparing Diuretic (Aldosterone Antagonist) Serum potassium Electrolytes Renal function Patients with heart failure and hypotension Not specified NA FDA Label (FDAd, 2011) LASIX® (furosemide) Serum electrolytes (particularly potassium) Serum creatinine Blood urea nitrogen Patients taking Laxis frequently during the first few months of therapy and periodically thereafter NA FDA Label (FDAe, 2013) Aldactone® (spironolactone) Serum electrolytes Elderly patients and those with significant renal or hepatic impairments Not specified NA FDA Label (FDAf, 2011) Hydrochlorothiazide Serum electrolytes Not specified Not specified NA ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 16 Table 4: Monitoring for Patients on Anticonvulsants Reference FDA Label (FDAg 2012) Medication Dilantin® (Phenytoin) Monitor Parameter Serum drug concentration (10 to 20 μg/mL) Population Not specified FDA Label (FDAh, 2013) Depakene® (Valproic acid) Serum drug concentration Not specified FDA Label (FDAi, 2013) Tegretol® (carbamazepine) Serum drug concentration Not specified Frequency When a change in the dosage form or brand is prescribed, careful monitoring of phenytoin serum levels should be carried out Rationale NA A good correlation has not been established between daily dose, serum concentrations, Not specified ©2014 National Committee for Quality Assurance Since valproate may interact with concurrently administered drugs which are capable of enzyme induction, periodic plasma concentration determinations of valproate and concomitant drugs are recommended during the early course of therapy Monitoring of blood levels has increased the efficacy and safety of anticonvulsants and aided in determining the cause of toxicity when more than one medication is being used Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 17 References Aronow, W.S. 1996. Prevalence of appropriate and inappropriate indications for use of digoxin in older patients at the time of admission to a nursing home. Journal of the American Geriatrics Society. 44(5), 588. Bates, D.W., Cullen, D.J., Laird, N., Petersen, L.A., Small, S. D., Servi, D., Laffel, G., Sweitzer, B.J., Shea, B.F., Hallisey, R., Edmondson, A. 1995. Incidence of adverse drug events and potential adverse drug events. Journal of the American Medical Association. 274(1), 29–34. Brenner, B.M., M.E. Cooper, D. de Zeeuw, et al. 2000. The losartan renal protection study--rationale, study design and baseline characteristics of RENAAL (Reduction in ENdpoints with the Angiotensin Antagonist Losartan). Journal of the renin-angiotensin-aldosterone system: Journal of the Renin-AngiotensinAldosterone System. 1(4): 328–35. Budnitz, D.S., N. Shehab, S.R. Kegler, C.L. Richards. Emergency department visits for adverse drug events in older adults: the contribution of potentially inappropriate medication use. Annals of Internal Medicine. 2007; 147: 755–65. Budnitz, D., et al. 2006. National surveillance of emergency department visits for outpatient adverse drug events. Journal of the American Medical Association. 296:1858–66. Budnitz, D.S., M.C. Lovegrove, N. Shehab, and C.L. Richards. 2011. Emergency hospitalizations for adverse drug events in older Americans. New England Journal of Medicine. 365(21), 2002–12. Burden, R., and C. Tomson. 2005. Identification, management and referral of adults with chronic kidney disease: Concise guidelines. Clinical Medicine. 