U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term Care Policy DEVELOPING QUALITY MEASURES FOR MEDICAID BENEFICIARIES WITH SCHIZOPHRENIA: FINAL REPORT January 2012 Office of the Assistant Secretary for Planning and Evaluation The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the Department of Health and Human Services (HHS) on policy development issues, and is responsible for major activities in the areas of legislative and budget development, strategic planning, policy research and evaluation, and economic analysis. ASPE develops or reviews issues from the viewpoint of the Secretary, providing a perspective that is broader in scope than the specific focus of the various operating agencies. ASPE also works closely with the HHS operating divisions. It assists these agencies in developing policies, and planning policy research, evaluation and data collection within broad HHS and administration initiatives. ASPE often serves a coordinating role for crosscutting policy and administrative activities. ASPE plans and conducts evaluations and research--both in-house and through support of projects by external researchers--of current and proposed programs and topics of particular interest to the Secretary, the Administration and the Congress. Office of Disability, Aging and Long-Term Care Policy The Office of Disability, Aging and Long-Term Care Policy (DALTCP), within ASPE, is responsible for the development, coordination, analysis, research and evaluation of HHS policies and programs which support the independence, health and long-term care of persons with disabilities--children, working aging adults, and older persons. DALTCP is also responsible for policy coordination and research to promote the economic and social well-being of the elderly. In particular, DALTCP addresses policies concerning: nursing home and community- based services, informal caregiving, the integration of acute and long-term care, Medicare post-acute services and home care, managed care for people with disabilities, long-term rehabilitation services, children’s disability, and linkages between employment and health policies. These activities are carried out through policy planning, policy and program analysis, regulatory reviews, formulation of legislative proposals, policy research, evaluation and data planning. This report was prepared under contract #HHSP23320095642WC between HHS’s ASPE/DALTCP and Mathematica Policy Research. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office_specific/daltcp.cfm or contact the ASPE Project Officer, Kirsten Beronio, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Kirsten.Beronio@hhs.gov. DEVELOPING QUALITY MEASURES FOR MEDICAID BENEFICIARIES WITH SCHIZOPHRENIA: Final Report Sam Simon Thomas Croghan Robert C. Saunders Sarah Hudson Scholle Milesh M. Patel Jeremy Gottlich Mathematica Policy Research January 30, 2012 Prepared for Office of Disability, Aging and Long-Term Care Policy Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Contract #HHSP22320095642WC The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. TABLE OF CONTENTS ACRONYMS ................................................................................................................... vi EXECUTIVE SUMMARY .............................................................................................. viii I. OVERVIEW OF THE PROJECT ............................................................................. 1 II. THE DEVELOPMENT OF SCHIZOPHRENIA QUALITY MEASURES: A CHRONOLOGY .................................................................................................. 3 1. Environmental Scan: Identify Appropriate Measure Topics and Concepts ......................................................................................................... 3 2. Define and Develop Initial Measure Specifications ......................................... 4 3. Convene Meetings of the Project Technical Advisory Group .......................... 4 4. Field-Test Measure Specifications with Key Stakeholders .............................. 5 5. Post Measure Specifications for Public Comment ........................................... 5 6. Pilot-Test Measures to Assess Usability, Validity, and Reliability .................... 5 III. SUMMARY OF KEY FINDINGS ............................................................................. 8 1. Measure Concepts Considered, Specified, and Tested, and Submitted for Endorsement............................................................................. 8 2. Field-Testing ................................................................................................. 11 3. Public Comment ............................................................................................ 11 4. Pilot-Testing .................................................................................................. 12 IV. LESSONS LEARNED ........................................................................................... 16 REFERENCES .............................................................................................................. 19 APPENDICES APPENDIX A. Measure Concepts for Patients with Schizophrenia........................ A-1 APPENDIX B. TAG Membership and Slide Decks ............................................... A-34 APPENDIX C. Memo Summarizing Focus Group Input ....................................... A-63 APPENDIX D. Summary of Public Comment ....................................................... A-68 APPENDIX E. Pilot-Testing Results ..................................................................... A-88 APPENDIX F. Schizophrenia Quality Measures: Numerator, Denominator and Exclusion Criteria ........................................... A-115 i LIST OF TABLES TABLE III.1. Pharmacological Concepts Considered, Specified, Tested, and Submitted ......................................................................................... 9 TABLE III.2. Psychosocial Concepts Considered, Specified, Tested, and Submitted ................................................................................................ 9 TABLE III.3. Physical Health Concepts Considered, Specified, Tested, and Submitted ....................................................................................... 10 TABLE III.4. Cross-Cutting Concepts Considered, Specified, Tested, and Submitted .............................................................................................. 10 TABLE III.5. Summary of Pilot-Testing Results: Evidence of Measure Usability, Validity, and Reliability ........................................................... 13 TABLE A.1. Measure Concept: Use of Antipsychotic Medications for Treatment of Schizophrenia ................................................................. A-2 TABLE A.2. Measure Concept: Continuity of Antipsychotic Medication ................... A-4 TABLE A.3. Measure Concept: Use of Clozapine in Treatment-Resistant Patients ................................................................................................ A-6 TABLE A.4. Measure Concept: Polypharmacy Treatment ....................................... A-8 TABLE A.5. Measure Concept: Outpatient Follow-up After Mental Health Hospitalization .................................................................................... A-10 TABLE A.6. Measure Concept: Use of Assertive Community Treatment Post-Hospitalization ........................................................................... A-11 TABLE A.7. Measure Concept: Use of Case Management ................................... A-14 TABLE A.8. Measure Concept: Use of Family Therapy ......................................... A-15 TABLE A.9. Measure Concept: Use of Supported Employment ............................ A-18 TABLE A.10. Measure Concept: Use of Any Psychosocial Treatment .................... A-20 ii TABLE A.11. Measure Concept: Use of Combination Antipsychotic Medication and Psychosocial ............................................................. A-21 TABLE A.12. Measure Concept: Monitoring of Metabolic Conditions Among Patients Taking Antipsychotic Medications ............................ A-23 TABLE A.13. Measure Concept: Weight Assessment and Counseling Among Patients with Schizophrenia who are Taking Antipsychotics .................................................................................... A-25 TABLE A.14. Measure Concept: Appropriate Health Maintenance and Prevention .......................................................................................... A-27 TABLE A.15. Measure Concept: Appropriate Infectious Disease Screenings ......................................................................................... A-29 TABLE A.16. Measure Concept: Screening and Counseling of Substance Use Disorders .................................................................................... A-30 TABLE A.17. Measure Concept: Tobacco Counseling ............................................ A-31 TABLE A.18. Measure Concept That Were Considered but Not Pursued Based on Expert Consultant Review .................................................. A-33 TABLE D.1. Public Comment Summary................................................................. A-68 TABLE E.1. Enrollee Information and Selected SMI Conditions by State .............. A-88 TABLE E.2. Enrollee Demographics ...................................................................... A-89 TABLE E.3a. Use of Antipsychotic Medication by Enrollee Characteristics ............. A-90 TABLE E.3b. Use of Antipsychotic Medication by State .......................................... A-91 TABLE E.4a. Antipsychotic Medication Possession Ratio by Enrollee Characteristic ..................................................................................... A-92 TABLE E.4b. Antipsychotic Medication Possession Ratio by State ......................... A-93 TABLE E.5a. Diabetes Screening Among Enrollees with Schizophrenia or Bipolar Disorder by Enrollee Characteristics ...................................... A-94 TABLE E.5b. Diabetes Screening Among Enrollees with Schizophrenia or Bipolar Disorder by State ................................................................... A-95 iii TABLE E.6a. Cardiovascular Health Screening Among Enrollees with Schizophrenia or Bipolar Disorder by Enrollee Characteristics ................................................................................... A-96 TABLE E.6b. Cardiovascular Health Screening Among Enrollees with Schizophrenia or Bipolar Disorder by State ....................................... A-97 TABLE E.7a. Diabetes Monitoring Among Enrollees with Schizophrenia by Enrollee Characteristics................................................................. A-98 TABLE E.7b. Diabetes Monitoring Among Enrollees with Schizophrenia by State .............................................................................................. A-99 TABLE E.8a. Cardiovascular Health Monitoring Among Enrollees with Schizophrenia by Enrollee Characteristics ....................................... A-100 TABLE E.8b. Cardiovascular Health Monitoring Among Enrollees with Schizophrenia by State .................................................................... A-101 TABLE E.9a. Cervical Cancer Screening Among Enrollees with Schizophrenia by Enrollee Characteristics ....................................... A-102 TABLE E.9b. Cervical Cancer Screening Among Enrollees with Schizophrenia by State .................................................................... A-103 TABLE E.10a. ED Utilization for Mental Health Conditions Among Enrollees with Schizophrenia by Enrollee Characteristics ................ A-104 TABLE E.10b. ED Utilization for Mental Health Conditions Among Enrollees with Schizophrenia by State ............................................. A-105 TABLE E.11a. 7-Day Follow-Up After Mental Health Discharge Among Enrollees with Schizophrenia by Enrollee Characteristics ................ A-106 TABLE E.11b. 7-Day Follow-Up After Mental Health Discharge Among Enrollees with Schizophrenia by State ............................................. A-107 TABLE E.12a. 30-Day Follow-Up After Mental Health Discharge Among Enrollees with Schizophrenia by Enrollee Characteristics ................ A-108 TABLE E.12b. 30-Day Follow-Up After Mental Health Discharge Among Enrollees with Schizophrenia by State ............................................. A-109 TABLE E.13. Distribution of Measures at the State Level ...................................... A-110 iv TABLE E.14. Utilization by Measure Performance Quartile ...................................... A-111 TABLE E.15. Enrollee Level Correlation Matrix ........................................................ A-112 TABLE E.16. State Measure Correlations, 2007-2008 ............................................. A-113 TABLE F.1. Measure Criteria: Numerators, Denominators and Exclusions ........... A-115 v ACRONYMS ACT assertive community treatment APA American Psychiatric Association ASPE Office of the Assistant Secretary for Planning and Evaluation BHO behavioral healthcare organization BMI body mass index CMS Centers for Medicare and Medicaid Services DHHS New Hampshire Department of Health and Human Services ED emergency department EHR electronic health record FFS fee-for-service FUH follow-up after hospitalization HCPCS Healthcare Common Procedure Coding System HbA1c Hemoglobin A1c HMO health maintenance organization ICSI Institute for Clinical Systems Improvement IQR interquartile range LAI long-acting injectable MAX Medicaid Analytic eXtract MBHO managed behavioral healthcare organization MMDLN Medicaid Medical Directors Learning Network NACBHDD National Association of County Behavioral Health and Developmental Disability Directors NAMI National Alliance on Mental Illness NCQA National Committee for Quality Assurance NICE National Institute for Health and Clinical Excellence NQF National Quality Forum PCP primary care provider PDC proportion of days covered PORT Patient Outcomes Research Team vi RCT randomized controlled trial SMI serious mental illness SPMI serious and persistent mental illness TAG Technical Advisory Group WFBH Wake Forest Baptist Health vii EXECUTIVE SUMMARY In August 2010, the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica Policy Research and its subcontractor--the National Committee for Quality Assurance-- to develop evidence-based quality measures to assess the quality of care provided to Medicaid enrollees diagnosed with schizophrenia. The goal of the project was to create a set of claims-based ambulatory care measures that meet National Quality Forum (NQF) criteria for importance, scientific acceptability, usability, and feasibility and would thus be suitable for submission to the NQF for endorsement consideration. The project began with a review of existing literature and other evidence describing evidence-based practices for people with schizophrenia. Assisted by expert consultants, this effort emphasized the findings of the Schizophrenia Patient Outcomes Research Team and allowed the team to create concepts for new measures that assess the quality of medication management, underuse of evidence-based psychosocial treatments, and access to primary care and preventive health services. Once the measure concepts were vetted by a Technical Advisory Group (TAG), we developed draft specifications and sought comment from measure stakeholders, including representatives from managed behavioral healthcare organizations (MBHOs), Medicaid medical directors, and state mental health directors to assess their perspectives on the importance, scientific acceptability, usability, and feasibility of the proposed measures. After these key stakeholders gave their input, measure specifications were posted for public comment, and they were pilot-tested using Medicaid Analytic eXtract (MAX) data from 2007 and 2008 to further assess their feasibility, reliability, and validity. Throughout the project, the project team received valuable advice and guidance from ASPE, members of the TAG, and our project consultants. The project team sought to develop measures in three domains, pharmacology, psychosocial care, and physical health, as well as cross-cutting measures that span several of these domains. Based on the review of the literature and feedback from the TAG and ASPE, we developed detailed specifications for an initial set of 17 measure concepts before settling on a final set of ten to be submitted to NQF for endorsement. Focus groups with state Medicaid and mental health leaders, as well as with MBHO staff, yielded remarkably consistent results. Key points included: (1) claims data are unreliable for identifying some behavioral health services, particularly evidence- based psychosocial treatments; (2) variation in financing of services for people with serious mental illness (SMI) limits the ability to consistently measure the quality of care across Medicaid programs; and (3) some candidate measures address problems that are not unique to patients with schizophrenia--measures could be broadened to include patients with bipolar disorder, schizophrenia, and severe forms of depression. The viii feedback from public comment was positive, with 87 percent of the comments either supporting the measures or supporting them with modifications. Overall, 9.7 percent of Medicaid recipients in our 22-state 2007 MAX dataset had schizophrenia and 12.8 percent had SMI (bipolar disorder and/or schizophrenia). The objective of pilot-testing was to determine the scientific acceptability of each measure to the extent practicable through the use of Medicaid claims data. Five of the ten proposed measures demonstrated significant variability in state-level performance, indicating general utility of the measures. Seven of the ten proposed measures demonstrated evidence of either construct or convergent validity. Construct validity was assessed by examining the association between measure performance and outcomes (schizophrenia-related (1) hospitalization, and (2) emergency department [ED] visits). We reported the percentage of people who were either hospitalized or visited the ED for schizophrenia, comparing the worst and best-performing quartiles of state performance for each measure. Seven measures demonstrated evidence of construct validity, indicated by the association between (higher) measure performance and (lower) rates of adverse events. Convergent validity was determined through enrollee-level measure correlations. Three of the ten measures demonstrated evidence of convergent validity. Nine of the ten measures demonstrated evidence of reliability, assessed between measures calculated during calendar year 2007 and 2008, either through test-retest correlations or relative performance stability over this time period. Although some of these results are encouraging, important limitations of our findings warrant consideration. First, use of Medicaid claims data as a source to implement and test schizophrenia quality measures limited the number of evidence- based practices that could be implemented as measures. This limitation prevented our ability to develop psychosocial measures. In addition, several topics could not be developed because the evidence base, tools, and methods for tracking these measures are immature. We also found that variation in the financing of services for people with SMI limited our ability to generalize measurement of the care provided by Medicaid programs. For example, the provision of services through state mental health systems, the coverage of mental health services through Medicare for dual-eligible beneficiaries, the prohibition of same-day billing of medical and behavioral health services, and interstate variation in Medicaid and disability standards all underscore the limitations of claims data to measure quality for enrollees with schizophrenia. Finally, the distinction between enrollees with schizophrenia and other SMI conditions is, in many cases, artificial. The project team, ASPE, and measure stakeholders all expressed the belief that conceptually, many issues related to schizophrenia also apply broadly to people with any SMI. Further work is needed to consider whether measures similar to the ones developed and tested under this contract would be relevant for people with bipolar disorder and other SMI. ix I. OVERVIEW OF THE PROJECT Despite enormous expenditures and remarkable breakthroughs in medical treatment, the United States behavioral health care system does not consistently deliver safe and effective treatment to those with serious and persistent mental illness (SPMI), many of whom go untreated or inadequately treated. Now, as the nation stands at the doorstep of fundamental reforms that offer insurance benefits for those without them, remove inequitable treatment limits and financial barriers to mental health treatments, and promote integrated primary and behavioral health care, we have an enormous opportunity to close the gap between the availability of effective treatments and providing them in a manner that promotes recovery. By enhancing transparency, new quality measures that promote feedback to providers and enable value-based purchasing represent an essential tool to achieve the full promise of these reforms. In August 2010, the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica Policy Research and its subcontractor--the National Committee for Quality Assurance (NCQA)--to develop evidence-based quality measures to assess the quality of care provided to Medicaid enrollees diagnosed with schizophrenia. The goal of the project was to create a set of claims-based ambulatory care measures that meet National Quality Forum (NQF) criteria for importance, scientific acceptability, usability, and feasibility and would thus be suitable for submission to the NQF for endorsement consideration. The project began with a review of existing literature and other evidence describing evidence-based practices for people with schizophrenia. Assisted by expert consultants, this effort emphasized the findings of the Schizophrenia Patient Outcomes Research Team (PORT) and allowed the team to create concepts for new measures that assess the quality of medication management, underuse of evidence-based psychosocial treatments, and access to primary care and preventive health services. Once the measure concepts were vetted by a Technical Advisory Group (TAG), we developed draft specifications and sought comment from measure stakeholders, including representatives from managed behavioral healthcare organizations (MBHOs), Medicaid medical directors, and state mental health directors to assess their perspectives on the importance, scientific acceptability, usability, and feasibility of the proposed measures. After these key stakeholders gave their input, measure specifications were posted for public comment, and they were pilot-tested using Medicaid Analytic eXtract (MAX) data from 2007 and 2008 to further assess their feasibility, reliability, and validity. Throughout the project, the project team received valuable advice and guidance from ASPE, members of the TAG, and our project consultants. This report presents a chronology of the process, key findings, and lessons learned during our project to develop claims-based measures of services provided to 1 Medicaid enrollees with schizophrenia that meet key NQF criteria. Chapter II reviews that process and describes how several findings in our data collection changed the course of measure development. Chapter III summarizes key findings from our field and pilot-testing efforts, and Chapter IV discusses lessons learned that we hope will improve the process of measure development and the quality of the resulting measures. The appendices contain all key documents produced throughout the project, including material presented at each TAG meeting, pilot-testing results, and the candidate measure summary information. 2 II. THE DEVELOPMENT OF SCHIZOPHRENIA QUALITY MEASURES: A CHRONOLOGY In developing new quality measures to assess the quality and appropriateness of care for Medicaid enrollees with schizophrenia, Mathematica and NCQA carried out the following tasks under guidance from ASPE: 1. Identified appropriate measure topics and concepts through an environmental scan and a review of the literature. 2. Defined and developed measure specifications. 3. Convened meetings of the project TAG. 4. Field-tested measures with key stakeholders. 5. Posted the measures for public comment. 