Draft Specification for Comprehensive Diabetes Care for Individuals with SMI
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Diabetes Care (not NQF-endorsed) and Minnesota Community Measurement’s Optimal Diabetes Care (NQF #0729))
Measure Dimension
Current Specification
Denominator Age 18 to 75 years of age.
Benefit Medical Continuous
Enrollment
No more than one gap in enrollment of up to 45 days during the measurement year. 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).
Denominator Details
Step 1: In claims data, identify diagnosis of Bipolar Disorder, Schizophrenia or Major Depression:
Identify individuals with schizophrenia, bipolar I disorder or major depression as those who met at least one of the following criteria during the measurement year:
At least one acute inpatient claim/encounter with any diagnosis of schizophrenia, bipolar I disorder or major depression.
At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or non-acute inpatient setting, on different dates of service with any diagnosis of schizophrenia or bipolar I disorder.
Step 2: Of the patients identified in Step 1, identify individuals with diabetes: There are two ways to identify individuals with diabetes: by pharmacy data and by claim/encounter data. The organization must use both methods to identify the eligible population, but an individual need only be identified by one to be included in the measure. Individuals may be identified as having diabetes during the measurement year or the year prior to the measurement year.
Pharmacy data
Individuals who were dispensed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis.
Claim/encounter data. Individuals who had a diagnosis of diabetes on claims for either (a) two face-to-face encounters in an outpatient setting or nonacute inpatient setting, on different dates of service; or (b) one face-to-face encounter in an acute inpatient or ED setting.
Numerator Total number of individuals who had each of the following during the measurement year: • Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%) • HbA1c control (<8.0%) • HbA1c control (<7.0%) • Eye exam
• LDL-C Screening
• LDL-C control (<100 mg/dL) • Medical attention for nephropathy
Draft Specification for Comprehensive Diabetes Care for Individuals with SMI
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Dimension
• Current tobacco use status and cessation counseling or treatment offered • For individuals with a diagnosis of ischemic vascular disease, documentation of
daily aspirin use or documentation of an accepted contraindication Numerator
Details
HbA1c Testing:
At a minimum, documentation in the medical record must include a note indicating the date when the HbA1c test was performed and the result. Organizations count notation of the following in the medical record as HbA1c testing: A1c, Hemoglobin A1c, HgbA1c, HbA1c, Glycohemoglobin A1c.
HbA1c Poor Control >9%:
The member is numerator compliant if the most recent HbA1c level is >9.0%. The
member is not numerator compliant if the result for the most recent HbA1c test during the measurement year is ≤9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.
HbA1c Control <8%:
The member is numerator compliant if the most recent HbA1c level is <8.0%. The member is not numerator compliant if the result for the most recent HbA1c test is ≥8.0% or is missing a result, or if an HbA1c test was not done during the measurement year. HbA1c control <7.0%*:
The member is numerator compliant if the most recent HbA1c level is <7.0%. The member is not numerator compliant if the result for the most recent HbA1c test is ≥7.0% or is missing a result, or if an HbA1c test was not performed during the measurement year.
*Note: Additional exclusion criteria are required for this indicator that will result in a different eligible population from all other indicators. See exclusion section for more information.
Eye Exam:
At a minimum, documentation in the medical record must include one of the following. A note or letter prepared by an ophthalmologist, optometrist, PCP or other health
care professional indicating that an opthalmoscopic exam was completed by an eye care professional, the date when the procedure was performed and the results, or
A chart or photograph of retinal abnormalities indicating the date when the fundus photography was performed and evidence that an eye care professional reviewed the results. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist. LDL-C Screening:
At a minimum, documentation in the medical record must include a note indicating the date when the LDL-C test was performed and the result. The organization may use a calculated or direct LDL for LDL-C screening.
Lipid management: LDL-C control <100 mg/dL:
Documentation in the medical record must include, at a minimum, a note indicating the date when the LDL-C test was performed and the result.