5(6): 635–42. Burnier, M., B. Waeber, J. Nussberger, et al. 1989. Effect of angiotensin converting enzyme inhibition in renovascular hypertension. Journal of Hypertension Suppl. 7(7): S27–31. Chobanian, A.V., G.L. Bakris, H.R. Black, et al. 2003. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 42(6): 1206–52. Coleman, J.J., S.E. McDowell, S.J. Evans, et al. 2010. Oversight: A retrospective study of biochemical monitoring in patients beginning antihypertensive drug treatment in primary care. British Journal of Clinical Pharmacology. 70(1): 109–17. Eadie, M.J. 2001. Therapeutic drug monitoring—antiepileptic drugs. British Journal of Clinical Pharmacology. 52 Suppl 1: 11S–20S. Federal Drug Administration (FDAa). LOTENSIN- benazepril hydrochloride tablet. Novartis Pharmaceutical Corporation; 2012. December 6, 2013. http://labels.fda.gov/ Federal Drug Administration (FDAb). COZAAR- losartan potassium tablet, film coated. Merck & Company, Inc.; 2013. December 6, 2013. http://labels.fda.gov/. Federal Drug Administration (FDAc). LANOXIN- digoxin tablet . Cardinal Health. 2013. December 6, 2013. http://labels.fda.gov/ Federal Drug Administration (FDAd). Lasix (furosemide) prescribing information. Bridgewater, NJ: SanofiAventis. 2011. December 6, 2013. http://labels.fda.gov/ Federal Drug Administration (FDAe). Aldactone (spironolactone) prescribing information. New York, NY; Pfizer. 2013. December 6, 2013. http://labels.fda.gov/ Federal Drug Administration (FDAf). Hydrochlorothiazide prescribing information. Morgantown, WV; Mylan pharmaceuticals. 2011. December 6, 2013. http://labels.fda.gov/ Federal Drug Administration (FDAg). Dilantin (phenytoin) prescribing information. New York, NY; Pfizer. 2012. December 6, 2013. http://labels.fda.gov/ Federal Drug Administration (FDAh). Depakene (valproic acid) prescribing information. North Chicago, IL; Abbvie Inc. 2013. December 6, 2013. http://labels.fda.gov/ Federal Drug Administration (FDAi). Tegretol ® (carbamazepine) prescribing information. East Hanover, NJ; Novartis. 2013. December 6, 2013. http://labels.fda.gov/ Field, T.S., B.H. Gilman, S. Subramanian, J.C. Fuller, D.W. Bates, and J.H. Gurwitz. 2005. The costs associated with adverse drug events among older adults in the ambulatory setting. Medical care. 43(12), 1171–76. Fishkind, D., B.E. Paris, and W.S. Aronow. 1997. Use of digoxin, diuretics, beta blockers, angiotensinconverting enzyme inhibitors, and calcium channel blockers in older patients in an academic hospital-based geriatrics practice. Journal of the American Geriatrics Society. 45(7), 809. Garg, R., and R. Gorlin R. 1997. The effect of digoxin on mortality and morbidity in patients with heart failure. The New England Journal of Medicine. 336(8): 525–33. Gaskin, D.J., B.A. Briesacher, R. Limcangco, and B.L. Brigantti. 2006 Exploring racial and ethnic disparities in prescription drug spending and use among Medicare beneficiaries. The American Journal of Geriatric Pharmacotherapy. 4(2), 96–111. ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 18 Gottlieb, S.S., S. Robinson, C.M. Krichten, et al. 1992. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. American Journal of Cardiology. 70(9): 890–3. Gurwitz, J.H., T.S. Field, L.R. Harrold, J. Rothschild, K. Debellis, A.C. Seger, C. Cadoret, L.S. Fish, L. Garber, M. Kelleher, and D.W. Bates. 2003. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Journal of the American Medical Association. 