6. Pilot-tested measures and evaluated the reliability and validity of measures using Medicaid claims data. 1. Environmental Scan: Identify Appropriate Measure Topics and Concepts The process for identifying the measure concepts included a review of the clinical literature prepared by ASPE, an environmental scan of treatment measure guidelines and existing measures by NCQA, and consultation with experts. We focused on measure concepts in three treatment domains specified by ASPE: pharmacotherapy, psychosocial treatment, and physical health. Drs. Julie Kreyenbuhl and Lisa Dixon, leaders of the Schizophrenia PORT at the University of Maryland School of Medicine, served as content experts and consultants to the project. Their role was to identify potential errors of interpretation, emphasis, inclusion, or omission prior to developing a report that summarized the scientific literature, clinical guidelines, and existing measures that are focused on the population of interest. The environmental scan identified systematic reviews (e.g., the Schizophrenia PORT reviews), measure specifications, and treatment guidelines and standards developed by professional societies and measurement organizations that relate to care for people with schizophrenia (Buchanan et al. 2010; Dixon et al. 2010). ASPE also conducted a supplemental review of the clinical literature restricted to human adult clinical trials, and in the case of pharmacologic agents, those that have advanced 3 beyond preliminary safety and efficacy testing (Sherry 2010). Because the PORT recommendations include only studies published through March 2008, the ASPE literature review identified more recent studies. In addition, we consulted with a multistakeholder TAG. To identify existing measures assessing care for people with schizophrenia, we searched measure databases from the NQF, the National Quality Measures Clearinghouse, the National Registry of Evidence-Based Programs and Practices through the Substance Abuse and Mental Health Services Administration, and the Center for Quality Assessment and Improvement in Mental Health. Measures were organized by the measure steward, name, description, numerator, denominator, data source, and measurement domain (that is, physical health, pharmacotherapy, and psychosocial interventions). The final measure concepts are presented in Chapter III. 2. Define and Develop Initial Measure Specifications Based on the review of the literature and feedback from the TAG and ASPE, we developed detailed specifications for an initial set of 17 measure concepts before settling on a final set of ten to be submitted to NQF for endorsement. Initial measure specifications included codes likely to be found on claims and that define populations eligible to be in the denominator, codes that adequately defined the nature of the processes or outcomes to be assessed (the numerator), and the appropriate time frames for assessment. We used the input of the TAG and our understanding of the MAX data to guide drafting measure specifications. Appendix A lists the original 17 measure concepts. 3. Convene Meetings of the Project Technical Advisory Group To guide the measure development process and provide the perspectives of all stakeholders, we convened three meetings of a multistakeholder TAG. This group included 16 members representing expertise in clinical care, research, state and federal policy, consumers, managed behavioral health care, and quality measurement. The TAG met three times by teleconference through the course of the project. During the first teleconference, we asked TAG members to review proposed measure concepts, identify potential gaps in these concepts, assess measure development priorities, and recommend measures to be specified and tested. Measure specifications and the testing plan for the selected concepts were then reviewed during the second TAG meeting. The third meeting consisted of reviewing the preliminary results of the field and pilot-testing. In addition, the TAG evaluated and provided further feedback on the specifications and recommended measures for NQF submission. Appendix B lists the TAG members and includes material presented at each TAG meeting. 4 4. Field-Test Measure Specifications with Key Stakeholders To inform our understanding of feasibility and usability, we conducted focus groups with: (1) State Medicaid Medical Directors; (2) representatives from MBHOs; and (3) State Mental Health Commissioners and Medical Directors (or their designees). The goal was to obtain feedback on attributes that are reviewed by NQF during the endorsement process, including the importance, usability, and feasibility of the measures. We asked focus group participants about their understanding of the measure specifications; the feasibility of implementing quality data for the measures through a claims-based system, including anticipated operational challenges in collecting and reporting the data; the relevance and importance of the measures to their program or organization; their interest in collecting information and receiving feedback on the measures; and any suggestions for refining the measures. Focus group testing with the State Medicaid Medical Directors occurred in conjunction with the Medicaid Medical Directors Learning Network meeting in Washington, DC, and 28 states were represented. Representatives of MBHOs were recruited from industry lists; individuals representing commercial and Medicaid plans in six states (Florida, Oklahoma, Pennsylvania, Illinois, Missouri, and Iowa) participated. We later added a focus group of state mental health commissioners and medical directors in response to suggestions from ASPE; officials from five states (California, Michigan, Missouri, Georgia, and Florida) participated. A memo summarizing our conversations with the focus groups is in Appendix C. 5. Post Measure Specifications for Public Comment For this task, NCQA developed and managed a dedicated web page to receive public comments. Candidate measures (excluding the HIV screening and psychosocial treatment measures) were posted September 15, 2011, through October 15, 2011, and included draft technical specifications, instructions, and supporting information for the public-comment period. We collated the public comments and reviewed them to identify themes and areas of concern. We then prepared a document summarizing the comments and action taken (Appendix D). Twenty-two organizations, including academic institutions, health plans, pharmaceutical companies, universities, and other health care associations, submitted a total of 67 comments. 6. Pilot-Test Measures to Assess Usability, Validity, and Reliability To assess the usability and scientific acceptability of the measures, we examined the distribution, content and convergent validity, and test-retest reliability of the candidate measures using MAX data from 2007 and 2008. Use of MAX data permits real-world assessment of measure usability for state Medicaid officials. At the same time, operationalization of quality measures in Medicaid claims data provides an opportunity to retrospectively assess measure validity by correlating measure 5 performance with outcomes such as schizophrenia-related hospitalization and emergency department (ED) use. The MAX data are standardized eligibility and claims files for each state that include person-level on every beneficiary enrolled in Medicaid during the calendar year. The MAX files are created from claims data that each state submits to the Centers for Medicare and Medicaid Services (CMS). Defining the Population Diagnosis of schizophrenia was inferred by either a single primary inpatient diagnosis or two outpatient primary diagnoses of schizophrenia.1,2 In response to comments from Medicaid medical directors, we modified and tested some measures to include persons with serious mental illness (SMI) defined by a single primary inpatient diagnosis or two outpatient primary diagnoses of either schizophrenia or bipolar disorder. In addition, we required that enrollees have 10 months of Medicaid eligibility, non- dual status, and qualification for Medicaid on the basis of a disability, which resulted in 1,019,123 Medicaid recipients who met our inclusion criteria.3 Overall, 9.7 percent of Medicaid recipients in our dataset had schizophrenia and 12.8 percent had SMI (bipolar disorder and/or schizophrenia) in 2007. Both of these populations were demographically diverse (Appendix Table E.2). About one in five enrollees with schizophrenia were diagnosed with diabetes (17 percent). Pilot-Test Methodology: Usability, Validity, and Reliability Pilot-testing the measures using MAX data took several forms. First, we evaluated measure importance (gaps in quality) and scientific acceptability (meaningful differences in performance) by assessing the distributional properties of each measure. This was accomplished by tabulating the minimum, maximum, median, mean, and interquartile range (IQR) for each measure at the state level. The IQR is demarcated by the values at the 25th and 75th percentiles of a distribution. Generally speaking, measures with a broader IQR are preferable to measures with a narrowly distributed IQR or those with an IQR at the very low or very high end of the distribution. For example, a measure with a narrow IQR may not be sufficiently sensitive to detect differences in quality. Measures with an IQR of at least 10 percentage points were considered to have the strongest evidence of usability for quality measurement purposes. 1 An ICD-9 code of 295.xx was used to flag schizophrenia. 2 Outpatient diagnoses were observed on different days. 3 We used MAX data from the following states in 2007: Alabama, Alaska, California, Connecticut, Georgia, Idaho, Illinois, Indiana, Iowa, Louisiana, Maryland, Missouri, Mississippi, New Hampshire, North Carolina, North Dakota, Nevada, Oklahoma, South Dakota, Washington DC, West Virginia, and Wyoming. These states were noted to have complete enrollment, fee-for-service (FFS) claims and encounter records. Although the sample was primarily enrolled in FFS plans, some states with complete encounter data were included in our analytic sample. 6 Validity and reliability are important characteristics of measure scientific acceptability. Construct validity was evaluated by examining enrollee outcomes with results displayed by quartile of state-level performance for each measure. We compared rates of schizophrenia-related hospitalization and ED utilization, for beneficiaries in the highest and lowest performing quartile for each quality measure. The difference between the outcomes among enrollees in the best and worst quartiles of state performance for each measure was tested using a one-way analysis of variance; an F-test significance level of p<0.01 was used to determine statistically different outcomes. For a given measure, construct validity was inferred when rates for adverse events among enrollees in high performing states were significantly better (i.e., lower) than the rates of adverse events among enrollees in low performing states. Convergent validity was examined through between-measure correlation coefficients. For example, we hypothesized that adherence to antipsychotics, as measured by a high rate of antipsychotic medication possession ratio, would be negatively associated with measures of mental health ED use and positively correlated with the measures of 30-day outpatient follow-up after a mental health related discharge. We identify measures with a Pearson correlation of at least 0.15 with two or more measures. We assessed measure reliability using state-level test-retest correlations with data from 2007 and 2008 MAX data.4 We identify measures with a year-to-year correlation of ≥0.30. We also examined the stability of relative performance quartiles between 2007 and 2008, with the expectation that at the state level, performance measures should not exhibit any discernible pattern of performance instability over time. In other words, measure stability would be demonstrated if a state was in the top quartile of performance for a given measure in 2007, the same state should demonstrate similar relative performance in 2008. Results from the pilot and field-testing efforts are summarized in the next section. 4 2008 data were available for a subset (N=16) of the 2007 states: Alabama, Alaska, Connecticut, Georgia, Idaho, Indiana, Iowa, Louisiana, Maryland, Mississippi, New Hampshire, North Carolina, Oklahoma, South Dakota, West Virginia, and Wyoming. 7 III. SUMMARY OF KEY FINDINGS The purpose of this measure development project was to identify, specify, and test at least three measures that address pharmacological treatment, psychosocial treatment, and physical health needs for patients with schizophrenia that can be calculated solely from Medicaid claims data. Ten measures met our rigorous criteria for measure development, including evidence review, consultation with the TAG, focus groups with key stakeholders, public comment, and pilot-testing using the MAX data. Tables III.1-III.4 list the measure concepts that we considered based on the environmental scan and initial input from the TAG; these concepts addressed the domains requested by ASPE (pharmacology, psychosocial treatment, and physical health) as well as a set of cross-cutting issues identified through the scan. We did not further pursue some of these topics because we did not believe that they could be assessed in claims; these measure concepts were not presented to the TAG (see Appendix B). Based on TAG recommendations, 13 measures were specified. Two (use of any psychosocial treatment and HIV screening) were dropped before testing in the MAX files. The psychosocial treatment measure was dropped because procedure codes used in claims data are ambiguous and thus do not provide sufficient detail to reflect the actual service provided, and because these codes are not used consistently in different states and programs. The HIV screening measure was dropped because of the lack of strong evidence suggesting a gap in care for people with schizophrenia. Based on the input received from the public comment period, we dropped the measure of general ED utilization due to provider attribution concerns, which resulted in ten measures that were later pilot-tested in the MAX data. 1. Measure Concepts Considered, Specified, and Tested, and Submitted for Endorsement The project team sought to develop measures in three domains, pharmacology, psychosocial care, and physical health, as well as cross-cutting measures that span several of these domains. Tables III.1-III.4 list the proposed measure concepts, the measures that were specified and tested in focus groups, the measures that were tested in the MAX data, and the measures submitted for NQF endorsement. The final ten measures submitted to NQF for endorsement consideration are listed in the last column. Appendix F consists of the proposed measures’ numerator, denominator, and exclusions. 8 TABLE III.1. Pharmacological Concepts Considered, Specified, Tested, and Submitted Measures Specified & Proposed Measure Measures Tested in Measures Submitted Tested in Focus Concepts MAX Files for NQF Endorsement Groups 1. Use of antipsychotic 1. Use of antipsychotic 1. Use of antipsychotic 1. Use of antipsychotic medications for medications for medications. medications. treatment of treatment of 2. Antipsychotic 2. Antipsychotic schizophrenia. schizophrenia. medication medication 2. Antipsychotic 2. Antipsychotic possession ratio. possession ratio. medication medication possession ratio. possession ratio. 3. Use of clozapine in treatment-resistant patients. 4. Polypharmacy treatment. Use of clozapine in treatment-resistant patients was dropped due to difficulty with identifying treatment-resistant patients from claims data and concerns about small denominator size. The polypharmacy treatment measure concept was dropped because there is insufficient evidence to define a polypharmacy threshold (e.g., two versus three antipsychotics) and lack of evidence regarding the impact of polypharmacy on quality of care. The TAG also was uncertain whether to broaden the concept to encompass other psychiatric medications (e.g., antidepressants). TABLE III.2. Psychosocial Concepts Considered, Specified, Tested, and Submitted Measures Specified & Proposed Measure Measures Tested in Measures Submitted Tested in Focus Concepts MAX Files for NQF Endorsement Groups 1. Use of Assertive 1. Use of any (None) (None) Community psychosocial Treatment (ACT) treatment. post-hospitalization. 2. Use of case management. 3. Use of family therapy. 4. Use of supported employment. 5. Use of cognitive behavioral therapy. 6. Use of social education. 7. Use of any psychosocial treatment. 8. Availability of psychosocial treatment. 9. Presence or duration of waiting list for psychosocial treatment. Use of ACT post-hospitalization, case management, family therapy, supported employment, cognitive behavioral therapy, and social education were dropped as a result of the inconsistent availability of these services across state Medicaid programs 9 and, where those services are available, unreliable coding and uncertain fidelity to the evidence-based models. Use of any psychosocial treatment was specified and tested in focus groups, but was dropped because of the fidelity and reliability concerns. Availability of and the presence or duration of a waitlist for psychosocial treatment are structural measures not suited to claims data measurement. TABLE III.3. Physical Health Concepts Considered, Specified, Tested, and Submitted Measures Specified & Proposed Measure Measures Tested in Measures Submitted Tested in Focus Concepts MAX Files for NQF Endorsement Groups 1. Monitoring of 1. Cervical cancer 1. Cervical cancer 1. Cervical cancer metabolic conditions screening for screening for screening for among patients women. women. women. taking antipsychotic 2. HIV screening. 2. Diabetes screening 2. Cardiovascular medications. 3. Diabetes screening (schizophrenia or health screening 2. Weight assessment (schizophrenia or bipolar disorder). (schizophrenia or and counseling bipolar disorder). 3. Cardiovascular bipolar disorder). among patients who 4. Cardiovascular health screening 3. Diabetes screening are taking health screening (schizophrenia or (schizophrenia or antipsychotics. (schizophrenia or bipolar disorder). bipolar disorder). 3. Appropriate health bipolar disorder). 4. Diabetes monitoring. 4. Diabetes monitoring. maintenance and 5. Diabetes monitoring. 5. Cardiovascular 5. Cardiovascular prevention. 6. Cardiovascular health monitoring. health monitoring. 4. Appropriate health monitoring. infectious disease screenings. 5. Screening and counseling of substance use disorders. 6. Tobacco counseling. Weight assessment and counseling among patients on antipsychotics was deemed identifiable only from chart data, which were out of scope for this project. Concerns about reliable documentation of tobacco and substance use screening and counseling in claims data resulted in removing these concepts from further consideration. HIV screening was dropped because of the lack of strong evidence suggesting a gap in care for people with schizophrenia. TABLE III.4. Cross-Cutting Concepts Considered, Specified, Tested, and Submitted Measures Specified & Proposed Measure Measures Tested in Measures Submitted Tested in Focus Concepts MAX Files for NQF Endorsement Groups 1. Use of combination 1. 7-day follow-up visit 1. 7-day follow-up visit 1. 7-day and 30-day antipsychotic after mental health after mental health follow-up visit after medication and hospital discharge. hospital discharge. mental health psychosocial 2. 30-day follow-up 2. 30-day follow-up hospital discharge. treatment. after mental health after mental health 2. Any mental health 2. Outpatient follow-up hospital discharge. hospital discharge. ED use. visit after 3. Any mental health 3. Any mental health hospitalization. ED use. ED use. 3. ED use. 4. Any ED use. 4. Continuous Medicaid enrollment. 10 The use of combination antipsychotic medication and psychosocial treatment measure concept was dropped due to the inability to capture psychosocial treatments reliably through claims data. 2. Field-Testing The focus groups with state Medicaid and mental health leaders, as well as with MBHO staff, yielded remarkably consistent results. Key points included: Claims data are unreliable for identifying some behavioral health services, particularly evidence-based psychosocial treatments. Variation in financing of services for people with SMI limits the ability to consistently measure the quality of care across Medicaid programs. For example, while some states reimburse for a bundled set of services collectively known as assertive community treatment (ACT), other states reimburse individual services that resemble services included in the ACT model. In other states, some of these services are provided outside of the Medicaid program, such as through the state mental health authority. Some candidate measures address problems that are not unique to patients with schizophrenia; measures could be broadened to include patients with bipolar disorder, schizophrenia, and severe forms of depression (SPMI). While focus group participants generally viewed the proposed measure concepts as important and relevant topics, they noted some gaps. In particular, Medicaid officials raised concerns about the lack of candidate measures addressing perceived problems of overuse of care for people with schizophrenia (for example, polypharmacy or hospital readmissions). The panels offered specific advice on technical specifications and testing. In particular, they recommended that the measures apply to patients not included in MAX files, specifically TANF enrollees and people with dual Medicare beneficiaries, who receive treatment through Medicaid programs. 3. Public Comment The feedback from public comment was positive, with 87 percent of the comments either supporting the measures or supporting them with modifications (Appendix D). The majority of the comments touched on issues that had been discussed by the project team and the TAG during the measure development process, such as expanding the denominator in the physical health screening measures to include anyone with SMI, including measures evaluating psychosocial care, and lowering the age of eligibility for the measures. 11 Some comments raised concerns about the accountability for measures; for example, several commenters expressed concern that offering cervical cancer screening was out of scope for psychiatrists and psychologists. The project team believes this is a misunderstanding on the part of providers. The state, not the provider, is the unit of accountability for these measures. Further, given the push toward integrated care, states may be held accountable for the coordination of care between medical and mental health settings. This may include encouraging mental health professionals, including psychiatrists, to inquire about these services and potentially refer for such services. This is no different from the expectation that psychiatrists address the metabolic condition of patients in their care. Therefore, we propose retaining screening measures. We received technical comments concerning coding of medication lists, including HbA1c tests as part of the diabetes screening measure, and methods to determine use of injectable antipsychotic medications. The project team carefully considered these concerns when finalizing measure specifications. The measure that received the least support from public comment was Emergency Department Utilization for People with Schizophrenia. Feedback centered on the measure being non-action-oriented because it included non-mental health admissions. Comments also focused on the measure possibly encouraging overuse of emergency servces. Based on this feedback, the broad measure of Emergency Department Utilization was not submitted for NQF endorsement. 4. Pilot-Testing The objective of pilot-testing was to determine the scientific acceptability of the measures based on NQF criteria. Table III.5, summarizes the evidence found for each measure through our pilot-testing activities using our 22-state MAX dataset (2007) and our 16-state MAX dataset (2008). Cells containing an ‘X’ indicate that a measure met predetermined criteria, summarized in Chapter II, which we used to assess differences in performance across states, validity, or reliability. An empty cell indicates that a measure did not meet the criterion in the corresponding column; however, as we discuss in the paragraphs that follow, this does not indicate a measure is without merit or should not be considered useful. In general, as we described below in further detail, caution is warranted in interpreting our pilot-testing findings, as testing results using Medicaid claims should not be used as the sole criteria for judging the merit of the measures. 