The member is numerator compliant if the most recent LDL-C level is <100 mg/dL. If the result for the most recent LDL-C test during the measurement
year is ≥100 mg/dL or is missing, or if an LDL-C test was not performed during the measurement year, the member is not numerator compliant.
Draft Specification for Comprehensive Diabetes Care for Individuals with SMI
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Dimension
The organization may calculate LDL-C levels from total cholesterol, HDL-C and triglycerides using the Friedewald equation if the triglycerides are less than or equal to 400 mg/dL.
(LDL-C) = (total cholesterol) – (HDL) – (triglycerides/5)
If lipoprotein (a) is measured, use the following calculation. (LDL-C) = (total cholesterol) – (HDL) –
(triglycerides/5) – 0.3 [lipoprotein (a)]
These formulae are used when all levels are expressed in mg/dL and cannot be used if triglycerides >400 mg/dL.
The Friedewald equation may not be used if a direct or calculated result is present in the medical record for the most recent LDL-C test.
Medical Attention for Nephropathy:
Nephropathy screening test. At a minimum, documentation must include a note indicating the date when a urine microalbumin test was performed, and the result. Any of the following meet the criteria for a urine microalbumin test:
24-hour urine for microalbumin Timed urine for microalbumin Spot urine for microalbumin
Urine for microalbumin/creatinine ratio 24-hour urine for total protein
Random urine for protein/creatinine ratio
Evidence of nephropathy. Any of the following meet the criteria for evidence of nephropathy.
Documentation of a visit to a nephrologist. Documentation of a renal transplant.
Documentation of medical attention for any of the following (no restriction on provider type):
o Diabetic nephropathy o ESRD
o CRF
o Chronic kidney disease (CKD) o Renal insufficiency
o Proteinuria o Albuminuria o Renal dysfunction o Acute renal failure (ARF)
o Dialysis, hemodialysis or peritoneal dialysis
A positive urine macroalbumin test. At a minimum, documentation in the medical record must include a note indicating the date when the test was performed, and a positive result. Any of the following meet the criteria for a positive urine
macroalbumin test:
o Positive urinalysis (random, spot or timed) for protein o Positive urine (random, spot or timed) for protein o Positive urine dipstick for protein
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Dimension
o Positive tablet reagent for urine protein o Positive result for albuminuria
o Positive result for macroalbuminuria o Positive result for proteinuria o Positive result for gross proteinuria
Note: “Trace” urine macroalbumin test results are not considered numerator compliant. Evidence of ACE inhibitor/ARB therapy. Documentation in the medical record
must include, at minimum, a note indicating that the member received an ambulatory prescription for ACE inhibitors/ARBs in the measurement year BP Control <140/90 mm Hg:
Organizations should use the medical record from which it abstracts data for the other CDC indicators. If the organization does not abstract for other indicators, it should use the medical record of the provider that manages the member’s diabetes. If that medical record does not contain a BP, the organization may use the medical record of another PCP or specialist from whom the member receives care.
To determine if BP is adequately controlled, the organization must identify the representative BP following the steps below
Step 1: Identify the most recent BP reading noted during the measurement year. Do not include BP readings that meet the following criteria:
Taken during an acute inpatient stay or an ED visit
Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole)
Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy) Reported by or taken by the individual
Step 2: Identify the lowest systolic and lowest diastolic BP reading from the most recent BP notation in the medical record. If there are multiple BPs recorded for a single date, use the lowest systolic and lowest diastolic BP on that date as the representative BP. The systolic and diastolic results do not need to be from the same reading when multiple readings are recorded for a single date.
Minnesota Community Measurement Optimal Diabetes Care Indicators: Current Tobacco Use and Cessation Counseling or Treatment:
Documentation of current tobacco use (1 = tobacco user; 2 = non-tobacco user; 3 = Not known). If individual is identified as a current tobacco user, date of cessation counseling or treatment during the measurement year is documented.
Aspirin Use:
Documentation in the medical record of daily aspirin use OR documentation of an accepted contraindication (any date) for individuals diagnosed with ischemic vascular disease during the measurement year or year prior to the measurement year.