289(9), 1107–16. Gurwitz, J.H., T.S. Field, J. Avorn, D. McCormick, S. Jain, M. Eckler, M. Benser, A.C. Edmonson, and D.W. Bates. 2000. Incidence and preventability of adverse drug events in nursing homes. The American Journal of Medicine. 109(2), 87–94. Hunt, A.W., M.H. Chin, et al. 2009. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 119(14): e391–479. Hurley, J.S., M. Roberts, L.I. Solberg, et al. 2005. Laboratory safety monitoring of chronic medications in ambulatory care settings. Journal of General Internal Medicine. 20(4): 331–3. Institute of Medicine. 2007. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press. Jannuzzi, G., P. Cian, C. Fattore, et al. 2000. A multicenter randomized controlled trial on the clinical impact of therapeutic drug monitoring in patients with newly diagnosed epilepsy. Epilepsia. 41(2): 222-30. Johannessen, S.I., and C.J. Landmark. 2010. Antiepileptic drug interactions - principles and clinical implications. Current Neuropharmacology. 8(3): 254–67. Juurlink, D.N., M. Mamdani, A. Kopp, et al. 2003. Drug-drug interactions among elderly patients hospitalized for drug toxicity. Journal of the American Medical Association. 289(13): 1652–8. Juurlink, D.N., M.M. Mamdani, D.S. Lee, et al. 2004. Rates of hyperkalemia after publication of the randomized aldactone evaluation study. New England Journal of Medicine. 351(6): 543–51. Krum, H., J. Bigger, R. Goldsmith, et al. 1995. Effect of long-term digoxin therapy on autonomic function in patients with chronic heart failure. Journal of American College of Cardiology. 25(2): 289–94. Lewey, J., W.H. Shrank, A.D. Bowry, E. Kilabuk, T.A. Brennan, and N.K. Choudhry. 2013. Gender and racial disparities in adherence to statin therapy: A meta-analysis. American Heart Journal. 165(5), 665–78. Lindenfeld, J., N.M. Albert, J.P. Boehmer, et al. 2010. HFSA 2010 comprehensive heart failure practice guideline. Journal of Cardiac Failure. 16(6): e1-194. McDowell, S.E., S.K. Thomas, J. Coleman, et al. 2013. A practical guide to monitoring for adverse drug reactions during antihypertensive drug therapy. Journal of the Royal Society of Medicine. 106(3): 87–95. Miao, Y., D. Dobre, H.J. Heerspink, et al. 2011. Increased serum potassium affects renal outcomes: A post hoc analysis of the reduction of endpoints in NIDDM with the angiotensin ii antagonist losartan (RENAAL) trial. Diabetologia. 54(1): 44-50. Packer, M., M. Gheorghiade, J. Young, et al. 1993. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. The New England Journal of Medicine. 329(1): 1–7. Packer, M. 1987. Adaptive and maladaptive actions of angiotensin ii in patients with severe congestive heart failure. American Journal of Kidney Disease. 10(1 Suppl 1): 66–73. Patsalos, P.N., D.J. Berry, B.F.D. Bourgeois, et al. 2008. Antiepileptic drugs—best practice guidelines for therapeutic drug monitoring: A position paper by the Subcommission on Therapeutic Drug Monitoring, Ilae Commission on Therapeutic Strategies. Epilepsia. 49(7): 1239–76. Pinkerman, C., P. Sander, J.E. Breeding, et al. 2013. Heart failure in adults. Institute for Clinical Systems Improvement (ICSI). 2013. Pitt, B., W. Remme, F. Zannad, et al. 2003. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. New England Journal of Medicine. 348(14): 1309–21. Pitt, B., F. Zannad, W.J. Remme, et al. 1999. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized aldactone evaluation study investigators. New England Journal of Medicine. 341(10): 709–17. Qato, D.M., G.C. Alexander, R.M. Conti, M. Johnson, P. Schumm, and S.T. Lindau. 2008. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. Journal of the American Medical Association. 300(24), 2867–78. Qato, D.M., S.T. Lindau, R.M. Conti, L.P. Schumm, and G.C. Alexander. 2010. Racial and ethnic disparities in cardiovascular medication use among older adults in the United States. Pharmacoepidemiology and Drug Safety. 19(8), 834–42. Raebel, M.A., et al. May 2006. Monitoring of drugs with a narrow therapeutic range in ambulatory care. American Journal of Managed Care. 12(5):268–74. ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 19 Raebel, M.A., D.L. McClure, S.R. Simon, et al. 2007. Laboratory monitoring of potassium and creatinine in ambulatory patients receiving angiotensin converting enzyme inhibitors and angiotensin receptor blockers. Pharmacoepidemiology and Drug Safety. 16(1): 55–64. Rodriguez-Monguio, R., M. Otero, J. Rovira. 2003. Assessing the economic impact of adverse drug effects. Pharmacoeconomics. 21:623–50. Roth, M.T., C.G. Moore, J.L. Ivey, D.A. Esserman, W.H. Campbell, and M. Weinberger. 2008. The quality of medication use in older adults: methods of a longitudinal study. The American Journal of Geriatric Pharmacotherapy. 6(4), 220–33. Slone Epidemiology Center. Patterns of medication use in the United States, 2006: a report from the Slone Survey. http://www.bu.edu/slone/files/2012/11/SloneSurveyReport2006.pdf (November 2013) Smellie, W.S., J. Forth, J. Coleman, et al. 2007. Best practice in primary care pathology: Review 6. Journal of Clinical Pathology. 60(3): 225–34. Steinman, M.A., S.M. Handler, J.H. Gurwitz, G.D. Schiff, and K.E. Covinsky. 2011. Beyond the prescription: medication monitoring and adverse drug events in older adults. Journal of the American Geriatrics Society. 59(8), 1513–20. Stelfox, H.T., et al. November 2004. An evaluation of the adequacy of outpatient monitoring of thyroid replacement therapy. Journal of Evaluation in Clinical Practice. 10(4):525–30. Svensson, M., F. Gustafsson, S. Galatius, et al. 2004. How prevalent is hyperkalemia and renal dysfunction during treatment with spironolactone in patients with congestive heart failure? J Card Fail. 10(4): 297–303. Swedberg, K., J. Cleland, H. Dargie, et al. 2005. Guidelines for the diagnosis and treatment of chronic heart failure: Executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society Of Cardiology. European Heart Journal. 26(11): 1115–40. Tomson, T., M.L. Dahl, and E. Kimland. 2007. Therapeutic monitoring of antiepileptic drugs for epilepsy. Cochrane Database Systematic Reviews. (1): CD002216. Uretsky, B., J. Young, F. Shahidi, et al. 1993. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: Results of the proved trial. Journal of American College of Cardiology. 22(4): 955–62. Young, J., M. Gheorghiade, B. Uretsky, et al. 1998. Superiority of "triple" drug therapy in heart failure: Insights from the proved and radiance trials. Journal of American College of Cardiology. 32: 686–92. ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 20 HEDIS® Health Plan Performance Rates: Annual Monitoring For Patients On Persistent Medications (MPM) COMMERCIAL PRODUCT LINE Table 1. HEDIS® MPM Measure Performance (ACE Inhibitors or ARBS)—Commercial HMO Plans Year 2011 2012 2013 Total Number of Plans 242 221 219 Plans Able to Report (%) 231 (95.5) 211 (95.5) 212 (96.8) Average 81.6 82.5 82.9 Standard Deviation 4.8 5.0 4.3 10th Percentile 77.0 78.1 78.1 25th Percentile 79.3 80.6 80.7 50th Percentile 82.0 82.9 83.2 75th Percentile 84.5 85.4 85.5 90th Percentile 86.5 87.4 87.5 50th Percentile 78.9 79.4 79.6 75th Percentile 81.2 81.7 81.6 90th Percentile 83.0 83.2 83.6 50th Percentile 60.1 60.2 58.4 75th Percentile 65.5 65.1 63.7 90th Percentile 70.0 69.6 69.7 50th Percentile 58.6 57.0 56.4 75th Percentile 61.6 61.0 59.7 90th Percentile 64.5 63.7 62.7 Table 2. HEDIS MPM Measure Performance (ACE Inhibitors or ARBS)—Commercial PPO Plans Year 2011 2012 2013 Total Number of Plans 172 189 200 Plans Able to Report (%) 171 (99.4) 188 (99.5) 198 (99.0) Average 78.4 78.8 79.2 Standard Deviation 4.2 4.3 3.7 10th Percentile 73.0 73.7 74.1 25th Percentile 76.5 77.0 77.2 Table 3. HEDIS MPM Measure Performance (Anticonvulsants)—Commercial HMO Plans Year 2011 2012 2013 Total Number of Plans 242 221 219 Plans Able to Report (%) 204 (84.3) 178 (80.5) 179 (81.7) Average 60.4 60.5 58.8 Standard Deviation 8.1 7.6 8.8 10th Percentile 52.4 51.3 48.5 25th Percentile 55.8 56.1 52.8 Table 4. HEDIS MPM Measure Performance (Anticonvulsants)—Commercial PPO Plans Year 2011 2012 2013 Total Number of Plans 172 189 200 Plans Able to Report (%) 158 (91.9) 172 (91.0) 179 (89.5) Average 57.9 56.9 56.3 Standard Deviation 5.9 6.3 5.4 10th Percentile 50.8 50.0 48.9 25th Percentile 54.8 53.0 53.0 ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 21 Table 5. HEDIS MPM Measure Performance (Digoxin)—Commercial HMO Plans Year 2011 2012 2013 Total Number of Plans 242 221 219 Plans Able to Report (%) 161 (66.5) 129 (58.4) 129 (58.9) Average 84.6 85.4 86.5 Standard Deviation 7.5 7.1 6.4 10th Percentile 75.0 75.9 78.7 25th Percentile 82.0 82.8 82.8 50th Percentile 85.4 86.2 86.8 75th Percentile 89.5 89.8 91.5 90th Percentile 92.9 93.5 94.3 25th Percentile 74.7 75.9 77.8 50th Percentile 79.7 79.9 81.0 75th Percentile 83.8 84.2 84.5 90th Percentile 85.9 87.3 87.8 25th Percentile 78.6 79.7 79.9 50th Percentile 81.4 82.4 82.9 75th Percentile 84.1 84.9 85.2 90th Percentile 86.1 87.0 87.2 25th Percentile 75.8 76.4 76.7 50th Percentile 78.5 79.0 79.1 75th Percentile 81.0 81.3 81.1 90th Percentile 83.1 82.9 83.3 Table 6. HEDIS MPM Measure Performance (Digoxin)—Commercial PPO Plans Year 2011 2012 2013 Total Number of Plans 172 189 200 Plans Able to Report (%) 126 (73.3) 140 (74.1) 145 (72.5) Average 79.1 79.2 80.6 Standard Deviation 6.5 7.3 6.1 10th Percentile 71.0 69.3 71.8 Table 7. HEDIS MPM Measure Performance (Diuretics)—Commercial HMO Plans Year 2011 2012 2013 Total Number of Plans 242 221 219 Plans Able to Report (%) 231 (95.5) 211 (95.5) 212 (96.8) Average 81.0 82.1 82.5 Standard Deviation 4.9 5.0 4.5 10th Percentile 76.0 77.7 77.8 Table 8. HEDIS MPM Measure Performance (Diuretics)—Commercial PPO Plans Year 2011 2012 2013 Total Number of Plans 172 189 200 Plans Able to Report (%) 171 (99.4) 188 (99.5) 198 (99.0) Average 78.1 78.4 78.8 Standard Deviation 4.3 4.4 3.8 10th Percentile 72.9 73.0 74.1 ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 22 Table 9. HEDIS MPM Measure Performance (Total)—Commercial HMO Plans Year 2011 2012 2013 Total Number of Plans 242 221 219 Plans Able to Report (%) 231 (95.5) 212 (95.9) 212 (96.8) Average 80.9 81.9 82.3 Standard Deviation 4.8 4.9 