12 TABLE III.5. Summary of Pilot-Testing Results: Evidence of Measure Usability, Validity, and Reliability Detection of Meaningful Validity Reliability Measure Differences IQR Construct Convergent Test-Retest Performance a b c d e Dispersion Validity Validity Correlation Stability Use of Antipsychotic X Medication Antipsychotic Possession Ratio X (≥80%) Diabetes Screening f X X X X X (SMI) Diabetes Monitoring X X X X X Cardiovascular Health Screening X X f (SMI) Cardiovascular X X X X Health Monitoring Cervical Cancer X X Screening ED Utilization for Mental Health N/A X Conditions Follow-up after Mental Health X X X Hospital Discharge (7-day) Follow-up after Mental Health X X X X Hospital Discharge (30-day) a. Dispersion indicated by an IQR of at least 10 percentage points (Appendix Table E.13). b. Construct validity indicated by significant performance differences between top and bottom quartile of measure performance for either schizophrenia-related hospitalization or ED utilization (Appendix Table E.14). c. Convergent validity indicated by Pearson r≥0.15 in hypothesized direction with at least 2 other measures (Appendix Table E.15). d. Reliability indicated by state-level test-retest correlation (2007-2008) Pearson r≥0.30 (Appendix Table E.16). e. Stability indicated by no more than 1 performance quartile change for any state between 2007 and 2008. For some measures, states had denominators <100 in 2008; these measure/state combinations were excluded from this analysis. f. Measure calculated among enrollees with schizophrenia or bipolar disorder. 1. Five of the ten proposed measures demonstrated significant variability in state-level performance. A key indicator of a quality measure’s utility is its ability to capture a wide range of performance. Appendix Table E.13 lists each measure and its distribution across the 22-state dataset. Table III.5 identifies the four measures with an IQR of at least 10 percentage points and those where the lower and upper bounds of the IQR did not encompass the tails of performance (either low or high), indicating measures with the greatest utility for quality measurement purposes. The measure “Use of Antipsychotic Medication” had the most restricted performance range (an IQR of 3 percentage points). For example, a state 13 performing at the lower end of the IQR (that is, the 25th percentile), reported 92 percent of recipients received an antipsychotic, while a state at the top end of the IQR (the 75th percentile) reported 95 percent of recipients received an antipsychotic. Therefore, we believe that this measure has limited value from a quality improvement perspective, since the performance range is restricted and is already near the top, thus limiting the potential for improvement. However, because antipsychotic use is a fundamental issue for this population and the measure was widely endorsed by our consultants (the TAG and stakeholder groups), “use of antipsychotic medication” has considerable utility as a monitoring measure. 2. Seven of the ten proposed measures demonstrated evidence of validity. We assessed validity using two approaches. To assess construct validity we examined the association between measure performance and outcomes (schizophrenia-related hospitalization and ED visits). We compared the percentage of people who hospitalized or visited the ED for schizophrenia, comparing the worst and best-performing quartiles of state performance for each measure. For example, we found enrollees in states with the highest rates of antipsychotic use had significantly lower rates of hospitalization for schizophrenia compared with enrollees in states with the lowest rates of antipsychotic use (Appendix Table E.14). Seven measures demonstrated evidence of construct validity. Convergent validity was determined through examination of recipient-level measure correlations (Appendix Table E.15). We considered measures with a correlation coefficient of 0.15 or greater with at least two other measures to demonstrate evidence of convergent validity. Three of the ten measures met this criterion. Although some of these results are encouraging, some important limitations of these measures warrant consideration. Our measures of schizophrenia-related hospitalization and schizophrenia-related ED visits assess adverse outcomes at one extreme of care and thus do not reflect the full spectrum of care. Further, measures that assess preventive care processes were not anticipated to have a significant effect on schizophrenia-related hospitalization or ED use, therefore this relationship warrants further investigation to understand this finding. 3. Nine of the ten measures demonstrated evidence of reliability. Reliability was assessed through correlation of state-level 2007 and 2008 performance. Seven of the ten measures demonstrated 2007-2008 correlation of 0.30 or higher at the state level (Appendix Table E.16). In addition, we compared each state’s performance quartile in 2007 with its performance quartile in 2008 to understand the stability of each measure. We defined stability as no more than a one-quartile performance difference between 2007 and 2008; six measures met this criterion (Table III.5). Only “Use of Antipsychotic Medications” failed to show a strong state-level year-to-year correlation (r=0.25) and showed a large performance 14 difference (a three-quartile change) between 2007 and 2008, although this difference was observed in a single, small state. In summary, we began with a list of 23 measure concepts to assess the care provided to Medicaid enrollees with schizophrenia, and arrived at a final list of ten measures for submission to NQF. These measures fall into three domains, pharmacological, physical health measures and cross-cutting measures. Current evidence and limitations of claims data prevented us from developing robust measures of psychosocial treatments. Appendix F details the numerator, denominator and exclusions for each of the ten proposed measures. 15 IV. LESSONS LEARNED While we successfully developed and tested ten quality measures, development of several additional measures was not feasible given the constraints of Medicaid claims data and Medicaid payment policies. The following discussion of our experience and lessons learned is designed to be instructive for future efforts in the development of quality measures for people with SPMI. 1. Use of Medicaid claims data as a source to implement and test schizophrenia quality measures presented several noteworthy limitations. Because of the limitations of the claims data, several evidence-based practices could not be implemented as measures. These limitations were particularly conspicuous when attempting to operationalize evidence-based guidelines for psychosocial treatments such as those recommended in the Schizophrenia PORT. In analyses using MAX data, we found psychosocial treatments are either inconsistently coded in claims data or not available at all. For example, claims for smoking cessation programs were not observed in the MAX data; therefore, this measure was not developed because it could not be assessed in claims data. Consequently, no psychosocial measures emerged from our measure development process, despite the strength of evidence for these practices. Specific evidence-based recommendations that could not be accurately identified in the claims data, and thus were not field or pilot-tested, included: Supported employment; Family psychoeducation; Assertive community-based treatment; Cognitive behavioral therapy; Social skills training. Claims-only assessment presents other challenges for measure development. Because mental health problems are difficult to diagnose, claims often contain incorrect information that present challenges to accurate case finding. We attempted to minimize this problem by requiring either an inpatient claim with a primary diagnosis of schizophrenia or two outpatient claims on different days with a primary diagnosis of schizophrenia, adapting definitions used by others (Busch, Frank & Lehman 2004). However, we acknowledge that claims are not an ideal source to identify this population and may provide an undercount of the target population as diagnosis fields are not required for payment of services. Although current guidelines specify follow-up with a mental health provider following hospitalization, performance on our candidate measure is assessed by follow-up with any provider because mental health providers cannot be identified in Medicaid claims. 16 Finally, use of MAX data to test the measures limits the external validity of our results. Our MAX analytic study population was purposely limited to Medicaid recipients with claims data so that we could reliably identify patients with schizophrenia and the services they received. As a result, our study population included primarily disabled, non-dual-eligible enrollees in FFS plans. However, this group represents only a minority of the universe of people with SMI who receive mental health treatment through Medicaid programs. In particular, because drugs treatments are reimbursed by Medicare Part D for dually-eligible enrollees we are unable to include them, thus eliminating about 40 percent of all disabled Medicaid recipients from performance assessment. 2. Several topics were of interest to ASPE, the development team, and stakeholders, but the evidence base, tools, and methods for tracking these measures are immature. For example, evaluating receipt of evidence-based psychosocial services may require measures that address the structures of care (e.g., availability of trained providers, supervision). State officials in particular were interested in measures addressing potential overuse of pharmacological treatments, which is challenging to document in the absence of tools for risk adjustment and symptom measurement. In addition, the evidence to support overuse measures is inconsistent. Patient-reported outcomes were also of interest to stakeholders, but they cannot be ascertained using claims data. There was considerable interest in focus groups and TAG on addressing the physical health needs of people with schizophrenia; however, there was not always evidence to provide a rationale for a particular focus on such people for a given test. Some highly important preventive services, in particular tobacco cessation counseling and assistance, are not feasible in claims data. While there was evidence of low rates of cervical cancer screening among women with schizophrenia, there was no such evidence of a gap in care for HIV screening. Continuity of Medicaid enrollment was proposed to assess whether people with schizophrenia have consistent access to services; however, some lapses in coverage may be related to desirable outcomes (such as employment), and it would not be possible to determine the reason for loss of coverage. As the evidence base grows and use of electronic medical records and other electronic data repositories (for example, registries) also grows, so too will the ability to implement evidence-based measures. 3. Quality measurement for Medicaid recipients with schizophrenia presents implementation issues. During the development process, and in particular during the field-testing process, we became aware of several issues related to measure implementation. Key implementation issues included measure attribution, variations in care financing, and the need for long look-back periods for several measures. For example, although the TAG and several stakeholders endorsed the inclusion of a general measure tracking ED use, some providers voiced concerns about attribution for this measure. Specifically, during the field-testing process, mental health providers felt they should not be held accountable for ED 17 visits for accidents or other non-mental health reasons. Consequently, we dropped the measure of general ED use from our pilot-testing. However, attribution of care processes and outcomes will likely prove controversial, though implementation of the proposed measures at the state (rather than the provider level) will help to minimize concerns over attribution. We found that variation in the financing of services for people with SMI limited our ability to measure the care provided by Medicaid programs. For example, the provision of services through state mental health systems, the coverage of mental health services through Medicare for dual-eligible beneficiaries, the prohibition of same-day billing of medical and behavioral health services, and interstate variation in Medicaid and disability standards all underscore the limitations of claims data to measure quality for enrollees with schizophrenia. Finally, we found that reliance on Medicaid claims to produce rates of health screening can require a large volume of data to address issues of “look-back” for selected conditions. For example, some health conditions have a screening recommendation of every five years. Therefore, to compute a health screening measure for these conditions, information systems require the capacity to look back over a five-year claims history, which for some states could be a daunting task. 4. The distinction between enrollees with schizophrenia and other SMI conditions is, in many cases, artificial. The project team, ASPE, and measure stakeholders all expressed the belief that conceptually, many issues related to schizophrenia also apply broadly to people with any SMI. It was outside the scope of this project to conduct the full evidence review and testing necessary for this work. Further work is needed to consider whether measures similar to the ones developed and tested under this contract would be relevant for people with bipolar disorder and other SMI. 18 REFERENCES Buchanan, Robert W. et al. (2010). “The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 71-93. Busch, Alisa B., Richard Frank and Anthony Lehman. “The effect of a managed behavioral health carve-out on quality of care for Medicaid patients diagnosed as having schizophrenia.” Archives of General Psychiatry, 61: 442-448. Dixon, Lisa B., Faith Dickerson, Alan S. Bellack, et al. (2010). “The 2009 PORT psychosocial treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 48-70. Sherry, Tisamarie (2010). “Guidelines for the Treatment of Schizophrenia: A Review of the Literature.” Unpublished draft report. 19 APPENDIX A. MEASURE CONCEPTS FOR PATIENTS WITH SCHIZOPHRENIA Overview The process for identifying the measure concepts included a review of the clinical literature by ASPE, an environmental scan of treatment measure guidelines and existing measures by NCQA, and consultations with Drs. Julie Kreyenbuhl and Lisa Dixon of the Schizophrenia PORT group at the University of Maryland Medical School. The measure concepts outlined below cover each of the three treatment domains (pharmacotherapy, psychosocial treatment, physical health).The measures that will be tested and ultimately submitted for NQF endorsement evaluate the ambulatory care population and utilize Medicaid claims/encounter data. The measures are to be reported by Medicaid plans (health maintenance organization [HMO] or FFS). A-1 TABLE A.1. Measure Concept: Use of Antipsychotic Medications for Treatment of Schizophrenia Measure Intent/Focus To determine whether patients have access to pharmacotherapy. Eligible Population Patients with schizophrenia. Numerator Patients with schizophrenia who were prescribed any antipsychotic medication. Evidence Supporting Antipsychotic medications represent the cornerstone of pharmacological the Measure treatment for patients with schizophrenia. These agents have been shown to improve psychopathology, reduce, relapse, and improve functioning (DSM-IV- TR). A systematic review by Dixon, Lehman & Levine (1995) found that antipsychotic medications that were developed and widely available prior to 1990 (first-generation antipsychotics) are efficacious in controlling the positive symptoms of schizophrenia and reduced its morbidity and mortality. Subsequent efficacy and effectiveness studies, such as the CATIE and CUTlASS studies, have focused on the comparative effectiveness of first and second-generation antipsychotics (Lieberman et al. 2005; Jones et al. 2006). Although there is evidence on use of antipsychotic medications for all mental health conditions, we found no epidemiological evidence on rates of antipsychotic use for adult patients with schizophrenia. There is some limited indication of usage in the elderly gleaned from individual studies using MEPS data (Jano et al. 2008) and for adults in Florida Medicaid (Busch et al. 2009): “Rates of antipsychotic prescribing increased and also were higher in maintenance phase (acute 53%-63%; maintenance 65%-74%)” after transition to managed care. Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline American Psychiatric Association treatment guideline (2004). National Collaborating Centre for Mental Health of the National Institute for Health and Clinical Excellence (NICE; UK) (2009). Measure Currently, there is an NQF-endorsed measure that measures antipsychotic Consolidations/ medication use and adherence. If we decide to move forward with this Limitations measure, NQF expects that we will work with the organization to harmonize our measures. If collaboration does not happen, we will need to explain to NQF the process we went through to try to harmonize the measures. A-2 References American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Schizophrenia. 2nd ed. Arlington, VA: American Psychiatric Association. Page 114. Ascher-Svanum, H. et al. (2010). “The cost of relapse and the predictors of relapse in the treatment of schizophrenia”. BMC Psychiatry, 10: 2. Busch, A.B., Lehman, A.F., Goldman, H. & Frank, R.G. (2009). “Changes over time and disparities in schizophrenia treatment quality.” Medical Care, 47(2), 199-207. Dixon, L.B., Lehman, A.F. & Levine, J. (1995). ”Conventional antipsychotic medications for schizophrenia.” Schizophrenia Bulletin, 21(4): 567-577. Olfson, M., Hansell, S. & Boyer, C.A. (1997). “Medication noncompliance.” New Dir Ment Health Serv, (73): 39-49. Masand, P.S., Roca, M., Turner, M.S. & Kane, J.M. (2009). “Partial adherence to antipsychotic medication impacts the course of illness in patients with schizophrenia: A review.” Prim Care Companion J Clin Psychiatry, 11(4): 147-154. National Collaborating Centre for Mental Health (2009). Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care. London (UK): National Institute for Health and Clinical Excellence (NICE). Page 41. Weiden, P.J. & Olfson, M. (1995). “Cost of relapse in schizophrenia.” Schizophrenia Bulletin, 21(3): 419-429. A-3 TABLE A.2. Measure Concept: Continuity of Antipsychotic Medication Measure Intent/Focus To determine whether patients have continuous access to antipsychotic medications during the year. Eligible Population Option 1 (Medication possession ratio) Number of days in measurement year with an active schizophrenia a diagnosis. Option 2 (Gap rate) Number of patients with an antipsychotic prescription. Numerator Option 1 (Medication possession ratio) Number of days filled. Option 2 (Gap rate) Number of patients with a gap in prescription fills. Evidence Supporting Non-adherence to treatment with antipsychotics is common, and medication the Measure non-adherence is a significant cause of relapse (Olfson, Hansell & Boyer 1997; Ascher-Svanum et al. 2010). Moreover, the relapse rate rises from 3.5% per month to 11.0% per month when antipsychotic medication is experimentally withdrawn (Weiden & Oflson 1995). There is some experimental evidence that failure to receive antipsychotics will result in greater relapse (Weiden & Oflson 1995), but we could find no experimental evidence to document subsequent harms. Understanding adherence patterns is important, as non-adherence to medication regimens increases treatment costs and the likelihood for patients to relapse. Costs for patients with prior relapse are about 3 times the costs for patients without prior relapse and include costs for outpatient services and medication. Patients with prior relapse were younger and had onset of illness at earlier ages, poorer medication adherence, more severe symptoms, a higher prevalence of substance use disorder, and worse functional status. (Ascher-Svanum et al. 2010) Similar patterns have been found in Medicaid data. Only 41% of Medicaid beneficiaries with schizophrenia were adherent to treatment with their antipsychotic medications; and, rates of medical hospitalization were lower for those who were adherent (7%) than for those who were non-adherent (13%) (Gilmer et al. 2004).Those who were adherent had significantly lower hospital costs (Gilmer et al. 2004). In a Maine Medicaid study, prescription discontinuities resulted in hospital costs that exceeded the cost savings associated with reduced prescription filling (Soumerai et al. 2008). For the gap in prescription fills concept, there is no evidence for a particular standard. One example using Florida Medicaid data used 30 days (Busch et al. 2009). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None A-4 Measure When using administrative data, measurement is restricted to what can be Consolidations/ observed, which for pharmacy utilization is the filling and payment of Limitations prescriptions. Thus, filling of prescriptions is a proxy for the concept of medication adherence. Currently there is an NQF-endorsed measure of medication use and adherence. If we decide to move forward with this measure, NQF expects that we will work with the organization to harmonize our measures. If collaboration does not happen, we will need to explain to NQF the process we went through to try to harmonize the measures. References Ascher-Svanum, H., et al. (2010). “The cost of relapse and the predictors of relapse in the treatment of schizophrenia”. BMC Psychiatry, 10: 2. Busch, A.B., Lehman, A.F., Goldman, H. & Frank, R.G. (2009). “Changes over time and disparities in schizophrenia treatment quality.” Medical Care, 47(2), 199-207. Dixon, L.B., Lehman, A.F. & Levine, J. (1995). ”Conventional antipsychotic medications for schizophrenia.” Schizophrenia Bulletin, 21(4): 567-577. Gilmer, T.P. et al. (2004). “Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia.” Am J Psychiatry, 161(4): 692-699. Law, M.R., Soumerai, S.B., Ross-Degnan, D. & Adams, A.S. (2008). “A longitudinal study of medication nonadherence and hospitalization risk in schizophrenia.” J Clin Psychiatry, 69(1): 47-53. Olfson, M., Hansell, S. & Boyer, C.A. (1997). “Medication noncompliance.” New Dir Ment Health Serv, (73): 39-49. Masand, P.S., Roca, M., Turner, M.S. & Kane, J.M. (2009). “Partial adherence to antipsychotic medication impacts the course of illness in patients with schizophrenia: A review.” Prim Care Companion J Clin Psychiatry, 11(4): 147-154. Soumerai, S.B. et al. (2008). “Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change.” Health Aff (Millwood), 27(3): w185-195. Weiden, P.J. & Olfson, M. (1995). “Cost of relapse in schizophrenia.” Schizophrenia Bulletin, 21(3): 419-429. a. For somebody enrolled for the entire year with indication of schizophrenia that applies for the whole year, this would be 365. For somebody enrolled for part of the year, this would be the number of days enrolled and has indication of schizophrenia. A-5 TABLE A.3. Measure Concept: Use of Clozapine in Treatment Resistant Patients Measure Intent/Focus To assess the extent to which patients are prescribed clozapine following failure of prior antipsychotic treatment. Eligible Population Treatment-resistant patients with schizophrenia. Numerator Treatment-resistant patients with schizophrenia who were prescribed clozapine. Evidence Supporting Treatment resistance may result in increased dosage of medications to the Measure achieve response or patient non-adherence and subsequent relapse. Excess dosing, particularly of second-generation antipsychotics may contribute to secondary health problems like metabolic syndrome (see physical health concepts below), while non-adherence and relapse result in worse patient outcomes and higher costs (see continuity concept above). Since the 2003 PORT guidelines, 12 new studies have provided evidence consistent with previous findings that clozapine is effective in people who have not responded to treatment with first-generation antipsychotics (Lehman & Steinwachs 1998; Lehman et al. 2004; Buchanan et al. 2010). The CATIE and CUTlASS trials also found that clozapine is more effective than other second-generation antipsychotics in improving symptoms in people who have failed to respond to a first-generation antipsychotic or second-generation antipsychotic (McEvoy et al. 2006; Lewis et al. 2006). The recommendations for use of clozapine are supported by a systematic review (Buchanan et al. 2010) and 2 sets of clinical guidelines. The APA treatment guidelines rated the clinical evidence as Level I (strong clinical evidence) for clozapine’s effectiveness over other medications after no/partial/sub-optimal response to two trials of antipsychotic medication and Level II (moderate clinical confidence) for using a 4-6 week trial as evidence of treatment resistance. Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline American Psychiatric Association treatment guideline (2004). National Collaborating Centre for Mental Health of the National Institute for Health and Clinical Excellence (NICE; UK) (2009). Measure How is treatment resistance or failure to respond to other antipsychotic Consolidations/ medications determined in claims data? Kane (1996) specified a set of criteria Limitations for treatment resistance that would be challenging to specify: available medications and other treatments are not useful in alleviating the target symptoms of schizophrenia (not only the positive and negative symptoms, but also disorganized or violent/aggressive behavior, thought disorder and suicidal ideation); occurrence of adverse side effects of medication; non-adherence to current treatment; presence of comorbid conditions such as substance misuse; failure of maintenance and relapse despite seemingly adequate doses of antipsychotics. A-6 References American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Schizophrenia. 