AMA PCPI Measures

34 Pages·2008·0.36 MB·English

Measure Status: FINAL - PCPI Approved
Physician Consortium for Performance Improvement®

The Physician Consortium for Performance Improvement®

Preventive Care & Screening
Physician Performance Measurement Set

PCPI Approved

September 2008
FINAL –PCPI APPROVED
Physician Consortium for Performance Improvement®
Work Group Members
Preventive Care & Screening
Work Group Members
Martin C. Mahoney, MD, PhD (Co-Chair) (family medicine)
Stephen D. Persell, MD, MPH (Co-Chair) (internal medicine)

Gail M. Amundson, MD, FACP (internal medicine/geriatrics) G. Timothy Petito, OD, FAAO (optometry)
Joel V. Brill MD, AGAF, FASGE, FACG (gastroenterology) Rita F. Redberg, MD, MSc, FACC (cardiology)
Steven B. Clauser, PhD Barbara Resnick, PhD, CRNP (nurse practitioner)
Will Evans, DC, Phd, CHES (chiropractic) Sam JW Romeo, MD, MBA
Ellen Giarelli, EdD, RN, CRNP (nurse practitioner) Carol Saffold, MD (obstetrics & gynecology)
Amy L. Halverson, MD, FACS (colon & rectal surgery) Robert A. Schmidt, MD (radiology)
Alex Hathaway, MD, MPH, FACPM Samina Shahabbudin, MD (emergency medicine)
Charles M. Helms, MD, Phd (infectious disease) Melanie Shahriary RN, BSN (cardiology)
Kay Jewell, MD, ABHM (internal medicine/geriatrics) James K. Sheffield, MD (health plan representative)
Daniel Kivlahan, PhD (psychology) Arthur D. Snow, MD, CMD (family medicine/geriatrics)
Paul Knechtges, MD (radiology) Richard J. Snow, DO, MPH
George M. Lange, MD, FACP (internal medicine/geriatrics) Brooke Steele, MD
Trudy Mallinson, PhD, OTR/L/NZROT (occupational therapy) Brian Svazas, MD, MPH, FACOEM, FACPM (preventive medicine)
Elizabeth McFarland, MD (radiology) David J. Weber, MD, MPH (infectious disease)
Jacqueline W. Miller, MD, FACS (general surgery) Deanna R. Willis, MD, MBA, FAAFP (family medicine)
Adrienne Mims, MD, MPH (geriatric medicine) Charles M. Yarborough, III, MD, MPH (occupational medicine)
Sylvia Moore PhD, RD, FADA (dietetics)
Work Group Staff
American Medical Association
Kerri Fei, MSN, RN
Kendra Hanley, MS
Karen Kmetik, PhD
Liana Lianov, MD, MPH
Shannon Sims, MD, PhD
Litjen Tan, MS, PhD
Richard Yoast, PhD

Consortium Consultants
Rebecca Kresowik
Timothy Kresowik, MD

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Table of Contents
Purpose of Measures..........................................................................................................................................................4
Intended Audience and Patient Population...................................................................................................................4
Importance of Topic:.........................................................................................................................................................4
Incidence, Prevalence, & Cost.....................................................................................................................................4
Disparities.......................................................................................................................................................................5
Opportunity for Improvement/Gap or Variation in Care..................................................................................5
Available Evidence........................................................................................................................................................6
Measure Harmonization....................................................................................................................................................6
Measure Testing & Implementation................................................................................................................................6
Measure Specifications......................................................................................................................................................7
Measure Exclusions............................................................................................................................................................7
Measure #1: Tobacco Use: Screening & Cessation Intervention.............................................................................10
Measure #2: Unhealthy Alcohol Use: Screening.........................................................................................................14
Measure #3: Unhealthy Alcohol Use: Screening & Brief Counseling.......................................................................17
Measure #7: Cervical Cancer Screening........................................................................................................................21
Measure #9: Pneumococcal Immunization..................................................................................................................25
Measure #10: Obesity Screening....................................................................................................................................28
Guideline Evidence Classification and Rating Schemes............................................................................................32

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.

THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND

© 2008 American Medical Association. All Rights Reserved

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the
proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA,
the Consortium and its members disclaim all liability for use or accuracy of any Current Procedural
Terminology (CPT®) or other coding contained in the specifications.

THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

CPT® contained in the Measures specifications is copyright 2007 American Medical Association.
© 2008 American Medical Association. All Rights Reserved. 3
CPT® Copyright 2007 American Medical Association
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Physician Consortium for Performance Improvement®
Purpose of Measures
These clinical performance measures, developed by the Physician Consortium for Performance
Improvement® (PCPI), are designed for individual quality improvement. The measures may also be used in
data registries, continuing medical education programs, and in board certification programs. Unless
otherwise indicated, the measures are also appropriate for accountability if appropriate methodological,
statistical, and implementation rules are achieved.

The measure titles listed below may be used for accountability:

Measure #1: Tobacco Use: Screening & Cessation Intervention
Measure #2: Unhealthy Alcohol Use: Screening
Measure #3: Unhealthy Alcohol Use: Screening & Brief Counseling
Measure #7: Cervical Cancer Screening
Measure #9: Pneumococcal Immunization
Measure #10: Obesity Screening

Measures that address influenza immunization, screening mammography, colorectal cancer screening, and
lipid screening are forthcoming.
Intended Audience, Care Setting and Patient Population
These measures are designed for use by physicians and eligible health professionals who provide
preventive care and screening services to patients aged 18 years and older.

These measures are meant to be used to calculate for performance and/or reporting at the individual
physician level.

Importance of Topic
Incidence, Prevalence, & Cost

Tobacco Use
• In 2006, approximately 20.8% (45.3 million) U.S. adults were current smokers1. There has not
been a significant change in this prevalence since 20042.
• During 1997-2001, approximately 438,000 premature deaths each year are attributed to smoking
or exposure to second hand smoke3.
• The 2006 National Survey on Drug Use and Health (NSDUH) found that approximately 72.9 million
(29.6%) Americans age 12 years and older were current users of tobacco4. A breakdown by type
of tobacco is as follows:
o 61.6 million persons (25.0%) were current cigarette smokers
o 13.7 million persons (5.6%) smoked cigars
o 8.2 million persons (3.3%) use smokeless tobacco
o 2.3 million (0.9%) smoked tobacco in a pipe
• Smoking attributable health care expenditures in 1998 were estimated to be $75.5 billion5. This,
plus the estimated productivity losses of $92 billion from 1997-2001 combine for a total of over
$167 billion per year3.

Alcohol Use
• The 2006 National Survey on Drug Use and Health reports that4:
o Approximately half (50.9%; 125 million persons) of Americans age 12 years and older
reported being current drinkers of alcohol
o 23% (57 million) persons age 12 years and older participated in binge drinking
o Heavy drinking was reported by 6.9% (17 million) persons age 12 years and older
• In 2001, excessive alcohol use was responsible for 75,000 preventable deaths and 2.3 million
years if potential life lost6.
• Economic costs associated with alcohol abuse are estimated to have been $184.6 billion in 1998.
This represents a 25% increase over the previous estimate of $148 billion in 1992.

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Cervical Cancer
• An estimated 11,070 women will be diagnosed with and 3,870 women will die from cervical
cancer in 20087Error! Bookmark not defined..
• The National Cancer Institute’s (NCI) Surveillance Epidemiology and End Results (SEER) Cancer
Statistics review reports that the age-adjusted incidence rate was 8.4 per 100,000 women per year
based on new cases diagnosed in 2001-20058.

Pneumococcal Disease
• An estimated 40,000 cases and more than 4,400 deaths due to invasive pneumococcal disease
occurred in 20059. More than half of these cases occurred in those who were candidates for
pneumococcal immunization9.
• Incidence rates for invasive pneumococcal disease vary greatly by age group. In 1998, incidence
rates were highest among children less than 2 years of age, followed by those 65 years of age and
older9.