4.4 10th Percentile 76.0 77.5 77.3 25th Percentile 78.5 80.1 79.8 50th Percentile 81.3 82.1 82.7 75th Percentile 83.8 84.5 85.0 90th Percentile 85.9 86.9 87.0 25th Percentile 75.9 76.2 76.6 50th Percentile 78.3 78.7 78.9 75th Percentile 80.7 80.9 80.8 90th Percentile 82.6 82.5 82.9 50th Percentile 91.8 92.1 92.6 75th Percentile 93.6 93.9 94.5 90th Percentile 94.9 95.2 96.1 50th Percentile 91.0 91.6 91.9 75th Percentile 92.4 92.8 93.2 90th Percentile 93.6 93.7 94.5 Table 10. HEDIS MPM Measure Performance (Total)—Commercial PPO Plans Year 2011 2012 2013 Total Number of Plans 172 189 200 Plans Able to Report (%) 171 (99.4) 188 (99.5) 199 (99.5) Average 77.8 78.2 78.5 Standard Deviation 4.2 4.3 3.9 10th Percentile 72.5 72.8 73.6 MEDICARE PRODUCT LINE Table 1. HEDIS MPM Measure Performance (ACE Inhibitors or ARBS)—Medicare HMO Plans Year 2011 2012 2013 Total Number of Plans 314 316 361 Plans Able to Report (%) 308 (98.1) 313 (99.1) 349 (96.7) Average 90.7 91.3 92.0 Standard Deviation 5.6 5.0 4.9 10th Percentile 86.1 87.4 88.5 25th Percentile 89.7 90.2 90.8 Table 2. HEDIS MPM Measure Performance (ACE Inhibitors or ARBS)—Medicare PPO Plans Year 2011 2012 2013 Total Number of Plans 128 139 155 Plans Able to Report (%) 127 (99.2) 139 (100.0) 152 (98.1) Average 90.8 91.4 91.6 Standard Deviation 2.9 3.0 3.4 10th Percentile 87.6 87.9 88.0 25th Percentile 89.2 89.8 90.0 ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 23 Table 3. HEDIS MPM Measure Performance (Anticonvulsants)—Medicare HMO Plans Year 2011 2012 2013 Total Number of Plans 314 316 361 Plans Able to Report (%) 262 (83.4) 281 (88.9) 286 (79.2) Average 68.2 67.4 66.7 Standard Deviation 10.4 10.2 9.9 10th Percentile 56.4 54.2 54.3 25th Percentile 62.5 61.6 60.2 50th Percentile 68.6 67.8 66.2 75th Percentile 73.9 73.6 71.6 90th Percentile 81.3 79.5 78.1 25th Percentile 62.7 62.0 60.7 50th Percentile 67.2 66.6 64.7 75th Percentile 72.8 72.0 70.0 90th Percentile 83.6 81.1 78.8 25th Percentile 91.5 91.8 93.3 50th Percentile 94.0 94.2 95.0 75th Percentile 95.6 95.8 96.5 90th Percentile 97.0 97.1 98.1 25th Percentile 90.5 91.0 91.7 50th Percentile 92.7 93.4 93.6 75th Percentile 94.0 95.0 95.0 90th Percentile 96.8 97.2 96.9 Table 4. HEDIS MPM Measure Performance (Anticonvulsants)—Medicare PPO Plans Year 2011 2012 2013 Total Number of Plans 128 139 155 Plans Able to Report (%) 102 (79.7) 118 (84.9) 127 (81.9) Average 69.1 68.5 66.3 Standard Deviation 10.8 11.0 11.9 10th Percentile 57.6 57.4 54.0 Table 5. HEDIS MPM Measure Performance (Digoxin)—Medicare HMO Plans Year 2011 2012 2013 Total Number of Plans 314 316 361 Plans Able to Report (%) 261 (83.1) 271 (85.8) 271 (75.1) Average 93.1 93.4 94.5 Standard Deviation 4.3 3.6 3.5 10th Percentile 88.4 88.9 90.6 Table 6. HEDIS MPM Measure Performance (Digoxin)—Medicare PPO Plans Year 2011 2012 2013 Total Number of Plans 128 139 155 Plans Able to Report (%) 108 (84.4) 124 (89.2) 134 (86.5) Average 92.7 93.2 93.2 Standard Deviation 3.1 3.4 3.3 10th Percentile 89.3 89.3 89.9 ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 24 Table 7. HEDIS MPM Measure Performance (Diuretics)—Medicare HMO Plans Year 2011 2012 2013 Total Number of Plans 314 316 361 Plans Able to Report (%) 308 (98.1) 313 (99.1) 348 (96.4) Average 90.9 91.6 92.2 Standard Deviation 5.7 5.0 5.0 10th Percentile 86.2 87.9 88.4 25th Percentile 89.9 90.5 91.1 50th Percentile 92.1 92.6 93.0 75th Percentile 93.8 