2nd ed. Arlington, VA: American Psychiatric Association. Page 114. Buchanan, R.W. et al. (2010). “The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 71-93. Kane, J.M. (1996). “Treatment-resistant schizophrenic patients.” J Clin Psychiatry, 57 Suppl 9: 35-40. National Collaborating Centre for Mental Health (2009). Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care. London (UK): National Institute for Health and Clinical Excellence (NICE). Page 41. A-7 TABLE A.4. Measure Concept: Polypharmacy Treatment Measure Concept Polypharmacy treatment. Measure Intent/Focus To determine simultaneous use of multiple antipsychotic medications, which may be harmful to patients. Eligible Population Patients with schizophrenia. Numerator Patients with schizophrenia who receive 3 or more antipsychotic medications (in a unit of time). Evidence Supporting If a patient is on an effective single antipsychotic medication, then multiple the Measure antipsychotic medications likely are not necessary and may expose the patient to side effects of the medication (e.g., weight gain). Some limited overlap in the course of 2 drugs may be expected to manage side effects of 1 of the antipsychotics (e.g., tardive dyskinesia, extrapyramidal side effects). However, expert opinion (Dixon & Kreyenbuhl, personal communication) suggests prescribing 3 or more such medications may indicate inappropriate quality of care. Kreyenbuhl et al. (2007) noted the problems of polypharmacy include drug interactions, adherence problems, costs, and potential for mortality impacts. Several RCTs show no difference between patients receiving polypharmacy-- usually tested as clozapine as an adjunct to one other antipsychotic medication, usually risperidone--and patients who receive monotherapy (Honer et al. 2006; Anil Yagcioglu et al. 2005; Shiloh et al. 1997). At least 1 RCT found positive benefits of polypharmacy (Josiassen et al. 2005). A case control study by Centorrino and colleagues (2005) found negative effects of polypharmacy, but such effects likely reflect selection bias (assignment of polypharmacy based on perceived difficulty of case). We could find no predefined cut point for polypharmacy beyond 2 medications. Increasingly, people who have responded inadequately to antipsychotic monotherapy are being treated with multiple antipsychotics, but there is a limited amount of research focused on the effects of antipsychotic polypharmacy (Horovitz-Lennon et al. 2009). At this point, the data is inconclusive about the magnitude of polypharmacy as it relates to the quality of treatment provided to patients with schizophrenia: polypharmacy may indicate treatment resistance, or it may signal variation in treatment practices. RAND’s VHA Mental Health Program Evaluation concluded that there was evidence to measure practice variation, but not quality of care. Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure The Joint Commission has a related measure for patients discharged from Consolidations/ inpatient hospitalization, but it is not specific to patients with schizophrenia. Limitations This measure may require harmonization. If the evidence is limited to clozapine, then perhaps the concept should be restricted to polypharmacy with clozapine; however, it may be difficult to distinguish clozapine-related polypharmacy from using clozapine to address treatment resistance after failure of other antipsychotic medications. A-8 References Anil Yagcioglu, A.E. et al. (2005). “A double-blind controlled study of adjunctive treatment with risperidone in schizophrenic patients partially responsive to clozapine: Efficacy and safety.” J Clin Psychiatry, 66(1): 63- 72. Centorrino, F. et al. (2004). “Multiple versus single antipsychotic agents for hospitalized psychiatric patients: Case-control study of risks versus benefits.” Am J Psychiatry, 161(4): 700-706. Honer, W.G. et al. (2006). “Clozapine alone versus clozapine and risperidone with refractory schizophrenia.” N Engl J Med, 354(5): 472-482. Horovistz-Lennon, M. et al. (2009). Veterans Health Administration Mental Health Program Evaluation Technical Manual. RAND Working Paper, 34. Josiassen, R.C. et al. (2005). “Clozapine augmented with risperidone in the treatment of schizophrenia: A randomized, double-blind, placebo- controlled trial.” Am J Psychiatry, 162(1): 130-136. Kreyenbuhl, J.A., Valenstein, M., McCarthy, J.F., Ganoczy, D. & Blow, F.C. (2007). “Long-term antipsychotic polypharmacy in the VA health system: Patient characteristics and treatment patterns.” Psychiatr Serv, 58(4): 489- 495. Shiloh, R. et al. (1997). “Sulpiride augmentation in people with schizophrenia partially responsive to clozapine. A double-blind, placebo-controlled study.” Br J Psychiatry, 171: 569-573. A-9 TABLE A.5. Measure Concept: Outpatient Follow-up After Mental Health Hospitalization Measure Intent/Focus To ensure a stable transition to subsequent community treatment and to monitor medication adherence in order reduce risk of readmission. Eligible Population Patients with schizophrenia discharged from the hospital. Numerator Patients with schizophrenia discharged from the hospital who receive a follow-up visit within a specified time interval. Evidence Supporting There is evidence related to the importance of community support for patients the Measure with schizophrenia, particularly regarding adherence (see above on adherence and below on psychosocial treatment), but we found no evidence related to outpatient follow-up visit after hospitalization. NCQA has a measure of 7-day and 30-day follow-up after mental health hospitalization; however, this applies to all mental health disorders. There is little evidence to support either threshold or the clinical consequences of failure to receive follow-up within 7-day or 30-days for mental health disorders generally (HEDIS 2011). None were found for schizophrenia. The concept is supported by APA treatment guidelines, which rate the evidence as Level II (moderate clinical confidence). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline American Psychiatric Association treatment guideline (2004). Measure This measure may have to be harmonized with the NCQA measure. NQF Consolidations/ may not consider the existing follow-up measure to be sufficient, particularly Limitations absent evidence for this specific population. References American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Schizophrenia. 2nd ed. Arlington, VA: American Psychiatric Association. Page 114. National Committee for Quality Assurance (2010). HEDIS 2011: Healthcare Effectiveness Data and Information Set, Follow-Up after Hospitalization for Mental Illness. Page 186-187. A-10 TABLE A.6. Measure Concept: Use of Assertive Community Treatment (ACT) Post-Hospitalization Measure Intent/Focus To assess the number of patients who receive ACT post-hospitalization. Eligible Population Patients with schizophrenia who were discharged from an inpatient setting in the measurement year. Numerator Patients with schizophrenia who were recently discharged from an inpatient setting who receive ACT. Evidence Supporting Patients with schizophrenia who are at high risk for discontinuation of the Measure treatment or for repeated crises require an array of clinical, rehabilitation, and social services to address their needs. Coordination, integration and continuity of services among providers over time can be substantially enhanced through ACT. RCTs examining ACT have consistently found that it reduces rates of hospitalization, the number of days hospitalized, and homelessness compared to standard care (Bustillo et al. 2001; Coldwell & Bender 2007; Nelson, Aubry & Lafrance 2007; Bond et al. 1988; Burns & Santos 1995), and results in the use of fewer emergency and more outpatient services (Lehman et al. 1997; Lehman et al. 1999; Scott & Dixon 1995b; Morse et al. 1992). Dixon and colleagues’ (2010) review of RCTs of ACT support these findings. Some studies have also found that ACT is associated with decreased symptoms (Stein & Test 1980; Morse et al. 1997), increased medication adherence (Stein & Test 1980), more days in stable community housing (Nelson, Aubry & Lafrance 2007), Programs with greater fidelity to the ACT model and targeted to individuals at high risk of hospitalization are generally more successful (Burns et al. 2007; Latimer 1999). ACT has also been used as a model for integrated treatment of individuals with both SMI and substance use disorders. While one study found that this intervention decreased substance use (Drake et al. 1998), two others found no effect on substance use specifically (Morse et al. 2006; Essock et al. 2006), but did find reduced hospitalizations and more days in stable housing relative to standard care. Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure Is ACT identified consistently in claims data? Are there multiple state-specific Consolidations/ codes for community treatment? Limitations References Bond, G.R. (1988). “Assertive case management in three CMHCs: A controlled study.” Hosp Community Psychiatry, 39: 411-418. Burns, T. et al. (2007). “Use of intensive case management to reduce time in hospital in people with severe mental illness: Systematic review and meta- regression.” BMJ, 335: 336. Bustillo, J. et al. (2001). “The psychosocial treatment of schizophrenia: An update.” Am J Psychiatry, 158: 163-175. A-11 References Chandler, D. et al. (1997). “A capitated model for a cross-section of severely (continued) mentally ill clients: Employment outcomes.” Community Ment Health J, 33: 501-516. Chandler, D. (1999). “Cost-effectiveness of a capitated assertive community treatment program.” Psychiatr Rehabil J, 22: 327-336. Coldwell, C.M. & Bender, W.S. (2007). “The effectiveness of assertive community treatment for homeless populations with severe mental illness: A meta-analysis.” Am J Psychiatry, 164: 393-399. Dixon, L.B. et al. (2010). “The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 48-70. Drake, R.E. et al. (1998). “Assertive community treatment for patients with co- occurring severe mental illness and substance use disorder: A clinical trial.” Am J Orthopsychiatry, 68: 201-215. Essock, S.M. et al. (2006). “Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders.” Psychiatr Serv, 57: 185-196. Fiander, M. et al. (2003). “Assertive community treatment across the Atlantic: Comparison of model fidelity in the UK and USA.” Br J Psychiatry, 182: 248-254. King, R. (2006). “Intensive case management: A critical re-appraisal of the scientific evidence for effectiveness.” Adm Policy Ment Health, 33: 529- 535. Latimer, E.A. (1999). “Economic impacts of assertive community treatment: A review of the literature.” Can J Psychiatry, 44: 443-454. Lehman, A.F. et al. (1997). “A randomized trial of assertive community treatment for homeless persons with severe mental illness.” Archives of General Psychiatry, 54: 1038-1043. Lehman, A.F. et al. (1999). “Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness.” Br J Psychiatry, 174: 346-352. Morse, G.A. et al. (1992). “Experimental comparison of the effects of three treatment programs for homeless mentally ill people.” Hosp Community Psychiatry, 43: 1005-1010. Morse, G.A. et al. (1997). “An experimental comparison of three types of case management for homeless mentally ill persons.” Psychiatr Serv, 48: 497- 503. Morse, G.A. et al. (2006). “Treating homeless clients with severe mental illness and substance use disorders: Costs and outcomes.” Community Ment Health J, 42: 377-404. Nelson, G., Aubry, T. & Lafrance, A. (2007). “A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless.” Am J Orthopsychiatry, 77: 350-361. A-12 Scott, J.E. & Dixon, L.B. (1995b). “Assertive community treatment and case management for schizophrenia.” Schizophrenia Bulletin, 21: 657-668. References Stein, L.I. & Test, M.A. (1980). “Alternative to mental hospital treatment. I. (continued) Conceptual model, treatment program, and clinical evaluation.” Archives of General Psychiatry, 37: 392-397. Ziguras, S.J. & Stuart, G.W. (2000). “A meta-analysis of the effectiveness of mental health case management over 20 years.” Psychiatr Serv, 51(11): 1410-1421. A-13 TABLE A.7. Measure Concept: Use of Case Management Measure Intent/Focus To assess whether patients in treatment for schizophrenia receive case management services. Eligible Population Patients with schizophrenia who were discharged from an inpatient setting in the measurement year. Numerator Patients with schizophrenia who were recently discharged from an inpatient setting who received case management during the measurement year. Evidence Supporting A meta-analysis of mental health case management concluded that clinical the Measure case management is generally effective in improving outcomes from mental health services, as measured by clients’ level of social functioning, symptoms, client and family satisfaction, and family burden of care (Ziguras & Stuart 2000). However, this review did not separately analyze effectiveness for patients with schizophrenia. A primary finding was that case management resulted in more hospitalizations, but for shorter lengths of stay, with net fewer hospital days per year. The authors also note that ACT is superior to clinical case management in reducing hospitalization, even if ACT and case management have similar effects on symptoms, satisfaction, and social functioning (Ziguras & Stuart 2000). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure Should this be for all patients with schizophrenia or just those who recently Consolidations/ discharged from a hospital stay? Limitations References Ziguras, S.J. & Stuart, G.W. (2000). “A meta-analysis of the effectiveness of mental health case management over 20 years.” Psychiatr Serv, 51(11): 1410-1421. A-14 TABLE A.8. Measure Concept: Use of Family Therapy Measure Concept Use of family therapy. Measure Intent/Focus To assess whether people with schizophrenia receive treatment that includes their family members. Eligible Population Patients with schizophrenia. Numerator Patients with schizophrenia who have a minimum number of visits for family therapy during the measurement year. Evidence Supporting Family interventions for individuals with schizophrenia may reduce the the Measure likelihood of relapse for the individual or reduce family members’ stress. A meta-analysis conducted by Pilling et al. (2002) highlights the benefits of family interventions over other treatments such as basic pharmacology in reducing relapses, readmissions to hospital, and symptoms. Among patients with a recent illness exacerbation, family psychoeducation interventions that are 6-9 months or longer significantly reduce rates of relapse and re- hospitalization, improve treatment adherence, lower stress and improve vocational outcomes among patients (Pfammatter, Junghan & Brenner 2006; Xiong et al. 1994; Mari & Streiner 1994; Pilling et al. 2002; Pitschel-Walz et al. 2001; Falloon et al. 1985; Mueser et al. 2001). Evidence of the effectiveness of a 6-9 month intervention for patients who have not had a recent illness exacerbation is weaker (Dyck et al. 2000; Magliano et al. 2006; Hazel et al. 2004; Dyck et al. 2002), but was still sufficient to support a recommendation of 6-9 months of family psychoeducation for stable patients (Dixon et al. 2010). Family psychoeducation interventions shorter than 6 months, but a minimum of 4 sessions, have been found to improve family and patient outcomes among both stable patients and patients who have had a recent relapse (Posner et al. 1992; Spiegel & Wissler 1987; Merinder et al. 1999; Pitschel- Walz et al. 2006). While not all shorter interventions have been found to be effective, most evidence supports the benefits of this treatment, particularly for family members (Vaughan et al. 1992). In a RCT, Barrowclough and colleagues (2001) found that using cognitive behavioral therapy and motivational interviewing in family treatment of patients with co-occurring schizophrenia and substance use disorders showed significantly greater improvement in patients’ general functioning and the number of days they were abstinent from substances (Barrowclough et al. 2001). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure Currently, it is not possible to identify patients who do not have family Consolidations/ members, who refuse to consent to family participation, and whose families Limitations refuse participation in treatment using claims data. This may be possible in the future through G-codes. The evidence suggests that a minimum of 4 family therapy visits is necessary to be effective; however, receiving even 1 family therapy visit may be too high for some programs to reach. A-15 References Barrowclough, C. et al. (2001). “Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders.” Am J Psychiatry, 158: 1706-1713. Dixon, L.B. et al. (2010). “The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 48-70. Dyck, D.G. et al. (2000). “Management of negative symptoms among patients with schizophrenia attending multiple-family groups.” Psychiatr Serv, 51: 513-519. Dyck, D.G. et al. (2002). “Service use among patients with schizophrenia in psychoeducational multiple-family group treatment.” Psychiatr Serv, 53: 749-754. Falloon, I.R. et al. (1985). “Family management in the prevention of morbidity of schizophrenia. Clinical outcome of a two-year longitudinal study.” Archives of General Psychiatry, 42: 887-896. Hazel, N.A. et al. (2004). “Impact of multiple-family groups for outpatients with schizophrenia on caregivers’ distress and resources.” Psychiatr Serv, 55: 35-41. Magliano, L. et al. (2006). “Patient functioning and family burden in a controlled, real-world trial of family psychoeducation for schizophrenia.” Psychiatr Serv, 57: 1784-1791. Mari, J.J. & Streiner, D.L. (1994). “An overview of family interventions and relapse on schizophrenia: Meta-analysis of research findings.” Psychol Med, 24: 565-578. Mueser, K.T. et al. (2001). “Family treatment and medication dosage reduction in schizophrenia: Effects on patient social functioning, family attitudes, and burden.” J Consult Clin Psychol, 69: 3-12. Pfammatter, M., Junghan, U.M. & Brenner H.D. (2006). “Efficacy of psychological therapy in schizophrenia: Conclusions from meta-analyses.” Schizophrenia Bulletin, 32(Suppl 1): S64-S80. Pilling, S. et al. (2002). “Psychological treatments in schizophrenia: I. Meta- analysis of family intervention and cognitive behaviour therapy.” Psychol Med, 32: 763-782. Posner, C.M. et al. (1992). “Family psychoeducational support groups in schizophrenia.” Am J Orthopsychiatry, 62: 206-218. Pitschel-Walz, G. et al. (2006). “Psychoeducation and compliance in the treatment of schizophrenia: Results of the Munich Psychosis Information Project Study.” J Clin Psychiatry, 67: 443-452. Sellwood, W. et al. (2001). “Needs-based cognitive-behavioural family intervention for carers of patients suffering from schizophrenia: 12-month follow-up.” Acta Psychiatr Scand, 104: 346-355. A-16 References Vaughan, K. et al. (1992). “The Sydney intervention trial: A controlled trial of (continued) relatives’ counseling to reduce schizophrenic relapse.” Soc Psychiatry Psychiatr Epidemiol, 27: 16-21. Xiong, W. et al. (1994). “Family-based intervention for schizophrenic patients in China. A randomised controlled trial.” Br J Psychiatry, 165: 239-247. A-17 TABLE A.9. Measure Concept: Use of Supported Employment Measure Concept Use of supported employment. Measure Intent/Focus To assess whether people with schizophrenia received or were offered supported employment. Eligible Population People with schizophrenia. Numerator People with schizophrenia who received or were offered supported employment during the measurement year. Evidence Supporting Employment is an important goal for some patients with schizophrenia, the Measure indicating improved social and economic functioning. The most empirically validated approach to vocational rehabilitation is supported employment combined with skills training. A number of RCTs have consistently found that supported employment is effective in helping people with schizophrenia to obtain competitive employment, work more hours and earn higher wages, and does not lead to negative clinical outcomes (Chandler et al. 1997; Drake et al. 1994, 1996; Bond et al. 1995; Drake et al. 1999; Lehman et al. 2002; Cook et al. 2005). It is therefore recommended for any person with schizophrenia who wishes to work. Greater fidelity to the supported employment model yields better employment outcomes (Becker et al. 2001, 2006; Catty et al. 2008), as does increased integration of mental health and vocational services (Cook et al. 2005). The individual effectiveness of other elements of the supported employment model is not known (Dixon et al. 2010). Overall, supported employment has been shown to improve the employment outcomes of persons with severe mental illness, although many clients who receive this service still fail to achieve their vocational goals (McGurk & Mueser 2004). A limitation of the evidence is that it has not been demonstrated that supported employment positively influences long-term job retention and economic independence (Lehman et al. 2002; Gold et al. 2006; Cook et al. 2005). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure It may be difficult to distinguish supported employment from traditional Consolidations/ vocational rehabilitation in service codes in administrative data. Would this Limitations measure be acceptable if it were applied to all patients with schizophrenia? Claims data will not identify employment as a goal and may not identify offers of supported employment. Perhaps this may be possible in the future through G-codes. A-18 References Chandler, D. et al. (1997). “A capitated model for a cross-section of severely mentally ill clients: Employment outcomes.” Community Ment Health J, 33: 501-516. Cook, J.A. et al. (2005). “Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment.” Am J Psychiatry, 162: 1948-1956. Dixon, L.B. et al. (2010). “The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 48-70. Drake, R.E. et al. (1994). “Rehabilitative day treatment vs. supported employment: I. Vocational outcomes.” Community Ment Health J, 30: 519- 532. Drake, R.E. et al. (1999). “A randomized clinical trial of supported employment for inner-city patients with severe mental disorders.” Archives of General Psychiatry, 56: 627-633. Gold, P.B. et al. (2006). “Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness.” Schizophrenia Bulletin, 32: 378-395. Lehman, A.F. et al. (2002). “Improving employment outcomes for persons with severe mental illnesses.” Archives of General Psychiatry, 59: 165-172. McGurk S.R., & Mueser K.T. (2004). “Cognitive functioning, symptoms, and work in supported employment: A review and heuristic model. Schizophrenia Research, 70(2-3): 147-173. Review. PubMed PMID: 15329293. A-19 TABLE A.10. Measure Concept: Use of Any Psychosocial Treatment Measure Concept Use of any psychosocial treatment. Measure Intent/Focus To assess whether patients with schizophrenia receive specialty mental health treatments, including ACT, individual, group or family therapy a intervention. Eligible Population Patients with schizophrenia. Numerator Patients with schizophrenia who received psychosocial treatment during the measurement year. Evidence Supporting Management of symptoms of schizophrenia cannot usually be addressed the Measure solely through pharmacotherapy. Psychosocial treatments focuses on addressing the impact of schizophrenia on an individual in the forms of isolation from families and friends; damage to social and working relationships; depression and demoralization; and an increased risk of self- harm, aggression, and substance abuse. Persistent symptoms that remain after the early recovery phase are an additional problem and add to the already disrupted developmental trajectory, particularly for young people who are experiencing their first episode of psychosis (Addington et al. 2010). Psychosocial interventions have a very important place in the treatment of schizophrenia. In fact, most schizophrenia treatment guidelines now have specific recommendations about including psychosocial and psychological interventions (Addington et al. 2010; APA 2004). APA rates the evidence as Level I (recommended with substantial clinical confidence) and II (moderate clinical confidence) for both acute phase and stabilization phase patients. Supporting evidence is based on the effectiveness of ACT and family therapy in particular (see concepts above). However, we found no evidence that a combined measure is indicative of improved outcomes. Busch and colleagues have used such a measure though to rate quality of care for patients with schizophrenia in a state Medicaid program, and performance was low (Busch et al. 2004). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline American Psychiatric Association treatment guideline (2004). Measure This measure may prove similar to the measure concept below for combined Consolidations/ medication and psychosocial treatment: if we use medications to identify the Limitations patients with schizophrenia, then the denominators will be the same. References American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Schizophrenia. 2nd ed. Arlington, VA: American Psychiatric Association. Page 114. Addington, J., Piskulic, D. & Marshell, C. (2010). “Psychosocial treatments for Schizophrenia.” Current Directions in Psychological Science, 19: 260. Busch, A.B., Frank, R.G. & Lehman, A.F. (2004). “The effect of a managed behavioral health carve-out on quality of care for Medicaid patients diagnosed as having schizophrenia.” Archives of General Psychiatry, 61(5): 442-448. a. The measure would assess whether a patient with schizophrenia received any of each of these kinds of services; it would not necessarily report separate rates for each type of services. A-20 TABLE A.11. Measure Concept: use of Combination Antipsychotic Medication and Psychosocial Measure Intent/Focus To assess whether people with schizophrenia receive antipsychotic medications and psychosocial treatment. Eligible Population Patients with schizophrenia. Numerator Patients with schizophrenia receiving both medication and psychosocial treatment during the measurement year. Evidence Supporting A number of pharmacological and psychosocial interventions are effective in the Measure reducing symptoms and improving the quality of life for people with schizophrenia. According to the APA, treatment programs need to combine medications with a range of psychosocial services to reduce the need for crisis-oriented hospitalizations and ED visits and to effect better recovery. The combination of medication treatment and psychosocial treatment can improve not only the symptoms of the illness but also the overall impact of the illness on an individual (Addington et al. 2010). Despite these findings, there are a number of studies that show that people with schizophrenia often do not receive these recommended treatments and thus receive poor quality care overall (Lehman, Steinwachs & PORT Co- Investigators 1998; Dickey et al. 2003; Young et al. 1998; Busch, Frank & Lehman 2004; Leslie & Rosenheck 2001). The components of this concept (psychosocial treatment and pharmacotherapy) are supported by clinical guidelines. The APA rated the evidence at Level I (substantial clinical confidence) for the combination of medications with psychosocial services; NICE guidelines recommend the use of pharmacological therapy in conjunction with psychosocial therapy but did not include a rating of the evidence. Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline American Psychiatric Association treatment guideline (2004). National Collaborating Centre for Mental Health of the National Institute for Health and Clinical Excellence (NICE; UK) (2009). Measure This measure may prove similar to the concept above for any psychosocial Consolidations/ treatment: if we use medications to identify patients with schizophrenia, then Limitations the denominators will be the same. A-21 References American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Schizophrenia. 2nd ed. Arlington, VA: American Psychiatric Association. Page 114. Addington, J., Piskulic, D. & Marshell, C. (2010). “Psychosocial treatments for Schizophrenia.” Current Directions in Psychological Science, 19: 260. Busch, A.B., Frank, R.G. & Lehman, A.F. (2004). “The effect of a managed behavioral health carve-out on quality of care for Medicaid patients diagnosed as having schizophrenia.” Archives of General Psychiatry, 61(5): 442-448. Dickey, B. et al. (2003). “Guideline recommendations for treatment of schizophrenia.” Archives of General Psychiatry, 60: 340-348. Lehman, A.F. et al. (2004). “The Schizophrenia Patient Outcomes Research Team (PORT): Updated treatment recommendations 2003.” Schizophrenia Bulletin, 39: 193-217. Leslie, D.L. & Rosenheck, R.A. (2001). “Use of pharmacy data to access quality of pharmacotherapy for schizophrenia in a national health care system: Individual and facility predictors.” Medical Care, 39: 923-933. Young, A.S. et al. (1998). “Measuring the quality of outpatient treatment for schizophrenia.” Archives of General Psychiatry, 55(7): 611-617. A-22 TABLE A.12. Measure Concept: Monitoring of Metabolic Conditions Among Patients Taking Antipsychotic Medications Measure Intent/Focus To determine appropriate monitoring for complications and side effects of using antipsychotic medications, which are associated with risk of weight gain and associated disorders, including diabetes and cardiovascular disease. Eligible Population Patients with schizophrenia who have a prescription for an antipsychotic medication. Numerator Patients with schizophrenia who have a prescription for an antipsychotic medication who receive a screening for blood sugar, lipids, and/or blood pressure. Evidence Supporting Monitoring complications of antipsychotic medications is important because the Measure the use of these medications in people with schizophrenia results in higher incidences of metabolic diseases, such as diabetes, and cardiovascular concerns, such as hyperlipidemia. Diabetes mellitus occurs in schizophrenia patients at higher rates than in the general population (Nielsen, Skadhede & Correll 2010; Dixon et al. 2000). Metabolic syndrome risk is 42.6% for males and 48.5% for females, compared to rates in the general population of 24% for males and 23% for females (Cohn et al. 2004). These effects occur for both first-generation and some second-generation antipsychotic medications. Patients with schizophrenia are likely to have higher levels and receive less treatment for elevated blood cholesterol. Patients with schizophrenia and elevated blood cholesterol levels are prescribed statins at approximately 25% of the rate in the general population. Furthermore, some but not all atypical antipsychotic drugs increase total and low-density lipoprotein cholesterol as well as triglycerides and decrease high-density lipoprotein cholesterol, all of which increase risks of CHD (Henneksen et al. 2005). Among patients with co-occurring schizophrenia and metabolic disorders, rates of non-treatment for diabetes, hyperlipidemia and hypertension ranged from 30.2% for diabetes, to 62.4% for hypertension and 88.0% for dyslipidemia (CATIE trial: Nasrallah et al. 2006). Atypical antipsychotic medications elevate the risk of metabolic conditions relative to typical antipsychotic medications (Nasrallah 2008). In a study of VA patients with schizophrenia benefit from primary care, primary care offered a survival benefit among patients with diabetes (Copeland et al. 2009). This measure concept is supported by systematic literature reviews including the Consensus Development Conference (2004). The Mount Sinai Conference (Marder et al. 2004) rated the quality of evidence for an association between specific antipsychotics and risk for diabetes as Level 2 (cohort studies, outcomes research, etc.). For hyperlipdemia, the Mount Sinai Conference rated the “[q]uality of evidence for an association between specific antipsychotics and risk for hyperlidemia: level 2 [cohort studies, outcomes research, etc.].” NICE and the APA (Level II, moderate clinical confidence) likewise recommend such monitoring. A-23 Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes (2004). American Psychiatric Association treatment guideline (2004). National Collaborating Centre for Mental Health of the National Institute for Health and Clinical Excellence (NICE; UK) (2009). Measure Should hypertension be a component in the metabolic screening measure Consolidations/ concept? Also should this measure create one overall rate or should there be Limitations separate rates in addition to the overall rate? Appropriate screening frequency will need to be taken into account for each condition. References Cohn, T., Prud’homme, D., Streiner, D., Kameh, H. & Remington, G. (2004). “Characterizing coronary heart disease risk in chronic schizophrenia: High prevalence of the metabolic syndrome.” Can J Psychiatry, 49(11): 753- 760. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes (2004). Diabetes Care, 27: 596. Henderson, D.C. (2002). “Atypical antipsychotic-induced diabetes mellitus: How strong is the evidence?” CNS Drugs, 16(2): 77-89. Marder, S.R. et al. (2004). “Physical health monitoring of patients with schizophrenia.” Am J Psychiatry, 161(8): 1334-1349. Nasrallah, H.A. (2008). “Atypical antipsychotic-induced metabolic side effects: Insights from receptor-binding profiles.” Mol Psychiatry, 13(1): 27-35. Nasrallah, H.A. et al. (2006). “Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: Data from the CATIE schizophrenia trial sample at baseline.” Schizophr Res, 86(1-3): 15-22. Nielsen, J., Skadhede, S. & Correll, C.U. (2010). “Antipsychotics associated with the development of type 2 diabetes in antipsychotic-naive schizophrenia patients.” Neuropsychopharmacology, 35(9): 1997-2004. A-24 TABLE A.13. Measure Concept: Weight Assessment and Counseling Among Patients with Schizophrenia who are Taking Antipsychotics Measure Intent/Focus To address weight gain as a side effect of antipsychotic medications. Eligible Population Patients with schizophrenia who have a prescription for an antipsychotic medication. Numerator Patients with schizophrenia who have a prescription for an antipsychotic medication, and who have evidence of weight assessment or counseling. Evidence Supporting Patients with schizophrenia have higher rates of obesity (Body Mass Index the Measure [BMI]>27) than the general population (42% v. 27%, respectively) (Allison et al. 1999), and multiple studies document effect of antipsychotics on weight gain (Allison et al. 1999; Wirshing et al. 1999; Allison et al. 2001; Volavka et al. 2002; Azorin et al. 2001; Bustillo et al. 1996). The Mount Sinai Conference (Marder et al. 2004) rated the quality of evidence of antipsychotics effect on weight at Level 1 (clear evidence from multiple RCTs). Modest weight loss has been associated with health benefits in the general population, including improved cardiovascular health among individuals who are overweight or obese according to the National Institutes of Health Clinical Guidelines (Dixon et al. 2010). The Schizophrenia PORT 2009 review included 7 randomized controlled investigations targeting weight loss among individuals with schizophrenia spectrum disorders. All 7 studies found support for greater weight loss (specifically 1-9 lbs; mean weight loss of 5.8 lbs across all 7 studies) among individuals who received the psychosocial intervention relative to those in the control condition (Dixon et al. 2010). The Schizophrenia PORT 2009 found further support for behavioral or psychoeducation-based interventions to promote modest weight loss among individuals with schizophrenia who are overweight or have recently experienced antipsychotic-related weight gain (Dixon et al. 2010). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline National Collaborating Centre for Mental Health of the National Institute for Health and Clinical Excellence (NICE; UK) (2009). Measure Should the eligible population include all antipsychotics or just second- Consolidations/ generation/atypical medications? Should we have separate rates for the Limitations different medication types (i.e., first-generation, second-generation and atypical)? It is possible that claims data may not identify overweight patients or nutrition counseling? In the future G-codes may be used to identify nutrition counseling. Appropriate screening frequency will need to be taken into account for each medication, specifically how long should a patient with schizophrenia be on a medication before getting screened? A-25 References Allison, D.B. & Casey, D.E. (2001). “Antipsychotic-induced weight gain: A review of the literature.” J Clin Psychiatry, 62(Suppl 7) : 22-31. Allison, D.B. et al. (1999). “The distribution of body mass index among individuals with and without schizophrenia.” J Clin Psychiatry, 60(4) : 215- 220. Azorin, J.M. et al. (2001). “A double-blind comparative study of clozapine and risperidone in the management of severe chronic schizophrenia.” Am J Psychiatry, 158(8): 1305-1313. Bustillo, J.R., Buchanan, R.W., Irish, D. & Breier, A. (1996). “Differential effect of clozapine on weight: A controlled study.” Am J Psychiatry, 153(6): 817- 819. Dixon, L.B. et al. (2010). “The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 48-70. Marder, S.R. et al. (2004). “Physical health monitoring of patients with schizophrenia.” Am J Psychiatry, 161(8): 1334-1349. Volavka, J. et al. (2002). “Clozapine, olanzapine, risperidone, and haloperidol in the treatment of patients with chronic schizophrenia and schizoaffective disorder.” Am J Psychiatry, 159(2): 255-262. Wirshing, D.A. et al. (1999). “Novel antipsychotics: comparison of weight gain liabilities.” J Clin Psychiatry, 60(6): 358-363. A-26 TABLE A.14. Measure Concept: Appropriate Health Maintenance and Prevention Measure Intent/Focus To address physical health problems of patients with schizophrenia. Eligible Population Patients with schizophrenia. Numerator Patients with schizophrenia who receive a blood pressure screening, flu shot, mammogram, pap smear, and colorectal cancer screening. Evidence Supporting The conditions investigated here are based on an initial list from discussion the Measure with our experts. Blood Pressure/Cardiovascular Hypertension and cardiovascular conditions are common among patients with schizophrenia with consequences that include increased rates of morbidity and mortality (Hennekens et al. 2005). In the United States hypertension affects approximately 15% of the general population and perhaps 19% of patients with schizophrenia, in large measure because of obesity. Patients with schizophrenia tend to be more obese than the general population, exacerbated by the excessive weight gain that accompanies treatment with certain atypical antipsychotic drugs. In addition, among patients with schizophrenia, their high rates of non-compliance with antipsychotic medications imply similar poor compliance with drugs of proven benefit for the treatment of hypertension, hence making it difficult for their health care providers to achieve the Joint National Commission VII guidelines for treatment of hypertension (Hennekens et al. 2005). Flu We found no evidence specific to this population. Women’s Health General guidelines for women’s health support screenings for various types of cancers, but recent studies have focused on the health needs of women with schizophrenia. Although most studies are plagued by methodological problems (Bushe et al. 2009), there is some observational evidence that women with schizophrenia are at particular risk for neglect of these needs (Linademer et al. 2006). Women with schizophrenia were less likely [than a community sample] to have received mammograms [68% v. 98%] or pelvic examinations and Pap tests [71% v. 96%] (Lindamer et al. 2003). Despite high rates of insurance (88%) and having a primary care provider (PCP) (91%), rates of pelvic exam (45.7%), Pap test (43.5%), and mammogram (41.3%) on the appropriate time interval were low; 1/3 received none of the screenings (Lindamer et al. 2006). Six of 13 studies report an increased or marginally increased incidence of breast cancer. These tend to be studies with more than 100 incident cases of breast cancer, greater than 100,000 person years follow-up and older populations (Bushe et al. 2009). Colorectal Cancer Screening The U.S. Preventive Services Task Force and Institute for Clinical Systems Improvement (ICSI) guidelines recommend colorectal cancer screening, but we found no evidence specific to this population. A-27 Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure This measure should either be stratified by gender or there should be Consolidations/ separate measures by gender. Limitations Should hypertension be a component in the metabolic screening measure concept? Also should this measure create one overall rate or should there be separate rates in addition to the overall rate? Appropriate screening frequency will need to be taken into account for each condition. Even though flu shots, if provided, may occur outside the claims data system (e.g., CVS/Walgreens), NCQA has found that influenza vaccination can be captured using claims data. References Bushe, C.J., Bradley, A.J., Wildgust, H.J. & Hodgson, R.E. (2009). “Schizophrenia and breast cancer incidence: A systematic review of clinical studies.” Schizophr Res, 114(1-3): 6-16. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes (2004). Diabetes Care, 27: 596. Hennekens, C.H., Hennekens, A.R., Hollar, D. & Casey, D.E. (2005). “Schizophrenia and increased risks of cardiovascular disease.” Am Heart J, 150(6): 1115-1121. Institute for Clinical Systems Improvement (2008). Colorectal Cancer Screening. Bloomington, MN: Institute for Clinical Systems Improvement. Lindamer, L.A. et al. (2003). “A comparison of gynecological variables and service use among older women with and without schizophrenia.” Psychiatr Serv, 54(6): 902-904. Lindamer, L.A., Wear, E. & Sadler, G.R. (2006). “Mammography stages of change in middle-aged women with schizophrenia: An exploratory analysis.” BMC Psychiatry, 6: 49. Tilbrook, D., Polsky, J. & Lofters, A. (2010). “Are women with psychosis receiving adequate cervical cancer screening?” Can Fam Physician, 56(4): 358-363. U.S. Preventive Services Task Force (2008). Screening for Colorectal Cancer, Topic Page. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/clinic/uspstf/uspscolo.htm. A-28 TABLE A.15. Measure Concept: Appropriate Infectious Disease Screenings Measure Intent/Focus To address the elevated risk of infection due to risky behavior (e.g., hepatitis C, HIV). Eligible Population Patients with schizophrenia. Numerator Patients with schizophrenia who receive a HIV, HBV, HCV, or other STD screening. Evidence Supporting Patients with schizophrenia are prone to engaging in high risk behaviors the Measure including drug use that make them susceptible to various infections common to the population of individuals with substance use disorders, including HIV, HBV, HCV, and STDs. One key study found prevalence of HIV of approximately 8 times that of the overall estimate for the United States; the prevalence of HBV almost 5 times the United States prevalence estimate; and the prevalence of HCV approximately 11 times the estimated United States adult population prevalence. Study participants were heterogeneous in terms of types of SMI, but 65% had schizophrenia or schizoaffective disorders (Rosenberg et al. 2001). Similar patterns were found in a private insurance plan in Iowa (patients with schizophrenia v. without) for hepatitis C (Carney et al. 2006). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure Appropriate screening frequency will need to be taken into account for each Consolidations/ condition. Limitations Should this be a measure with one overall rate or should there be separate rates in addition to the overall rate? References Carney, C.P., Jones, L. & Woolson, R.F. (2006). “Medical comorbidity in women and men with schizophrenia: A population-based controlled study.” J Gen Intern Med, 21(11): 1133-1137. Rosenberg, S.D. et al. (2001). “Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness.” Am J Public Health, 91(1): 31-37. A-29 TABLE A.16. Measure Concept: Screening and Counseling of Substance Use Disorders Measure Intent/Focus To address the elevated risk of substance use disorders in patients with schizophrenia. Eligible Population Patients with schizophrenia who have a co-occurring substance use disorder. Numerator Patients with schizophrenia who have a co-occurring substance use disorder who receive a screening or counseling service for substance use disorder in the measurement year. Evidence Supporting Smoking, alcohol and substance use disorders are prevalent among people the Measure with schizophrenia. Individuals with these co-occurring disorders require pharmacologic and psychosocial interventions to treat their addictions (Regier et al. 1990). Patients with schizophrenia have a higher risk of abuse/dependence problems: Odds ratios from a private insurance plan in Iowa (patients with schizophrenia v. without): OR=12.57 (10.16-15.55) for alcohol abuse/dependence, OR=35.42 (28.35-44.27) for illicit substance abuse/dependence (Carney, Jones & Woolson 2006). The concept is supported by a systematic review that includes several RCTs demonstrating the effectiveness of substance use treatment for people with SMI, including schizophrenia. The strength of the evidence is limited though as “many studies relevant to the treatment of SUDs in schizophrenia do not have samples with 50% or more persons with schizophrenia or schizoaffective diagnoses. Most studies of SUDs in individuals with schizophrenia are conducted in real-world clinic settings, where there is little or no separation of individuals by diagnosis in terms of providing treatment…6 RCTs were available that included more than 50% of individuals with schizophrenia” (Dixon et al. 2010). Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure We will only be able to identify substance use disorders that are treated Consolidations/ through diagnoses on claims, so we cannot assess those who may have Limitations undiagnosed or untreated substance use disorders. References Carney, C.P., Jones, L. & Woolson, R.F. (2006). “Medical comorbidity in women and men with schizophrenia: A population-based controlled study.” J Gen Intern Med, 21(11): 1133-1137. Dixon, L.B. et al. (2010). “The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 48-70. Regier, D.A. et al. (1990). “Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study.” JAMA, 264(19): 2511-2518. A-30 TABLE A.17. Measure Concept: Tobacco Counseling Measure Intent/Focus To address the elevated smoking risks among patients with schizophrenia. Eligible Population Patients with schizophrenia who are smokers. Numerator Patients with schizophrenia who are smokers who receive counseling about smoking in the measurement year. Evidence Supporting Smoking causes a variety of health problems including cardiovascular the Measure disease and lung and other cancers. “In the general US population, cigarette smoking is the leading avoidable cause of all premature death, as well as mortality from cancer” (Henneksen et al. 2005). Smoking, alcohol and substance use disorders are prevalent among people with schizophrenia (Regier et al. 1990). While one-quarter of the United States population smokes cigarettes, three-quarters of patients with schizophrenia smoke and tend to smoke more per day than those who do not have schizophrenia (Henneksen et al. 2005). Patients with schizophrenia in a private insurance plan were found to have nearly 3 times the odds of nicotine abuse/dependence as the population of enrollees. (Carney, Jones & Woolson 2006). A prospective study of the French population found that patients with schizophrenia had a nearly 4-fold higher rate of mortality than the general population (Tran et al. 2009). For men, lung cancer was the most common cause of cancer mortality, with an SMR of 2.2 (95% CI, 1.6-3.3). We found no studies regarding use of other tobacco products by this population or treatment for such problems. The Schizophrenia PORT 2009, based on its comprehensive review, recommends pharmacological and smoking cessation education interventions for this population. Type of Evidence RCT/Experimental designs Supporting the Observational studies Measure Systematic literature reviews Meta-analyses Expert opinion Guideline Guideline None. Measure It is possible that it may be difficult to identify smokers using claims data. Consolidations/ NCQA uses survey measures to capture its smoking cessation measure. Limitations Perhaps this can be coded in the future through G-codes. Smoking/tobacco use can be captured as part of the substance use disorder concept above. A-31 References Buchanan, R.W., Kreyenbuhl, J., Kelly, D.L., Noel, J.M., Boggs, D.L., Fischer, B.A. et al. (2010). “The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements.” Schizophrenia Bulletin, 36(1): 71-93. Carney, C.P., Jones, L. & Woolson, R.F. (2006). “Medical comorbidity in women and men with schizophrenia: A population-based controlled study.” J Gen Intern Med, 21(11): 1133-1137. Hennekens, C.H., Hennekens, A.R., Hollar, D. & Casey, D.E. (2005). “Schizophrenia and increased risks of cardiovascular disease.” Am Heart J, 150(6): 1115-1121. Regier, D.A. et al. (1990). “Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study.” JAMA, 264(19): 2511-2518. Tran, E. et al. (2009). “Cancer mortality in patients with schizophrenia: An 11- year prospective cohort study.” Cancer, 115(15): 3555-3562. A-32 TABLE A.18. Measure Concepts That Were Considered but Not Pursued Based on Expert Consultant Review Measure Concept Feasibility Concept Continuous Medicaid Enrollment Intent Some lapses in coverage may be related to To assess whether people with schizophrenia desirable outcomes, such as employment. We have consistent access to services. would not be able to distinguish desirable from undesirable outcomes. Availability of Psychosocial Treatment Intent Structural measures cannot not be identified To assess whether the service system offers easily from claims. evidence-based psychosocial interventions. Use of Cognitive Behavioral Therapy Intent This concept is not captured administratively. It To assess whether people with schizophrenia represents the content/therapeutic approach of receive cognitive behavioral therapy. one or more interventions, but is only captured in the medical record. Presence or Duration of Waiting List for Psychosocial Treatment Intent This is a structural access and availability Psychosocial treatments are effective and delays measure which is beyond the scope of this in treatment raise the risk of episodic relapses, project. This concept is not captured discontinuities in treatment. administratively. Use of Social Education Intent This concept is not captured administratively. It To assess whether people with schizophrenia represents the content/therapeutic approach of receive social education. one or more interventions, but is only captured in the medical record. NOTE: In collaboration with ASPE and the expert consultants, the measure concepts listed in Table A.18 were rejected outright as infeasible. A-33 APPENDIX B. TAG MEMBERSHIP AND SLIDE DECKS Name Affiliation Area of Expertise Alisa Busch, MD, MS Harvard Medical School Clinical/psychiatry McLean Hospital Enola Proctor, PhD, MSW Washington University Clinical/social work David Shern, PhD Mental Health America Consumer Dan For, MD, MPH Johns Hopkins University Measurement Wilma Thownshend, MSW SAMHSA Consumer Lorrie Rickman-Jones, PhD Illinois Department of Human State mental health policy Services Eric Hamilton ValueOptions Managed behavioral health Alexander Young, MD, MSHS University of California, Los Measurement Angeles Peter Delaney, PhD, LCSWC SAMHSA Federal mental health policy Ben Druss, MD Emory University Clinical/psychiatry Maureen Corcoran VORYS Health Care Advisors State and federal mental health policy Mike Fitzpatrick NAMI Consumer Bob Heinssen, PhD NIMH Federal mental health policy a Anita Yuskauskas, PhD CMS Federal mental health policy/ Medicaid b Peggy Clark, MSW, MPA CMS Federal mental health policy/ Medicaid b Phil Wang, MD, DrPH NIMH Federal mental health policy a. Participated in final two TAG meetings. b. Participated in first TAG meeting. A-34 A-35 A-36 A-37 A-38 A-39 A-40 A-41 A-42 A-43 A-44 A-45 A-46 A-47 A-48 A-49 A-50 A-51 A-52 A-53 A-54 A-55 A-56 A-57 A-58 A-59 A-60 A-61 A-62 APPENDIX C. MEMO SUMMARIZING FOCUS GROUP INPUT MATHEMATICA Policy Research 600 Maryland Ave., SW, Suite 550 Washington, DC 20024-9220 Telephone (202) 484-9220 Fax (202) 863-1763 http://www.mathematica-mpr.com MEMORANDUM TO: Lisa Patton, Ph.D., Office of the Assistant Secretary for Planning and Evaluation Hakan Aykan, Ph.D., Office of the Assistant Secretary for Planning and Evaluation FROM: Thomas W. Croghan, M.D., Mathematica Policy Research, Inc. Sarah Hudson Scholle, Dr.P.H., National Committee for Quality Assurance DATE: 6/13/2011 SUBJECT: Testing of Measures for Medicaid Beneficiaries with Schizophrenia SITUATION We are required to produce a final set of three measures that address pharmacological treatment, psychosocial treatment, and physical health needs for patients with schizophrenia and that can be calculated solely from data drawn from Medicaid claims. We have identified eight candidate measures that were identified through an environmental scan, detailed review of the major recommendations from the Schizophrenia PORT study, and discussions with the Technical Advisory Group (TAG). We reviewed with the TAG the evidence base for candidate measure concepts in the context of NQF’s endorsement criteria (importance, scientific acceptability, usability, feasibility). As part of testing to support submission of these measures to the National Quality Forum (NQF) for endorsement, we discussed the candidate measures with the Medicaid Medical Directors Learning Network (MMDLN) to obtain input on the usability and feasibility of the candidate measures. In the remainder of this memorandum, we outline our analysis of their extensive feedback and options for modifying the measures and testing process. A-63 BACKGROUND The MMDLN identified several challenges to using the measures identified and dimensions of care that the candidate measures do not address: Claims data are unreliable for identifying some behavorial health services, particularly evidence-based psychosocial treatments such as those recommended in the Schizophrenia PORT. Variation in the financing of services for people with serious mental illness limits the ability to generalize about the quality of care provided by Medicaid programs. This includes: Provision of services through state mental health systems; Coverage of services through Medicare for dual-eligibles; Prohibitions on same-day billing of medical and behavioral health services; Inter-state variation in Medicaid and disability standards. The testing process using the Medicaid Analyic Extract (MAX) data can reliably identify patients with schizophrenia from the pool of disabled non-dual Medicare beneficiaries. However, this is only one portion of the universe of potential patients (e.g., TANF enrollees; dual Medicare beneficiaries) who receive treatment through Medicaid programs. The candidate measures do not capture perceived problems of overuse that they believe have a signficiant impact on quality and costs of care. The medical directors mentioned polypharmacy, inpatient utilization, and failure to utilize generic drugs as topics of interest. The candidate measures address problems that are not unique to patients with schizophrenia; they suggested broadening the target population to include patients with bipolar disorder, schizophrenia, and severe forms of depression (severe and persistent mental illness, or SPMI). ANALYSIS We have reviewed the feedback from the MMDLN and prepared for ASPE’s consideration options for changes to the measures, changes to the specifications, and changes to the testing process. A-64 Options for Changing the Set of Candidate Measures 1. Create measures of overuse: We could develop new measures related to polypharmacy, use of inpatient care, and use of generic drugs. Utilization measures could be used to establish benchmarks for cross-state comparisons. Advantages: This would demonstrate responsiveness to key Medicaid officials who would be responsible for making quality improvements based on the measures. Disadvantages: The TAG concluded that the evidence for these measures is weak or inconsistent. These measures are thus more appropriate for utilization management initiatives than for quality improvement. Inpatient utilization measures might also require risk adjustment, which ASPE determined to be out- of-scope and makes cross-state comparisons less feasible. 2. Drop the evidence-based psychosocial measure: Another option is to drop the psychosocial measure given the challenges in identifying the evidence-based services from the Schizophrenia PORT in claims data--a problem noted in our claims data testing and TAG discussions as well as the MMDLN focus group. Advantages: The measure has such low feasibility that it is impossible to assess the reliability and validity of the measure in claims data testing, making NQF endorsement unlikely. Dropping this measure would free resources to more extensively test the other measures. Disadvantages: This measure had the strongest evidence base and would have been important for achieving ASPE’s goal of balance between pharmacological, psychosocial and physical health treatment. 3. Drop the HIV screening measure: There is not an endorsed HIV measure; regular screening is recommended only for those at increased for the disease. Advantages: Dropping the measure would be consistent with evidence that patients with schizophrenia are not at greater risk of HIV. Disadvantages: None. Options for Changing Measure Specifications 1. Expand the denominator for the diabetes and cardiovascular screening and monitoring measures to include people with SPMI: The monitoring measures apply to patients who have a diagnosis of diabetes or cardiovascular disease, so the measures would apply equally well to people with SPMI. The screening measures apply to patients who use antipsychotic medications and so likely should apply to people with SPMI. A-65 Advantages: Reporting the measures for patients with serious mental illness, or stratified by these conditions, would permit ASPE to have a broader impact on behavioral health quality monitoring. Disadvantages: We need to review recent recommendations from AHRQ about antipsychotic medication usage to evaluate the appropriateness of the screening measure for the other conditions. There may be challenges with stratified reporting due to diagnostic instability (e.g., misdiagnosis of schizophrenia as bipolar disorder and vice versa). 2. Reframe the cervical cancer screening and Emergency Department (ED) utilization measures as stratifications of existing measures: ED utilization and cervical cancer measures are already NQF-endorsed. It is unclear whether NQF would consider stratified measures to be new or an adaptation of existing measures. Advantages: stratification would allow state Medicaid programs to adapt measures they are already reporting to the mental health population. Disadvantages: No obvious disadvantages. 3. Broaden measures populations: A third option is to include patients with other severe and persistent mental illnesses. Advantages: Limiting measurement of important concepts such as screening for physical health conditions and side effects to those with schizophremia is an artificial distinction without clinical justification. Doing so would limit the usefulness of the measures for state Medicaid programs. Disadvantages: Our project has limited funding; expanding the populations for measures is potentially beyond its current scope. Options for Changing the Testing Process 1. Conduct additional focus groups with state mental health program directors and consumers: Given the interaction between Medicaid and state mental health departments, it may be useful to obtain the perspective from those programs, and consumers. Advantages: Discussions with these groups may provide a more balanced picture of the usability and feasibility of the measures. Disadvantages: The current budget permits only one new focus group with mental health program directors; public comment may substitute for the consumer focus group. A-66 2. Test the measures with states in their Medicaid data systems: We could identify states that are willing to calculate the measures from their claims data. Advantages: State Medicaid data provides a more robust test of the measures by adding non-disabled and possibly Medicare dual-eligibles. We would learn more about the feasibility from the states. Testing directly with states would substitute for testing using the MAX files; testing with MAX data has been delayed because of delays in obtaining a license to use the MediSpan grouper. Disadvantages: State capacity to calculate the measures likely varies; we may learn only that some states are better equipped to perform such measurement activities. States are unlikely to complete the testing in the timeframe of the current contract. It is unclear that any state would have access to the Medicare claims for dual beneficiaries. RECOMMENDATIONS Based on our discussion with the MMDLN, we are concerned that the measures as specified will not be endorsed by the NQF. We recommend the following changes to the set of measures under consideration, the specifications of the measures, and the testing process in order to achieve ASPE’s objectives for measurement and accountability for seriously mentally ill: 1. Drop the evidence-based psychosocial services measure and the HIV measure: Claims data as currently collected by Medicaid programs are not adequate for capturing the evidence-based psychosocial services reliably. The evidence for elevated HIV risk in this population is weaker than initially thought based on the environmental scan. 2. Expand the population for the diabetes and cardiovascular screening and monitoring measures and report an overall “serious mental illness” rate: The pool of affected individuals extends beyond people with schizophrenia, providing greater impact for the measures. 3. Add a focus group discussion with state mental health program directors: A focus group with state mental health program directors will provide additional insight into the interaction between the Medicaid and state mental health program systems and permit a more balanced assessment of the measures’ usability by states and policymakers in a public reporting system. A-67 APPENDIX D. SUMMARY OF PUBLIC COMMENT A-68 TABLE D.1. Public Comment Summary Organization Feedback Comments Comments Disposition Name Type Modified Schizophrenia Measure Set -- Overall Accountable Support with In Central Oregon our Oregon Health Plan/SPMI population dies at the average Consider approaching NCQA will share this Behavioral modification. age of 45. Preliminary reasoning includes poor overall physical health, lack of these measures in a more thought with Mathematica. Health Alliance medical care follow-up and side effects from the long-term use of antipsychotic holistic way due to the fact medications. Standards must be set with this high risk population to ensure that that the SMI population in both physical and mental health are actively tracked to receive adequate services general a high risk group. to improve overall health and life expectancy. I also fear how indigent individuals are fairing. More attention should be focused on the holistic view of this at risk population subgroup with better follow-up and improved access. University of Support. Long-Acting Depot preparations are going to revolutionize outcomes and decrease Consider focusing on a The measure is intended to California, recidivism. The reason they are not being used today in great numbers is the very long-term solution, which include injectables as part Irvine poor reimbursement. One small study showed that if every schizophrenic in this would be focusing on of the definition of country was on a long-acting injectable (LAI), within 6 months half of our psychiatry LAIs. antipsychotic medication. hospitals would no longer be needed. The cost savings would be close to $11 Will verify that list includes Billion dollars per year. So the way to get greater use is to increase the them. reimbursement for the practitioner who administers the injection. I see this as the biggest cost saving and patient improvement program in the history of our treatment of schizophrenia. Please contact me for this concept. Seven Support with Good set of measures. I am sure that it will get shorter, but I want to include 2 Consider adding Smoking assessment and Counties modification. additional measures: one for smoking assessment and one for exercise measures for smoking exercise assessment are Services assessment. The smoking assessment is critical. Along with bad antipsychotic assessment and exercise not readily available in management it is one of the 2 major killers for people with schizophrenia. Let's start assessment. claims and therefore assessing and offering evidence-based interventions. cannot be included. National Support with Why are you beginning at age 25 when adult Medicaid begins at age 22 and early Concerned that the age TAG recommended 25 to Association of modification. onset schizophrenia can begin as early as 17? Issue is that you need be create a specifications in the ensure stability of County clear line between adolescence and adulthood. measures are not diagnosis. Behavioral representative of Medicaid Health and or early onset Developmental schizophrenia. Disability Directors (NACBHDD) New Support with The list of antipsychotics needs to be updated. Concerned that the list of NCQA and Mathematica Hampshire modification. antipsychotics are not will review the list of Department of updated. antipsychotics. Health and Human Services (DHHS) A-69 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified Kaiser Health Support with Kaiser Permanente is supportive of a creation of a measure set for people with 1. Concerned that plans 1. These are intended for Plan modification. schizophrenia focusing on the pharmacological and physical health needs of this will be burdened by split state Medicaid use, so population. The group recognizes that people with schizophrenia often receive sub- coverage, where states may have optimal care in the areas which these candidate measures seek to address. We are behavioral health capacity to integrate glad to have been a part of this discussion and look forward to working to improve coverage is carved out across settings. the quality of care that our members with schizophrenia receive. There is a concern and physical health 2. ED visits are treated like however, that given that most of the Kaiser Permanente members who are coverage is provided by other outpatient settings Medicaid recipients, have split coverage. In most regions, the behavioral health the plan. and so require a second coverage is carved out and provided at the community mental health clinic level 2. Concerned that OP visit with while their physical health coverage is provided with the Kaiser Permanente diagnoses made in the schizophrenia diagnosis system. This might make coordinating this care difficult and data collection nearly ED setting are to qualify. impossible. Comments on Inclusion Criteria: There is consensus that the diagnoses erroneous and we proposed are adequate for identification of people with schizophrenia and that the should consider number of visits in differing venues was reasonable. There was a concern raised requiring 2 visits on however, about how diagnoses made in an ED would count. Diagnoses made in separate dates with the the ED are often erroneous and depending on how these are included, may same diagnosis. increase the denominator. If ED diagnoses would require 2 visits on separate dates with the diagnoses, this could address the issue. Gulf Coast Support with Over 30 years of respected research supports the use of a biopsychosocial model Concern that the The concerns raised do not Health Center modification. for effective and efficient treatment of schizophrenia, as well as schizoaffective and proposed measures do account for the difficulty of bipolar disorders including psychosis. You limit measures of treatment quality/ not go nearly far enough. collecting data for effectiveness to medical encounters, specifically readmission to an inpatient facility. performance measures. The designation "health care" should replace the term medical, to more accurately NCQA will share these measure treatment which really works. Additionally, by your standard, “treatment” is thoughts with Mathematica. successful if the person is not readmitted for inpatient services. So all the psychotic persons wandering our streets, sleeping on our park benches and clogging up our county jails received successful treatment, by your limited measure(s). Diseases like diabetes, primary hypertension, alcohol and other drug dependence, schizophrenia, bipolar disorder--and several other disorders--need to be treated as chronic conditions by a varied mix of care providers, not limited to medical practitioners. And quality measures of successful treatment must include quality of life components, the bare basics being clothing, housing, and employment. Your current measure of "success" has caused a mushroom-like proliferation of intensive outpatient and partial hospitalization programs, with 20% of the price tag for this "treatment" (for persons without both Medicare AND Medicaid coverage) falling directly on the shoulders of the patients you are purportedly treating in a successful manner. Your quality measure for schizophrenia treatment is woefully inadequate. A-70 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified University of Support with It is quite clear that these measures fit a model of care that predates the emerging Consider including a NCQA will share this Pittsburgh modification. recovery approach. I have no particular issues with them except there inadequacy measure about individuals thought with Mathematica. to care quality care--all these things could be done without a recovery framework. I being admitted understand that you considered other measures but found the data sources too involuntarily, put into weak to support their use. Obviously we need to develop and Implement other seclusion/ restraints or measures--and soon. Candidate measures I would suggest is if there is any given forced medications. evidence that the person receiving services was supported in the opportunity to outline their own goals for care or had any role in shared decision making about the care and its goals. I hope your report suggests this. In the mean time--I would suggest that you consider as a measure how often individuals are admitted involuntarily, put into seclusion/ restraints or given forced medications. This data is collected, so should be available. Clearly all efforts to decrease coercion in the context of care are elements of improved care. The campaign to radically reduce seclusion and restraint proves the merit of collecting this data as a quality indicator. University of Support with One final measurable recovery oriented quality measure would be if they were ever 1. Consider adding a 1. Peer support is unlikely Pittsburgh modification. encountered by a peer support specialist during their care, and if so, to what extent. measure that looks at to be captured in claims This should show in billing data and in electronic health records (EHRs). Also data people with data and will be that could be available is to track how many persons with schizophrenia get on schizophrenia that inconsistent across state disability if they have no source of income, how long it takes and how many ever encountered a peer if collected. come off. Harder to get but an incredibly important element of care. Thanks. I would support specialist during 2. Will consider for future be very happy to discuss Any of these ideas if that would be useful. treatment. This would projects. show in billing data and EHRs. 2. Consider adding a measure that looks at how long it takes people on disability to get off it. National Support. We applaud NCQAs work on these measures. The measures are practical, timely Support. Support. Council for and necessary. Community Behavioral Healthcare A-71 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified American Support with I am writing on behalf of the American Psychological Association the largest Concerned that These measures were in Psychological modification. organization of psychologists worldwide with over 154,000 members. The psychosocial measures the original list of potential Association Association supports NCQA’s efforts to measure important aspects of both physical are not included. measures, but plans do not and mental health care for Medicaid beneficiaries with schizophrenia. The proposed currently have the ability to measures can be used to further the important goals of improving access to care gather all the data using and quality of care for this vulnerable population. However, we disagree with the claims. decision not to include measures of psychosocial care and recommend that you develop a measure(s) for this important aspect of schizophrenia treatment. There is NCQA will share these substantial evidence of the benefits of psychosocial care. For example, a 2011 thoughts with Mathematica. study by Grant et al. found that low-functioning patients with schizophrenia who were treated with cognitive therapy showed statistically significant and clinically meaningful improvements in functioning and reductions in symptom severity (http://archpsyc.ama-assn.org/cgi/content/full/archgenpsychiatry.2011.129). An excellent source of relevant data in this area is the Schizophrenia PORT project. PORT recently released a comprehensive summary of current evidence-based psychosocial interventions for patients with schizophrenia along with specific treatment recommendations (http://schizophreniabulletin.oxfordjournals.org/content/36/1/48.full.pdf+html). In addition, the “Resolution on APA Endorsement of the Concept of Recovery for People with Serious