Obesity
• Since 1980, the number of persons considered to be overweight or obese has risen steadily10.
• In 2003-2004 67% of adults aged 20-74 were overweight (includes the category of obese) and 34%
were obese.
• The percent of adults considered overweight but not obese has remained about the same since
1960-1962 at about 32%-34%.

Health Care Disparities

The Partnership for Prevention/National Commission on Prevention Priorities published a report in
August 2007 that outlines the disparities regarding use of preventive services. The data below is taken
from this report11. Disparities were calculated using non-Hispanic whites as the reference group. The
higher the value, the greater the disparity. For example, a value of .55 means that group was 55% less
likely to receive the service than non-Hispanic whites. A value of zero means that there is no disparity,
while a negative value means that racial/ethnic group was more likely to receive the service than non-
Hispanic whites.

Preventive Service Hispanic Black only, Asian only, American Multiple Race,
non-Hispanic non-Hispanic Indian/Alaska non-Hispanic
Native
Smokers Advised to Quit .48 .02 .40 .03 .03
adult smokers 18+
Smokers Offered Assistance to Quit .55 .00 N/A -.02 .11
adult smokers 18+
Cervical Cancer Screening .11 .02 .25 N/A N/A
women 18-64
Pneumococcal Immunization .55 .34 .45 N/A N/A
adults 65+

As reported by the Partnership for Prevention/National Commission on Prevention Priorities, there is
currently no data being collected across the national population regarding screening and brief
intervention for unhealthy alcohol use12.

Opportunity for Improvement / Gap or Variation in Care
It has been reported that overall, adults receive approximately half of all recommended medical care.13,14

From 1998-200015:
• 3% of patients had smoking status documented at least once
• 61% of patients that were documented smokers had their smoking status indicated on more than
50% of office visits
• 12% of patients identified as smokers had documentation that advice to quit smoking was given
at least once during the year
• 45% of patients were screened for problem drinking
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• 54.4% of women had the date and result of their last Pap smear documented in their medical
record and 86.9% of women who had not had a Pap smear in the last three years had one
performed
• 63.8% of patients aged 65 and older had documentation in their medical record of being offered
the pneumococcal vaccine at least once
• 40.8% of patients’ medical records contained documentation of height and 66.4% of patients’
medical records contained documentation of weight at least once.

Additionally:
• Data from the National Center for Health Statistics show that in 200516:
o 17.1% of adults aged 50-64 and 56.2% of adults aged 65 years and older reported ever
receiving pneumococcal immunization.

Available Evidence
Evidenced-based clinical practice guidelines and consensus standards are available for preventive care and
screening services. This measurement set is based on clinical guidelines from the following:

• United States Preventive Services Task Force
• Department of Health and Human Services/Public Health Service
• National Quality Forum
• Centers for Disease Control

The performance measures found in this document have been developed with these guidelines, enabling
the physician to track his or her performance in individual patient care across patient populations. Please
note that the provision of preventive care and screening services must be based on individual patient
needs and professional judgment. Performance measures are not to be used as a substitute for clinical
guidelines and individual physician clinical judgment. There may be instances where an individual patient
falls outside the age range for the performance measure(s), however this does not mean that they should
not receive the service. Whether or not a patient should undergo a specific screening service is a decision
that needs to be made between the patient and the physician while weighing the risks and benefits of the
service, along with individual patient preference.

Measure Harmonization:
When hospital or plan-level measures are available for the same measurement topics, the PCPI attempts to
harmonize the measures to the extent feasible. The measures in the Preventive Care & Screening
measurement set were aligned with the National Committee for Quality Assurance’s Health Effectiveness
Data Set (HEDIS), as well as other existing measures for preventive care and screening services. This may
differ by measure. Please see individual measure documentation for specifics regarding harmonization.

Measure Testing & Implementation
Measure Testing & Implementation

Measures from the previous Preventive Care and Screening (2003) measurement set have been included in
the following programs/demonstration projects. The PCPI welcomes additional feedback and information
on the use and implementation of these measures.