94.1 94.8 90th Percentile 95.1 95.5 96.1 25th Percentile 89.9 90.6 90.4 50th Percentile 91.2 92.0 92.2 75th Percentile 92.8 93.3 93.4 90th Percentile 94.0 94.3 94.4 25th Percentile 89.1 89.8 90.0 50th Percentile 91.2 91.6 92.0 75th Percentile 93.2 93.5 94.0 90th Percentile 94.5 94.9 95.5 25th Percentile 89.1 89.6 89.5 50th Percentile 90.7 91.3 91.5 75th Percentile 92.3 92.5 92.8 90th Percentile 93.3 93.5 94.2 Table 8. HEDIS MPM Measure Performance (Diuretics)—Medicare PPO Plans Year 2011 2012 2013 Total Number of Plans 128 139 155 Plans Able to Report (%) 127 (99.2) 139 (100.0) 151 (97.4) Average 91.2 91.8 91.9 Standard Deviation 2.8 2.9 3.2 10th Percentile 87.9 88.5 88.7 Table 9. HEDIS MPM Measure Performance (Total)—Medicare HMO Plans Year 2011 2012 2013 Total Number of Plans 314 316 361 Plans Able to Report (%) 309 (98.4) 313 (99.1) 350 (97.0) Average 90.2 90.9 91.4 Standard Deviation 5.7 5.0 5.0 10th Percentile 85.9 86.8 87.2 Table 10. HEDIS MPM Measure Performance (Total)—Medicare PPO Plans Year 2011 2012 2013 Total Number of Plans 128 139 155 Plans Able to Report (%) 127 (99.2) 139 (100.0) 152 (98.1) Average 90.6 91.2 91.3 Standard Deviation 2.9 3.0 3.4 10th Percentile 87.4 87.6 88.0 ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 25 MEDICAID PRODUCT LINE Table 1. HEDIS MPM Measure Performance (ACE Inhibitors or ARBS)—Medicaid HMO Plans Year 2011 2012 2013 Total Number of Plans 184 191 213 Plans Able to Report (%) 130 (70.7) 157 (82.2) 176 (82.6) Average 86.0 85.9 86.3 Standard Deviation 4.1 5.4 4.6 10th Percentile 79.9 80.2 80.8 25th Percentile 83.6 83.7 84.6 50th Percentile 86.5 86.9 87.1 75th Percentile 88.6 89.2 89.2 90th Percentile 90.6 91.3 91.2 25th Percentile 63.2 61.7 61.8 50th Percentile 68.6 65.3 66.0 75th Percentile 72.6 70.3 70.7 90th Percentile 76.6 74.7 73.7 25th Percentile 87.5 87.9 87.5 50th Percentile 90.3 91.0 90.8 75th Percentile 93.3 93.4 93.2 90th Percentile 95.5 95.6 95.0 25th Percentile 82.8 83.2 83.8 50th Percentile 85.8 86.4 86.7 75th Percentile 88.6 88.9 89.1 90th Percentile 90.7 91.3 91.3 Table 2. HEDIS MPM Measure Performance (Anticonvulsants)—Medicaid HMO Plans Year 2011 2012 2013 Total Number of Plans 184 191 213 Plans Able to Report (%) 113 (61.4) 130 (68.1) 136 (63.9) Average 67.7 65.2 65.8 Standard Deviation 7.2 7.9 6.8 10th Percentile 57.6 53.7 55.6 Table 3. HEDIS MPM Measure Performance (Digoxin)—Medicaid HMO Plans Year 2011 2012 2013 Total Number of Plans 184 191 213 Plans Able to Report (%) 59 (32.1) 75 (39.3) 94 (44.1) Average 89.7 90.3 90.2 Standard Deviation 5.3 4.9 4.3 10th Percentile 80.4 83.3 83.7 Table 4. HEDIS MPM Measure Performance (Diuretics)—Medicaid HMO Plans Year 2011 2012 2013 Total Number of Plans 184 191 213 Plans Able to Report (%) 130 (70.7) 156 (81.7) 174 (81.7) Average 85.5 85.4 86.0 Standard Deviation 4.5 5.4 5.0 10th Percentile 79.3 78.5 80.0 ©2014 National Committee for Quality Assurance Draft Document for HEDIS 2015 Public Comment—Obsolete After March 19, 2014 26 Table 5. HEDIS MPM Measure Performance (Total)—Medicaid HMO Plans Year 2011 2012 2013 Total Number of Plans 184 191 176 Plans Able to Report (%) 132 (71.7) 157 (82.2) 176 (82.6) Average 83.9 83.9 84.5 Standard Deviation 4.1 5.0 4.5 10th Percentile 78.3 78.5 79.3 25th Percentile 81.8 81.2 82.4 ©2014 National Committee for Quality Assurance 50th Percentile 84.2 84.8 85.4 75th Percentile 86.7 87.0 87.3 90th Percentile 88.2 88.6 89.0