Mental Illness” provides citations to several important studies that demonstrate the value of psychological interventions (http://www.apa.org/practice/leadership/smi/recovery-resolution.pdf). The Association resolution highlights the need to make potentially beneficial services accessible. In addition, the “Resolution on APA Endorsement of the Concept of Recovery for People with Serious Mental Illness” provides citations to several important studies that demonstrate the value of psychological interventions (http://www.apa.org/practice/leadership/smi/recovery-resolution.pdf). The Association resolution highlights the need to make potentially beneficial services accessible, particularly for minorities and people of lower socioeconomic status such as Medicaid beneficiaries. OptumHealth Support with Thank you for focusing on this very important diagnostic category for our Medicaid Consider looking at Will consider for future Behavioral modification. population. As we mention in our comments, our most significant concern is that the outcomes in future projects. Solutions reliability of the results may be compromised based on potentially low measure development. denominators. We hope that the development of these datasets will encourage states to review common datasets and have standard, consistent expectations. Overall, these metrics are a very good start. We encourage NCQA to find ways to look at treatment outcome measures in future metrics. There may be ways to look at “treat to remission” and relapse prevention measures using normed instruments. OptumHealth Behavioral Solutions would value the opportunity to work with you to develop future measures. A-72 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified American Support with The CPT code 90862 (Pharmacological Management) is often used for clinical Consider adding the CPT NCQA and Mathematica Psychiatric modification encounters with psychiatrists, and should be added to the specifications of these code 90862 will evaluate this code and Association measures (e.g., in establishing the diagnosis) as appropriate. The specifications of (Pharmacological its applicability to the (APA) these measures should clearly indicate that these are system-level measures. Management) in the measure set. Should these measures be expanded for institution or clinician level analysis in the measure specifications. future, additional specification would be required. Some measures, such as the measure on follow-up after hospitalization (FUH), involves many factors and may not be appropriate for measurement and accountability at the clinician level of analysis. We understand the rationale for excluding psychosocial interventions from this measure set, and encourage that additional interventions be considered for inclusion as the tools for performance measurement advance. National Support. NAMI would like to express strong support for the Quality Measures for Medicaid Support. Support. Alliance on Beneficiaries with Schizophrenia developed by the NCQA. As the nation’s largest Mental Illness organization representing people living with SMI and their families, NAMI applauds (NAMI) NCQA for this important effort to move forward with this groundbreaking effort to more effectively assess treatment and outcomes in the Medicaid program. NAMI is especially supportive of the breadth of these proposed measures and the inclusion of key indicators for psychiatric treatment such as treatment adherence, ED utilization and post-acute care follow-up services. However, even more important are the diverse measures for medical comorbidities experienced by Medicaid beneficiaries living with schizophrenia including cardiovascular, diabetes and cervical cancer screening and monitoring. Implementation of the measures will be critical for the field of publicly funded mental health services. For decades, data, outcome measures and accountability in publicly funded mental health services has lagged far behind other major health care disciplines. In many states, existing data have been non-existent for available services, service needs and positive outcomes. Further, what data has existed is rarely standardized across states or public sector health plans, making comparisons and the identification of useful avenues for improvement extremely difficult. This is especially the case with the Medicaid program where accountability is spread across CMS (a federal agency whose role is limited to retroactively matching state spending), state Medicaid programs and state mental health agencies that oversee local providers. For years, federal officials, state mental health agencies and community providers have haggled over leadership definitions, and strategies for addressing the data collection and outcome measure Cardiovascular Health and Diabetes Monitoring BJC Support with Specify that Hemoglobin A1c (HbA1c) be used, not glucose. The American Consider only using Review guidelines and HealthCare modification. Diabetes Association now recommends HbA1c for screening and for monitoring. It HbA1c testing for evidence for cardiovascular is more reliable and readily testable as it can be done any time of the day with any screening and monitoring and diabetes screening amount of food or drink consumed. HbA1c is the standard for monitoring diabetes. to stay consistent with the and monitoring. It is much easier to have a system to test for it for both screening and monitoring American Diabetes rather than fasting glucose for screening and HbA1c for monitoring. Association's recommendation. Kaiser Health Support. Support. Support. Support. Plan A-73 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified OptumHealth Support with 1. Denominators for this measure will be extremely small, due to small plan size 1. Concern about small 1. Review the MAX data to Behavioral modification. and the low prevalence of the diagnosis along with, making the results difficult to numbers for the look at potential small Solutions interpret. There will be even fewer enrollees in this metric as they will need to be denominator and numbers problems. both diagnosed with schizophrenia and with either cardiovascular disease or recommend decreasing 2. Review the MAX data to diabetes. In order to maximize the denominator, we recommend decreasing the the eligible age to 21 look at continuous eligible age to 21 years old. Also, this population switches plans often, so a years old. enrollment. continuous enrollment requirement of one year with only a 45 day gap will 2. Concern that 3. Discuss the table's eliminate many members. We suggest allowing up to 2 non-consecutive one- continuous enrollment usefulness in the month gaps. of year with only 1 gap measure. 2. Table B. Is this table necessary--we recommend that you remove it? If it remains, will eliminate many it needs to be modified. It includes codes for ophthalmological services, but does members, and not include Healthcare Common Procedure Coding System (HCPCS) codes recommend 2 non- which are often used for this population and mandated by states (e.g., T1015 for consecutive 1-month medication management). We also recommend inclusion of telehealth codes gaps. (e.g., Q3014). 3. Consider removing or revisiting Table B (Codes to Identify Visit Type). APA Support. We suggest including physical findings such as weight and BMI as monitoring Consider adding weight Will consider for future requirements when this type of data can be more easily captured for performance and BMI monitoring to the projects. measurement purposes (e.g., broader use of EHRs). physical health measures for schizophrenia when there is broader use of EHRs. NAMI Support. 3. Measure Relevance: As noted above, NAMI strongly support this proposed Support. Support. measure for cardiovascular health and diabetes monitoring. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. Feasibility of data collection. Cardiovascular Health and Diabetes Screening BJC Support with Specify that HbA1c be used, not glucose. Glucose is a much less reliable screen Consider only using Review guidelines and HealthCare modification. due to the need for it to be fasting. The American Diabetes Association now HbA1c testing for evidence for cardiovascular recommends HbA1c for screening. It is more reliable and readily testable as it can screening and monitoring and diabetes screening be done any time of the day with any amount of food or drink consumed. HbA1c is to stay consistent with the and monitoring. the standard for monitoring diabetes. It is much easier to have a system to test for it American Diabetes for both screening and monitoring rather than fasting glucose for screening and Association's HbA1c for monitoring. recommendation. Kaiser Health Support with Relevance: We are concerned that both screening recommendations are too Concern that screenings Measures are specified for Plan modification. frequent. Would like to suggest that the frequency of screenings be reconciled are too frequent and will people with schizophrenia, against recommendations from the American Diabetes Association. not allow actionability. therefore a high frequency of screenings should not be American Usefulness: We agree that the measure would be useful in improving an issue. quality of care. Collection: This data could be collected. A-74 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified Bristol-Myers Support with It is important that a lab test is done before or at the time of a new prescription to Consider adding a rate Will consider for future Squibb modification. ensure appropriate decision making. We would suggest an additional measure that looks at the projects. Company such as the percentage of members with schizophrenia and who were prescribed percentage of people that any antipsychotic medication during the measurement year who received a received a diabetes and diabetes/cardiovascular health screening prior to or at the time of their initial cardiovascular screening prescription. prior to or at the time of their initial antipsychotic prescription. OptumHealth Support with 1. Denominators for this measure will be small, due to small plan size and the low 1. Concern about small 1. Review the MAX data to Behavioral modification. prevalence of the diagnosis, making the results difficult to interpret. In order to numbers for the look at potential small Solutions maximize the denominator, we recommend decreasing the eligible age to 21 denominator and numbers problems. years old. Also, this population switches plans often, so a continuous enrollment recommend decreasing 2. Review the MAX data to requirement of 1 year with only a 45 day gap will eliminate many members. We the eligible age to 21 look at continuous suggest allowing up to two non-consecutive 1-month gaps. years old. enrollment. 2. Many of these members receive injectables, but the specs are silent on how to 2. Concern that 3. Discuss the inclusion of handle this. continuous enrollment specifications for of year with only 1 gap injectables. will eliminate many members, and recommend 2 non- consecutive 1-month gaps. 3. Concern that the measure does not specify how to handle people that receive injectables. APA Support. We suggest including physical findings such as weight and BMI as screening Consider adding weight Will consider for future requirements when this type of data can be more easily captured for performance and BMI monitoring to the projects. measurement purposes (e.g., broader use of EHRs). physical health measures for schizophrenia when there is broader use of EHRs. A-75 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified NAMI Support. 2. Measure Relevance: NAMI is strongly supportive of both cardiovascular and Support. Support. diabetes screening and monitoring measures. There is a large and growing body of research demonstrating the tragedy of medical comorbidities and early mortality experienced by people living with schizophrenia. In 2006, the National Association of State Mental Health Program Directors released a series of reports documenting lower life expectancy and premature mortality for individuals with SMI served in the public sector mental health system. These reports examined medical histories and post-mortem records and found alarming rates of medical comorbidities that were directly related to premature death among these individuals: heart disease, pulmonary disorders, diabetes, etc. that were significantly higher than the general population not diagnosed with SMI. In the aggregate, these reports found life expectancy is 25 years lower than the general population. To put this in graphic terms, an American living with schizophrenia has a life expectancy that barely approaches that of an adult in Bangladesh. To be clear, this amounts to a crisis and national disgrace that BOTH the public health AND public mental health systems must come to grips with. The causes of these higher rates of medical comorbidities among non-elderly adults with SMI are varied and complicated. Significantly higher rates of tobacco consumption are documented in this population. Likewise, incidence of co-occurring substance abuse are not uncommon among adults with SMI. There is emerging evidence that poor diet and sedentary lifestyle are also major contributors among those individuals living on disability benefits (Supplemental Security Income and Social Security Disability Insurance) that for many amount to a sub-poverty monthly income. For many individuals living with mental illness the side effects associated with the psychotropic. Cervical Cancer Screening for Women with Schizophrenia Wake Forest Support with This metric should not be a review criterion for the performance of a treating Concern that the measure Clarify that the measure University modification. psychiatrist for a person with schizophrenia. it does not fit with the boundaries of asks psychiatrists to does not ask a psychiatrist School of the psychiatrists competence. perform a cervical cancer to perform cervical cancer Medicine screening, because the screening. The measure screening does not fall asks the entity being within the boundaries of a measured to identify psychiatrist's expertise. patients with a schizophrenia diagnosis that had a cervical cancer screening. Wake Forest Do NOT I believe this is the responsibility of the PCP. Concern that the measure Clarify that the measure Baptist Health Support. asks psychiatrists to does not ask a psychiatrist (WFBH) perform a cervical cancer to perform cervical cancer screening, because the screening, but asks the screening does not fall entity being measured to within the boundaries of a identify patients with a psychiatrist's expertise. schizophrenia diagnosis that had a cervical cancer screening. A-76 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified WFBH Do NOT Do NOT Support. Do NOT Support. Do NOT Support. Support. Wake Health Support with How can a psychiatrist manage cervical cancer screening? Concern that the measure Clarify that the measure modification. asks psychiatrists to does not ask a psychiatrist perform a cervical cancer to perform cervical cancer screening, because the screening. The measure screening does not fall asks the entity being within the boundaries of a measured to identify psychiatrist's expertise. patients with a schizophrenia diagnosis that had a cervical cancer screening. University of Do NOT A treating psychiatrist cannot control whether a female patient goes to a Concern that the measure Clarify that the measure Nevada Support. gynecologist to have Cervical Cancer Screening and cannot do exam himself. He asks psychiatrists to does not ask a psychiatrist School of can only refer, so this should not be a quality measure. perform a cervical cancer to perform cervical cancer Medicine screening, because the screening. The measure screening does not fall asks the entity being within the boundaries of a measured to identify psychiatrist's expertise. patients with a schizophrenia diagnosis that had a cervical cancer screening. Kaiser Health Do NOT Relevance: We feel this may be redundant to existing measures. Although an 1. Concern about how the 1. This measure is not Plan Support. appreciation that this issue is often overlooked in women with schizophrenia, We measure aligns with the designed for HEDIS. It is have some concerns about the alignment of this with evidence. existing HEDIS cervical a separate measure for cancer screening which states will collect Usefulness: We have concerns about how this measure would interface with the measure. The proposed data. existing HEDIS measures for cervical cancer screening. Would these patients be in measure just focuses 2. NCQA and Mathematica both denominators? on the members with will review and discuss schizophrenia, who are the evidence base for Collection: This data could be collected via claims. likely already in the the proposed measure. HEDIS measure. 2. Concern that the proposed measure does not align with current evidence. A-77 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified OptumHealth Support with 1. Denominators for this measure will be extremely small, due to small plan size 1. Concern about small 1. Review the MAX data to Behavioral modification. and the low prevalence of the diagnosis, along with the focus on females, making numbers for the look at potential small Solutions the results difficult to interpret. In order to maximize the denominator, we denominator and numbers problems. recommend decreasing the eligible age to 21 years old. Also, this population recommend decreasing 2. Review the MAX data to switches plans often, so a continuous enrollment requirement of 1 year with only the eligible age to 21 look at continuous a 45 day gap will eliminate many members. We suggest allowing up to 2 non- years old. enrollment. consecutive 1-month gaps. 2. Concern that 3. Discuss the table's 2. Table B. Is this table necessary--we recommend that you remove it? If it remains, continuous enrollment usefulness in the it needs to be modified. It includes codes for ophthalmological services, but does of year with only 1 gap measure. not include HCPCS codes which are often used for this population and mandated will eliminate many 4. Does the age range by states (e.g., T1015 for medication management). We also recommend members, and specifications make inclusion of telehealth codes (e.g., Q3014). recommend 2 non- sense? They are 3. Please clarify the age range. It says 22-65 in the description but 25-65 in the consecutive 1-month consistent with the eligible population section. gaps. current HEDIS measure 4. Remove the inclusion of women who had a Pap test during the 2 years prior to 3. Consider removing or logic. the measurement year. It will be unusual in some markets to have 2 years of revisiting Table B 5. The 2 years look-back claims prior to the measurement period and the goal is to encourage annual Pap (Codes to Identify Visit period is optional. tests. Type). Review evidence to see 4. Clarify age range. if guidelines recommend 5. Consider changing the annual Pap tests. numerator to women who had a Pap test in the measurement year only, because some markets will not have 2 years of claims, and the goal is to encourage annual Pap tests. APA Support. We support this measure, but suggest that the measure include justification and a Consider including the The specifications are not description of the gap in care within the specifications. There are many general measure justification and designed to include the medical screenings that could have been included in this measure set (e.g., a description of how this measure rationale. NCQA colonoscopy), so the rationale as to why this screening was singled out would be measure addressed the and Mathematica will useful. gap in care within the consider publishing the specifications. measure workups with the specifications. A-78 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified NAMI Support. 6. Measure Relevance: NAMI applauds inclusion of this measure. As with the Concern that cervical Discuss with Mathematica measures for cardiovascular disease and diabetes mentioned above, the current cancer screening is a how to account for state of basic health and wellness screening such as that for cervical cancer for mental health risk for members with a history of women living with schizophrenia is abysmal. Measure usefulness for improving women with a history of sexual trauma and quality of care for Medicaid recipients with schizophrenia. In NAMI’s view, NCQA sexual trauma or who members with paranoia should move forward on this measure. It will be important given its relevance to have paranoia symptoms. symptoms. any reasonable assessment, and could serve as an accurate and reliable proxy, If the measure did not for assessing how a Medicaid health plan is doing in meeting the basic health exclude members with this care needs of female enrollees with schizophrenia. Feasibility of data collection history, then it will be NAMI would offer caution to NCQA in moving forward on this measure with incumbent on Medicaid respect to women living with schizophrenia that have a history of sexual trauma, plans to provide better or for those that experience symptoms of paranoia as part of schizophrenia. It will education about the be incumbent on Medicaid health plans complying with these measures to screening prior to the sensitive to the unique needs of these patients with respect to a procedure such procedure. as cervical cancer screening. NAMI recommends that these plans undertake careful beneficiary education about the procedure, its risks and its effectiveness as an evidence prevention and early intervention service. Emergency Department Utilization Kaiser Health Do NOT Relevance: We have a concern regarding the inclusion criteria; would this include 1. Concern that the 1. Will discuss issue with Plan Support. any ED visit or only those for an acute exacerbation of their schizophrenia measure will not be Mathematica. symptoms? actionable. 2. Any ED visit counts for a 2. Will any ED visit count, person diagnosed with Usefulness: We do not feel that this measure would not be as useful as the other or only an ED visit for a schizophrenia. candidate measures. schizophrenia symptom? Collection: The data could be collected. OptumHealth Do NOT The ED visits used to identify inclusion in the numerator are not tied to a specific Concern that this measure For this measure, a lower Behavioral Support. problem or diagnostic code. This measure, therefore, does not reflect the does not have enough rate represents better Solutions effectiveness of care. Medicaid enrollees with a diagnosis of schizophrenia are at focus and will encourage performance. NCQA will increased risk of living in poverty, having comorbid medical illnesses and not having health plans to provide clarify that in the adequate support or supervision. Assigning a rate to ED utilization may encourage unnecessary treatment specification. NCQA and health plans to address an issue that is not an established medical or treatment that will only increase Mathematica will discuss issue. The unintended consequences of this focus may be squandered resources resource use. the level of focus needed in and even potential restrictions on access to emergency services. the measure. APA Do NOT We do not feel we can support this measure without justification and a description Concern that this measure Will review ED measure Support. of the gap in care included within its specifications. ED admissions unrelated to the does not have enough definition. diagnosis of schizophrenia should not be counted in the numerator. focus. A-79 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified NAMI Support. 5. Measure Relevance: This measure is extremely important for assessing Support. Support. treatment of schizophrenia. In most communities, hospital EDs have become the frontline for interfacing with untreated mental illness and the principal intervention for acute psychosis. Inclusion of this measure is integral to any assessment of acute care. EDs are the main portal to an inpatient psychiatric bed. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. This measure will be extremely important in assisting health plans in assessing the performance of community-based providers in serving plan enrollees with schizophrenia. It is also important that measure not be diluted by removal diagnostic codes unrelated to acute psychosis. In many cases, individuals with schizophrenia present in hospital EDs with a broad range of medical conditions that are directly related to an acute psychiatric episode (i.e., injury sustained as part of a suicide attempt or injury related to co-occurring substance abuse). Feasibility of data collection In NAMI’s view, utilization of EDs should be relatively easy for Medicaid health plans to collect and aggregate. Follow-Up After Hospitalization for Schizophrenia BJC Support with Specify 7 "calendar" days and 30 "calendar days". Organizations easily move these Clarify that the days are HEDIS measure HealthCare modification. standards to their business days. The data collected and standard sought should calendar days and not specifications do not be "a week after discharge" and "a month after discharge" (i.e., calendar days). business days. specify calendar days versus business days. All HEDIS measures use calendar days. NACBHDD Support with Separate acute inpatient care for a mental health reason from other acute inpatient Consider separating the The measure only looks at modification. episodes. Otherwise, findings will be ambiguous. measure by the type of acute inpatient episodes for acute inpatient event. members that had a schizophrenia diagnosis upon discharge. Kaiser Health Support with Kaiser Permanente has several comments. 