• Centers for Medicare and Medicaid Services Physician Quality Reporting Initiative (PQRI)

© 2008 American Medical Association. All Rights Reserved. 6
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Measure Endorsement / Selection

The following measures from the previous Preventive Care & Screening (2003) measurement set were
endorsed by the NQF:

• Adult Influenza Immunization
• Tobacco Use

The following measure from the previous Preventive Care and Screening (2003) measurement set was
selected by the AQA:

• Tobacco Use

Measure Specifications:
The PCPI seeks to specify measures for implementation using multiple data sources, including paper
medical record, administrative (claims) data, and particular emphasis on Electronic Health Record Systems
(EHRS). Draft specifications to report on these measures for Preventive Care and Screening using
administrative (claims) data are included in this document. We have identified codes for these measures,
including ICD-9 and CPT (Evaluation & Management Codes, Category I and where Category II codes would
apply). Specifications for additional data sources, including EHRS, will be fully developed at a later date.
Measure Exclusions:
For process measures, the Consortium provides three categories of reasons for which a patient may be
excluded from the denominator of an individual measure:

• Medical reasons
Includes:
- not indicated (absence of organ/limb, already received/performed, other)
- contraindicated (patient allergic history, potential adverse drug interaction, other)

• Patient reasons
Includes:
- patient declined
- economic, social, or religious reasons
- other patient reasons

• System reasons
Includes:
- resources to perform the services not available
- insurance coverage/payor-related limitations
- other reasons attributable to health care delivery system

These measure exclusion categories are not available uniformly across all measures; for each measure,
there must be a clear rationale to permit an exclusion for a medical, patient, or system reason. The
exclusion of a patient may be reported by appending the appropriate modifier to the CPT Category II code
designated for the measure:

• Medical reasons: modifier 1P
• Patient reasons: modifier 2P
• System reasons: modifier 3P

Although this methodology does not require the external reporting of more detailed exclusion data, the
PCPI recommends that physicians document the specific reasons for exclusion in patients’ medical records
for purposes of optimal patient management and audit-readiness. The PCPI also advocates the systematic
review and analysis of each physician’s exclusions data to identify practice patterns and opportunities for
© 2008 American Medical Association. All Rights Reserved. 7
CPT® Copyright 2007 American Medical Association
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quality improvement. For example, it is possible for implementers to calculate the percentage of patients
that physicians have identified as meeting the criteria for exclusion.

Please refer to documentation for each individual measure for information on the acceptable exclusion
categories and the codes and modifiers to be used for reporting.

Measures #1-10 in the Preventive Care and Screening measurement set are process measures.

For outcome measures, the PCPI specifically identifies all acceptable reasons for which a patient may be
excluded from the denominator. Each specified reason is reportable with a CPT Category II code
designated for that purpose.

There are no outcome measures in the Preventive Care & Screening measurement set.

The PCPI continues to evaluate and likely will evolve its methodology for handling exclusions as it gains
experience in the use of the measures. The PCPI welcomes comments on its exclusions methodology
References