The following are accepted aspirin or anti-platelet medications: Aspirin
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Dimension Ticlid (ticlopidine) Pravigard (aspirin/pravastatin) Aggrenox (aspirin/dypyridamole) Low dose enteric-coated 81 mg aspirin (Ecotrin or Bayer) Accepted contraindications:
• Anticoagulant use, Lovenox (Enoxaparin) or Coumadin (Warfarin) • Any history of gastrointestinal (GI)* or intracranial bleed (ICB) • Allergy to ASA
*Gastroesophogeal reflux disease (GERD) is not automatically considered a contraindication but may be
included if specifically documented as a contraindication by the physician. Contraindication considerations:
If ASA date field is completed (individual is taking ASA), leave the ASA
contraindication date field blank. For patients taking Coumadin or Lovenox AND ASA, enter the aspirin use date and NOT the contraindication date.
Contraindication date does not need to be in the measurement period. If only the month and year is known, i.e., “GI Bleeding-June 2007”, enter a valid date to indicate the time, i.e., 6/01/2007. Look back at least 3 or more years for contraindication date. If individual is on anticoagulant, enter the most recent date.
If the ASA has been discontinued prior to a surgical procedure, do not count this as a contraindication. Document this individual as taking aspirin during the measurement period.
If there is no documentation of aspirin use, anti-platelets, or a contraindication, then both date fields should be blank.
Exclusions for aspirin use:
The following may be exclusions if specifically documented by the physician: • Use of non-steroidal anti-inflammatory agents
• Documented risk for drug interaction
• Uncontrolled hypertension defined as >180 mmHg systolic, >110 mmHg diastolic pressure
• Other provider documented reason for not being on ASA therapy Exclusions Required exclusions for HbA1c Control <7%:
Exclude members who meet any of the following criteria.
• 65 years of age and older as of December 31 of the measurement year.
• ABG or PCI. Dated documentation of CABG or PCI in the measurement year or the year before the measurement year.
• IVD. Documentation of an IVD diagnosis. Look as far back as possible in the member’s history through December 31 of the measurement year. Appropriate diagnoses include:
o –IVD.
o –Ischemic heart disease. o –Angina.
o –Coronary atherosclerosis. o –Coronary artery occlusion. o –Cardiovascular disease.
o –Occlusion or stenosis of precerebral arteries (including basilar, carotid and vertebral arteries).
o –Atherosclerosis of renal artery.
o –Atherosclerosis of native arteries of the extremities. o –Chronic total occlusion of artery of the extremities.
Draft Specification for Comprehensive Diabetes Care for Individuals with SMI
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Dimension
o –Arterial embolism and thrombosis. o –Atheroembolism.
o
• Thoracoabdominal or thoracic aortic aneurysm. Documentation of thoracoabdominal aneurysm or thoracic aortic aneurysm. Look as far back as possible in the member’s history through December 31 of the measurement year.
• CHF. Documentation of CHF or cardiomyopathy diagnosis. Look as far back as possible in the member’s history through December 31 of the measurement year. • Prior MI. Documentation of prior MI. Look as far back as possible in the member’s
history through December 31 of the measurement year.
• CRF/ESRD. Documentation of Stage 4 or 5 CRF or ESRD. Look as far back as possible in the member’s history through December 31 of the measurement year. • Dementia. Documentation of dementia. Look as far back as possible in the member’s
history through December 31 of the measurement year.
• Blindness. Documentation of blindness in one or both eyes. Look as far back as possible in the member’s history through December 31 of the measurement year. • Amputation (lower extremity). Documentation of lower extremity amputation. Look as
far back as possible in the member’s history through December 31 of the measurement year
Optional Exclusions:
• Individuals with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur at any time in the individual’s history, but must have occurred by December 31 of the measurement year.
• Individuals with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur during the measurement year or the year prior to the measurement year, but must have occurred by December 31 of the measurement year.
Note: Organizations that apply optional exclusions must exclude individuals from the denominator for all indicators.
