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Recommended Starter Set

The Ambulatory Care Quality Alliance

Clinical Performance Measures for Ambulatory Care

The Ambulatory care Quality Alliance (AQA), the American Academy of Family Physicians (AAFP), American College of Physicians (ACP), America's Health Insurance Plans (AHIP), and Agency for Healthcare Research and Quality (AHRQ), consists of a large body of stakeholders that represents clinicians, consumers, purchasers, health plans and others. This document provides performance measures to be used a "starter set" for developing measures for ambulatory care.

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At the January 17-18, 2005, meeting, the large stakeholder group directed the AQA Performance Measurement Workgroup to propose a starter set of measures for ambulatory care, which align with agreed-upon parameters and address agreed-upon specific conditions/areas. The workgroup is recommending that the performance measures contained in this document serve as this starter set.

This recommendation was developed by the workgroup after significant discussion. The workgroup started with the "strawman" list of measures presented at the January meeting—all of which were part of the Centers for Medicare & Medicaid Services (CMS)/American Medical Association (AMA) Physician Consortium/National Committee for Quality Assurance (NCQA) ambulatory care performance measurement set that was submitted to National Quality Forum (NQF) for expedited review. Utilizing a modified "Delphi" exercise to help facilitate the discussion, the workgroup considered and primarily selected measures based on their ability to meet the following criteria:

Clinical importance and scientific validity.
Feasibility.
Relevance to physician performance.
Consumer relevance.
Purchaser relevance.

Other factors considered include whether measures were preliminarily approved by NQF's expedited review process and comments made during the last stakeholder meeting in January.

While the workgroup believes that this is a sound set of measures that meets primary goals, such as addressing the Institute of Medicine's (IOM) priority areas, they continue to recognize that this is an initial step in a multi-year process. Additional work needs to be done to build a more complete set of measures, which includes additional efficiency measures, sub-specialty measures, cross-cutting measures, patient experience measures and others.

Prevention Measures

Topic	Measures
1. Breast Cancer Screening^a	Percentage of women who had a mammogram during the measurement year or year prior to the measurement year.
2. Colorectal Cancer Screening^a	The percentage of adults who had an appropriate screening for colorectal cancer. One or more of the following: Fecal occult blood testing (FOBT): during measurement year. Flexible sigmoidoscopy: during the measurement year or the four years prior to the measurement year. DCBE: during the measurement year or the four years prior. Colonoscopy: during the measurement or nine years prior.
3. Cervical Cancer Screening^a	Percentage of women who had one or more Pap tests during the measurement year or the two prior years.
4. Tobacco Use^b	Percentage of patients who were queried about tobacco use one or more times during the two-year measurement period.
5. Advising Smokers to Quit^a	Percentage of patients who received advice to quit smoking.
6. Influenza Vaccination^a	Percentage of patients 50-64 who received an influenza vaccination.
7. Pneumonia Vaccination^a	Percentage of patients who ever received a pneumococcal vaccine.

Coronary Artery Disease (CAD)

Topic	Measures
8. Drug Therapy for Lowering LDL Cholesterol^b	Percentage of patients with CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines).
9. Beta-Blocker Treatment after Heart Attack^a	Percentage of patients hospitalized with acute myocardial infarction (AMI) who received an ambulatory prescription for beta-blocker therapy (within 7 days discharge).
10. Beta-Blocker Therapy—Post MI^a	Percentage patients hospitalized with AMI who received persistent betablocker treatment (6 months after discharge). Note: This measure was not reviewed by the NQF and therefore it is not approved.

Heart Failure

Topic	Measures
11. ACE Inhibitor/ARB Therapy^b	Percentage of patients with heart failure who also have LVSD who were prescribed ACE inhibitor or ARB therapy. Angiotensin receptor blocker (ARB) drugs are collected under this measure.
12. LVF Assessment^b	Percentage of patients with heart failure with quantitative or qualitative results of LVF assessment recorded.

Diabetes

Note: These measures were not approved during the NQF expedited review, as NQF has taken previous action on diabetes measures.

Topic	Measures
13. HbA1C Management^a	Percentage of patients with diabetes with one or more A1C test(s) conducted during the measurement year.
14. HbA1C Management Control^a	Percentage of patients with diabetes with most recent A1C level greater than 9.0% (poor control).
15. Blood Pressure Management^b	Percentage of patients with diabetes who had their blood pressure documented in the past year less than 140/90 mm Hg.
16. Lipid Measurement^a	Percentage of patients with diabetes with at least one Low Density Lipoprotein cholesterol (LDL-C) test (or ALL component tests).
17. LDL Cholesterol Level (<130mg/dL)^a	Percentage of patients with diabetes with most recent LDL-C less than 100 mg/dL or less than 130 mg/dL.
18. Eye Exam^a	Percentage of patients who received a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) during the reporting year or during the prior year if patient is at low risk for retinopathy. A patient is considered low risk if all three of the following criteria are met: The patient is not taking insulin. The patient has an A1C less than 8.0%. The patient has no evidence of retinopathy in the prior year.

Asthma

Topic	Measures
19. Use of Appropriate Medications for People w/ Asthma^a	Percentage of individuals who were identified as having persistent asthma during the year prior to the measurement year and who were appropriately prescribed asthma medications (e.g. inhaled corticosteroids) during the measurement year.
20. Asthma: Pharmacologic Therapy^b	Percentage of all individuals with mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.

Depression

Topic	Measures
21. Antidepressant Medication Management^a	Acute Phase: Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug during the entire 84-day (12-week) Acute Treatment Phase.
22. Antidepressant Medication Management^a	Continuation Phase: Percentage of adults who were diagnosed with a new episode of depression and treated with an antidepressant medication and remained on an antidepressant drug for at least 180 days (6 months).

Prenatal Care

Topic	Measures
23. Screening for Human Immunodeficiency Virus^b	Percentage of patients who were screened for HIV infection during the first or second prenatal visit.
24. Anti-D Immune Globulin^b	Percentage of D (Rh) negative, unsensitized patients who received anti-D immune globulin at 26-30 weeks gestation.

Quality Measures Addressing Overuse or Misuse

Topic	Measures
25. Appropriate Treatment for Children with Upper Respiratory Infection (URI)^a	Percentage of patients who were given a diagnosis of URI and were not dispensed an antibiotic prescription on or 3 days after the episode date.
26. Appropriate Testing for Children with Pharyngitis^a	Percentage of patients who were diagnosed with pharyngitis, prescribed an antibiotic and who received a group A streptococcus test for the episode.

^a. This performance measure was developed by and is owned by and the National Committee for Quality Assurance ("NCQA").

This performance measure is not a clinical guideline and does not establish a standard of medical care. NCQA makes no representations, warranties or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures.

NCQA holds a copyright in this measure and can rescind or alter the measure at any time. This measure may not be modified by anyone other than NCQA. Anyone desiring to use or reproduce the measure without modification for a noncommercial purpose may do so without obtaining any approval from NCQA. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. © 2004 National Committee for Quality Assurance, all rights reserved.

^b. Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium for Performance Improvement (the Consortium), are intended to facilitate quality improvement activities by physicians.

These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for all potential applications. The Consortium encourages the testing and evaluation of its Measures.

Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be responsible for any use of these Measures.

Current as of May 2005

Internet Citation:

The Ambulatory Care Quality Alliance Recommended Starter Set: Clinical Performance Measures for Ambulatory Care. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/aqastart.htm