1 Centers for Disease Control and Prevention. Cigarette smoking among adults – United States. 2006.
MMWR. 2007;56:1157-1161.
2 Centers for Disease Control and Prevention. Cigarette smoking among adults – United States, 2004.
MMWR. 2005;54:1121-1124.
3 Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential
life lost, and productivity losses – United States, 1997-2001. MMWR. 2005;54:625-628.
4 Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2006 National
Survey on Drug Use and Health: National Findings. Rockville, MD. 2007.
5 Centers for Disease Control and Prevention. Smoking attributable mortality, morbidity, and economic
costs (SAMMEC): adult and maternal child health software. Atlanta, GA. US Department of Health and
Human Services, CDC; 2004. Cited by: Centers for Disease Control and Prevention. Annual smoking
attributable mortality, years of potential life lost, and productivity losses – United States, 1997-2001.
MMWR. 2005;54:625-628.
6 Centers for Disease Control and Prevention. Alcohol-attributable death and years of potential life lost –
United States, 2001. MMWR. 2004;53:866-870.
7 American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society; 2008.
8 Ries LAG, Melbert D, Krapcho M, Stinchcomb DG, Howlader N, Horner MJ, Mariotto A, Miller BA, Feuer EJ,
Altekruse SF, Lewis DR, Clegg, L, Eisner MP, Reichman M, Edwards BK (eds). SEER Cancer Statistics Review,
1975-2005, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/scr/1975_2005/, based
on November 2007 SEER data submission, posted to the SEER website, 2008.
9 Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-
Preventable Diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 10th ed. Washington
DC: Public Health Foundation, 2007.
10 National Center for Health Statistics. Health, United States, 2007: With Chartbook on Trends in the
Health of Americans. Hyattsville, MD: 2007. Available at: http://www.cdc.gov/nchs/hus.htm. Accessed
January 2008.
11 National Commission on Prevention Priorities. Preventive Care: A National Profile on Use, Disparities,
and Health Benefits. Partnership for Prevention, August 2007.
12 National Commission on Prevention Priorities. Data Needed to Assess Use of High-Value Preventive
Care: A Brief Report from the National Commission on Prevention Priorities. Partnership for Prevention,
August 2007.
13 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States.
N EnglJ Med. 2003;348:2635-2645.
14 Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J
Med. 2006;354:1147-1156.
15 Technical Appendix to McGlynn EA, Asch SM, Adams JL, et al. Who is at greatest risk for receiving poor
quality health care? N Engl J Med 2006;354:1147-1156. Available at
http://www.rand.org/pubs/working_papers/WR-174-1. Accessed January 2008.
© 2008 American Medical Association. All Rights Reserved. 8
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16 National Center for Health Statistics. Health, United States, 2007: With Chartbook on Trends in the
Health of Americans. Hyattsville, MD: 2007. Available at: http://www.scs.gov/nchs/hus.htm. Accessed
January 2008.
© 2008 American Medical Association. All Rights Reserved. 9
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Measure Status: FINAL - PCPI Approved
Physician Consortium for Performance Improvement®

Measure #1: Tobacco Use: Screening & Cessation
Intervention
Preventive Care & Screening

This measure may be used as an Accountability measure.
Measure Description
Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the
two-year measurement period AND who received cessation counseling intervention if identified as a
tobacco user
Measure Components
Numerator Patients who were screened for tobacco use* at least once during the two-year
Statement measurement period AND who received tobacco cessation counseling intervention**
if identified as a tobacco user

*Includes use of any type of tobacco
** Cessation counseling intervention includes brief counseling (3 minutes or less),
and/or pharmacotherapy
Denominator All patients aged 18 years and older who were seen twice for any visits or who had
Statement at least one preventive care visit during the two year measurement period
Denominator Documentation of medical reason(s) for not screening for tobacco use (eg, limited
Exclusions life expectancy)
Supporting The following evidence statements are quoted verbatim from the referenced clinical
Guideline guidelines.

The USPSTF strongly recommends that clinicians screen all adults for tobacco use
and provide tobacco cessation interventions for those who use tobacco products. (A
Recommendation) (USPSTF, 2003)1

During new patient encounters and at least annually, patients in general and mental
healthcare settings should be screened for at-risk drinking, alcohol use problems
and illnesses, and any tobacco use. (NQF, 2007)2

All patients should be asked if they use tobacco and should have their tobacco-use
status documented on a regular basis. Evidence has shown that clinic screening
systems, such as expanding the vital signs to include tobacco status or the use of
other reminder systems such as chart stickers or computer prompts, significantly
increase rates of clinician intervention. (Strength of Evidence = A) (U.S. Department
of Health & Human Services-Public Health Service, 2008)3

All physicians should strongly advise every patient who smokes to quit because
evidence shows that physician advice to quit smoking increases abstinence rates.
(Strength of Evidence = A) (U.S. Department of Health & Human Services-Public
Health Service, 2008)3

Minimal interventions lasting less than 3 minutes increase overall tobacco
abstinence rates. Every tobacco user should be offered at least a minimal
intervention whether or not he or she is referred to an intensive intervention.
(Strength of Evidence = A) (U.S. Department of Health & Human Services-Public
Health Service, 2008)3