1. Consider adding 1. NCQA will discuss with Plan modification. telephone visits to the Mathematica. Relevance of measure: We agree that this measure is quite relevant. Much of our measure numerator. 2. This measure is not care is provided via telephone visits, which currently do not count toward meeting 2. Concern about how the designed for HEDIS. It is this measure. Could telephone visits be included in this measure? measure aligns with the a separate measure for existing HEDIS follow- which states will collect Usefulness: We agree that the measure would be useful in improving quality of up measure. The data. care. However, we have concerns on how this proposed measure would interface proposed measure just with the existing HEDIS measures for follow-up after psychiatric hospitalization. focuses on the Would these patients be in both denominators? members with schizophrenia, who are Collection: This data would be difficult to collect for members who have carved out likely already in the behavioral health coverage. HEDIS measure. American Support. We support the inclusion of a measure of follow-up care by a mental health Support. Support. Psychological practitioner after hospitalizations for schizophrenia, as it will help to avoid Association unnecessary hospital readmissions and promote continuity of care. A-80 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified OptumHealth Support with 1. Outpatient follow-up visits should allow for services that are clinically 1. Consider adding 1. NCQA will discuss with Behavioral modification. recommended for this population. These include telehealth appointments telephone visits to the Mathematica. Solutions (Q3014), and clinic based appointments, which are mandated by some states measure numerator. 2. NCQA will discuss with (e.g., T1015 (medication management); T1017, T1017 HK, T1017 HA (case 2. Consider allowing Mathematica. management); and H0032 and H0032 TS (treatment plan and treatment plan follow-up with PCPs 3. The measure does not review)). In addition, consideration should be given to follow-up visits with PCPs and peer support specify a schizophrenia and peer support groups/services, both of which are non-standard services that groups. diagnosis for the follow- can be useful in engaging patients in treatment. 3. Concern that measure up. It only specified a 2. This measure is not consistent with the standard FUH measure around how looks at follow-up for schizophrenia diagnosis readmissions are handled. This measure requires a readmission with a only people diagnosed for the denominator schizophrenia diagnosis. It is possible, especially early in the patient’s treatment, with schizophrenia. For (discharge from an acute that a member could be readmitted for another mental illness diagnosis. people in the early inpatient setting). 3. Denominators for this measure will be small, due to small plan size and the low stages of treatment, it is 4. Review the MAX data to prevalence of the diagnosis, making the results difficult to interpret. In order to possible that the follow- look at potential small maximize the denominator, we recommend decreasing the eligible age to 21 up will be listed under numbers problems. years old. Also, this population switches plans often, so a continuous enrollment another mental health 5. Review the MAX data to requirement of one year with only a 45 day gap will eliminate many members. We diagnosis. look at continuous suggest allowing up to 2 non-consecutive 1-month gaps. 4. Concern about small enrollment. numbers for the denominator and recommend decreasing the eligible age to 21 years old. 5. Concern that continuous enrollment of year with only 1 gap will eliminate many members, and recommend 2 non- consecutive 1-month gaps. APA Support with The definition of “mental health practitioner” was referenced but not made available Clarify the definition for Include definitions in final modification. for review in the public comment materials. mental health practitioner. specifications. A-81 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified NAMI Support. 4. Measure Relevance: NAMI strongly supports inclusion of this measure. Support. Support. Meaningful and timely follow-up care after inpatient care has long been difficult in the treatment of schizophrenia. Despite requirements placed on inpatient settings through accreditation bodies such as Joint Commission on Accreditation of Healthcare Organizations and Commission on Accreditation of Rehabilitation Facilities with respect to discharge planning, follow-up care often lacks coordination and accountability. Too often, there is little an inpatient provider can do to hold a community-based provider or individual clinician accountable for rendering care or treatment included in a discharge plan. This measure is a tremendous step forward in allowing a Medicaid health plan to hold a range of providers accountable for follow-up care. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. This measure will be extremely useful is assessing post-inpatient follow-up care for the BOTH psychiatric and medical treatment. Feasibility of data collection. This measure is extremely useful for assessing post-acute care. NAMI would note that the 7-day and 30-day intervals for follow-up care after an inpatient stay are standard measures that hospitals and data systems routinely use now. Thus, it should relatively easy and efficient for Medicaid health plans to acquire such data from providers. Collection of this data will also allow for comparisons and greater accountability in assessing how follow-up care schizophrenia looks when weighed against follow-up care for other medical conditions. NAMI would also note that this draft measure contains no allowance for a gap in Medicaid health plan enrollment, as there are for the other measures. NAMI recommends that NCQA retain this provision. Finally, NAMI would also urge NCQA to retain to the breadth of this measure as encompassing both inpatient psychiatric care, as well as inpatient medical care for plan enrollees with schizophrenia. Use and Continuity of Antipsychotic Medications New Support with Please modify age--I do not understand why people under 25 years were omitted. Consider modifying the TAG recommended 25 to Hampshire modification. Young people with schizophrenia are an extremely high need population and age limits to include ensure stability of DHHS antipsychotic treatment is extremely important for their care. younger people. diagnosis. Kaiser Health Support with Kaiser Permanente agrees this measure is relevant and useful in improving the Concern that some NCQA will share this Plan modification. quality of care for this population. We have a concern that information about prescription data will not thought with Mathematica. prescriptions filled in owned and contracted pharmacies could not be collected. be captured. National Support with Would suggest that you include all antipsychotic medications to the list regardless Consider being more The measure is intended to Council for modification. of delivery mechanism, inclusive of long-acting injection medications. comprehensive with the include injectables as part Community antipsychotic medication of the definition of Behavioral list by including long antipsychotic medication. Healthcare action and injectable Will verify that list includes medications. them. A-82 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified Johnson & Support with The candidate measure “Use & Continuity of Antipsychotic medications” utilizes the Consider including LAI The measure is intended to Johnson modification. “proportion of days covered” (PDC) calculation to derive the measure, which we medications in the include injectables as part Health Care understand would exclude LAI medications. The resulting measurement would not measures. This would of the definition of Systems incorporate an important treatment choice that physicians often choose for patients require changes to the antipsychotic medication. that have difficulty staying on their medication. We believe this would compromise specifications for Use and Will verify that list includes the actual measure objective, namely improved adherence. It is important to note Continuity of Antipsychotic them. that the utilization of LAIs, which can provide medication “on board” for patients up medications. to one month, has increased over the last few years. That trend is expected to continue as newer LAIs enter the marketplace. Johnson & Johnson Health Care Systems, Inc. Mercer Support with Please consider the inclusion of long-acting injections such as Haldol Decanoate, Consider including LAI The measure is intended to University modification. Invega Sustenna, Prolixin Decanoate and Risperidal Consta. These agents play a medications in the include injectables as part College of vital role on patient adherence. Our society has an unusual position regarding these measures. This would of the definition of Pharmacy and agents, however, we must realize that patient adherence is a major issue in this require changes to the antipsychotic medication. Health population and this type of formulation provides an added option for patient specifications for Use and Will verify that list includes Sciences treatment. Continuity of Antipsychotic them. medications. Valley Mental Support with LAIs are integral in treating this illness and a big part of future medication Consider including LAI The measure is intended to Heath modification. development. You are missing the boat by not incorporating LAI medicines in your medications in the include injectables as part measures measures. This would of the definition of require changes to the antipsychotic medication. specifications for Use and Will verify that list includes Continuity of Antipsychotic them. medications. A-83 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified OptumHealth Support with 1. Denominators for this measure will be small, due to small plan size and the low 1. Concern about small 1. Review the MAX data to Behavioral modification. prevalence of the diagnosis, making the results difficult to interpret. In order to numbers for the look at potential small Solutions maximize the denominator, we recommend decreasing the eligible age to 21 denominator and numbers problems. years old. Also, this population switches plans often, so a continuous enrollment recommend decreasing 2. Review the MAX data to requirement of 1 year with only a 45 day gap will eliminate many members. We the eligible age to 21 look at continuous suggest allowing up to 2 non-consecutive 1-month gaps. years old. enrollment. 2. Table B. Is this table necessary--we recommend that you remove it? If it 2. Concern that 3. Discuss the table's remains, it needs to be modified. It includes codes for ophthalmological services, continuous enrollment usefulness in the but does not include HCPCS codes which are often used for this population and of year with only 1 gap measure. mandated by states (e.g., T1015 for medication management). We also will eliminate many 4. NCQA will share this recommend inclusion of telehealth codes (e.g., Q3014). members, and thought with 3. Many of these members receive injectables, but the specifications are silent on recommend 2 non- Mathematica. how to handle this. consecutive 1-month 5. NCQA will look at this 4. PDC calculation is missing in step 6. gaps. issue. 5. September only has 30 days, so index prescribing period needs to be revised. 3. Consider removing or revisiting Table B (Codes to Identify Visit Type). 4. Consider including LAI medications in the measures. This would require changes to the specifications for Use and Continuity of Antipsychotic medications. 5. Consider revised prescribing days for September for PDC calculation Mercy Support with I was concerned that Injectable. Therapy was not considered as a cornerstone to Consider including LAI The measure is intended to Behavioral modification. the Continuity piece. This is the most effective way to ensure continuity both in the medications in the include injectables as part Health community and during the transition from hospital to community. I definitely believe measures. This would of the definition of that to make recommendations without including all options is misinforming. I am a require changes to the antipsychotic medication. large user and proponent of long-acting therapies for keeping people healthy and specifications for Use and Will verify that list includes safe in the community. Continuity of Antipsychotic them. medications. A-84 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified Cerebral Palsy Support with As a behavioral health executive with 35 years of experience managing inner city, Consider including LAI The measure is intended to of New Jersey modification. comprehensive community mental health centers, I think it is excellent to see "use medications in the include injectables as part and continuity of antipsychotic medication" identified as a quality measure. measures. This would of the definition of Medication non-adherence puts patients at extreme risk for adverse outcomes and require changes to the antipsychotic medication. adds millions of dollars to the cost of health care in regards to rapid readmissions. I specifications for Use and Will verify that list includes believe, however, it is crucial that long-acting injections be added to the measure. Continuity of Antipsychotic them. LAIs offer a superior way of monitoring adherence, offer a superior method of medications. delivering the medication and offer a much less stressful adherence plan for consumers who are easily overwhelmed by trying to adhere to multiple doses of daily oral antipsychotics. I strongly urge the NCQA to include long-acting in this measure. APA Support with The following medications appear to be absent from the table: iloperidone; Consider adding NCQA and Mathematica modification. lurasidone; and asenapine. The following medications are included in the table but iloperidone; lurasidone; will review the list of are no longer available in the United States: trifluoperazine; mesoridazine; and and asenapine to the antipsychotics. molindone. When electronic prescribing is more prevalent in the future, we suggest medication measure. The consider differentiating between prescriptions that were not written versus following medications are prescriptions which were written but not filled by the patient. Quality improvement included in the table but approaches will differ depending on which is the cause of lack of medication use or are no longer available in continuity. the United States: trifluoperazine; mesoridazine; and molindone. NAMI Support. 1. Measure Relevance: NAMI strong supports the relevance of this measure. Support. Support. Treatment adherence has always been a major challenge in schizophrenia. The currently available medications to treat schizophrenia each vary significantly in terms of how they address the complex symptoms of the disorder--from the positive symptoms such as delusional thinking, paranoia and auditory hallucinations, to the negative symptoms such as social withdrawal, flat mood and isolation. In addition, each of the currently available compounds has unique side effect profiles that can vary significantly among individual patients. In some instances, the more effective a medication is controlling symptoms and improving functioning, the more likely individual patients are to stop taking their medication. Finally, one of the very symptoms of schizophrenia is a condition known as “anosognosia” or lack of insight into delusional thinking or paranoia. This condition inevitably results in lack of treatment adherence in many consumers. It is critical that this assessment of treatment adherence be included in these proposed measures. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. In NAMI’s view, both the proposed “use” measure and the “continuity” measure are integral to helping meet the goal of improving quality. Feasibility of data collection NAMI strongly supports the proposed 6-step process set forth in the measure for identifying the numerator compliance. NAMI would urge NCQA not to retreat from the 80% minimum standard for the intake period included in the measure. At the same time, NAMI would urge NCQA to expand the list of compounds included in Table C of the draft measures. It is critical that this list be as inclusive as possible. First, the list should be expanded to include alternative delivery technologies available for existing compounds such as long-acting A-85 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified Inclusion of Bipolar Disorder in the Denominator BJC Do NOT No. People with Bipolar Disorder are treated with a number of medications in Concern that including NCQA will pass share this HealthCare Support. addition to the antipsychotics. Those other medications can contribute to weight bipolar disorder will thought with Mathematica. gain, and thus affect risk factors for heart disease, weight and diabetes. Therefore confound the data due to including bipolar in the denominator confounds the data unless all those medication differences. medications which have weight gain as a side effect are included (i.e., several of the anti-depressants and mood stabilizers; e.g., trazadone, lithium, etc.) NACBHDD Support with Run 2 separate analyses for schizophrenia and bipolar. Otherwise results will be Concern that the results of NCQA will share this modification. ambiguous. the data will be thought with Mathematica. ambiguous. University of Do NOT Bipolar disorder does not always require treatment with an antipsychotic (e.g., Concern that including NCQA will share this Nevada Support. when patient is on Depakote or Lithium and the bipolar disorder is in remission). bipolar disorder will thought with Mathematica. School of Sometimes it is contraindicated. Thus bipolar disorder should not be included in the confound the data due to Medicine numerator or denominator. medication differences. Kaiser Health Support with Please consider making this based upon the use of medications known to increase Consider changing the The measures are intended Plan modification. risk of diabetes and dyslipidemia, rather than limit this to those with a specific measure focus away from to focus on people with diagnosis and medication. a specific diagnosis to a schizophrenia. focus on medications known to increase the risk of diabetes and dyslipidemia. National Support. Support. Support. Support. Council for Community Behavioral Healthcare American Support. We support the proposed expansion of measure denominators to include Medicaid Support. Support. Psychological beneficiaries with bipolar disorder in order to increase screening and monitoring of Association cardiovascular health and diabetes. Bristol-Myers Support. I would like to indicate support for the expansion of the denominator beyond Consider adding bipolar NCQA will share this Squibb schizophrenia to include patients with bipolar disorder for the following reasons: disorder to the measure thought with Mathematica. Company Patients with bipolar disorder typically suffer from a high burden of comorbid denominators, because medical problems, including metabolic issues. Bipolar patients are often overweight patients with this and likely to meet criteria for “metabolic syndrome”, placing them at increased risk diagnosis suffer from of developing cardiovascular disease, stroke and Type 2 diabetes. Moreover, comorbid medical several medications used to treat bipolar disorder pose hazards for increasing body problems. weight and worsening metabolic parameters. Given that obesity and illness of the endocrine/metabolic system have been correlated with poorer outcomes, the appropriate monitoring of metabolic health remains critical for this patient group. OptumHealth Support. Support. Support. Support. Behavioral Solutions A-86 TABLE D.1 (continued) Organization Feedback Comments Comments Disposition Name Type Modified APA Support. We support the expansion of the cardiovascular screening and monitoring Consider expanding the Discuss recommendation measures to the diagnosis of bipolar disorder, and suggest that these measures be cardiovascular measures with Mathematica. considered for expansion to all patients treated with atypical antipsychotic to anyone treated with medications, regardless of diagnosis, given the increased risk of cardiovascular atypical antipsychotic illness. medications, regardless of diagnosis. NAMI Support. NAMI strongly endorses extension of these measures to bipolar disorder in the Support. NCQA will share these denominator. As with schizophrenia, bipolar disorder is a complex mental disorder thoughts with Mathematica. with multiple phases and a diverse pathology of symptoms--mania, extreme mood swings, depression, anxiety, mixed state and, in some instances, psychotic features. Treatment for bipolar disorder is often complex and can involve prescribing of multiple compounds. As with schizophrenia, treatment adherence is often challenging for many individuals living with bipolar disorder. In fact, a number of the existing atypical antipsychotic compounds listed in the draft adherence measure are approved by the Food and Drug Administration for treatment of bipolar disorder (e.g., mood stabilizing agents). Likewise, persons with bipolar disorder experience many of the complex medical comorbidities (including cardiovascular disease, diabetes and cervical cancer) of individuals living with schizophrenia. In addition, they have nearly identical needs with respect to follow-up care after a hospital admission. Finally, they also utilize EDs for a diverse array of needs that often associated with failure to access treatment. For these reasons, NAMI urges that NCQA extend all 6 measures for schizophrenia to bipolar disorder. A-87 APPENDIX E. PILOT-TESTING RESULTS A-88 TABLE E.1. Enrollee Information and Selected SMI Conditions by State FFS Disabled Meet All Total FFS b c Schizophrenia or Schizophrenia and & Non-Dually Inclusion Schizophrenia Bipolar Disorder d e State FFS Disabled a Bipolar Disorder Bipolar Disorder Eligible Criteria N N N N N Percent N Percent N Percent N Percent AL 903,809 210,887 111,630 52,351 4,071 7.8 1,201 2.3 5,067 9.7 205 0.4 AK 126,203 15,747 8,510 2,670 270 10.1 114 4.3 379 14.2 5 0.2 CA 10,654,123 1,128,827 628,773 348,599 36,571 10.5 12,404 3.6 45,920 13.2 3,055 0.9 CT 465,746 68,349 30,397 19,875 2,699 13.6 1,215 6.1 3,629 18.3 285 1.4 DC 77,172 34,998 23,741 12,700 1,716 13.5 703 5.5 2,239 17.6 180 1.4 GA 1,104,108 282,632 151,295 66,548 6,177 9.3 1,870 2.8 7,617 11.4 430 0.6 ID 229,423 36,382 20,555 7,613 781 10.3 648 8.5 1,329 17.5 100 1.3 IL 2,380,314 344,733 171,810 103,202 12,781 12.4 5,580 5.4 15,956 15.5 2,405 2.3 IN 970,830 148,624 72,925 38,034 3,198 8.4 1,793 4.7 4,778 12.6 213 0.6 IA 479,755 71,302 33,342 14,413 1,376 9.5 675 4.7 1,907 13.2 144 1.0 LA 1,155,231 197,309 124,592 58,473 4,314 7.4 1,180 2.0 5,258 9.0 236 0.4 MD 835,727 138,739 84,577 41,442 4,340 10.5 2,718 6.6 6,495 15.7 563 1.4 MO 721,719 187,957 99,510 55,677 4,775 8.6 3,910 7.0 8,021 14.4 664 1.2 MS 745,543 171,082 93,910 41,175 3,377 8.2 803 2.0 4,039 9.8 141 0.3 NH 144,366 22,315 8,848 4,682 374 8.0 228 4.9 581 12.4 21 0.4 NC 1,655,892 283,473 153,256 66,404 5,670 8.5 2,777 4.2 7,932 11.9 515 0.8 ND 73,449 10,883 4,594 2,041 219 10.7 59 2.9 268 13.1 10 0.5 NV 197,548 39,964 23,054 8,567 749 8.7 348 4.1 1,039 12.1 58 0.7 OK 783,335 103,287 55,442 27,102 2,600 9.6 1,330 4.9 3,720 13.7 210 0.8 SD 131,924 19,026 8,709 3,591 279 7.8 73 2.0 346 9.6 6 0.2 WV 289,435 113,811 72,220 41,844 1,933 4.6 2,090 5.0 3,806 9.1 217 0.5 WY 77,782 9,869 5,179 2,120 142 6.7 72 3.4 203 9.6 11 0.5 Total 24,203,434 3,640,196 1,986,869 1,019,123 98,412 9.7 41,791 4.1 130,529 12.8 9,674 0.9 SOURCE: Mathematica analysis of 2007 MAX data. a. FFS, non-dual disabled enrollees with 10 months of eligibility. b. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. c. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is bipolar disorder. d. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia or bipolar disorder. e. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia and 1 inpatient or 2 outpatient claims where the primary diagnosis is bipolar disorder. A-89 TABLE E.2. Enrollee Demographics Meet All b Schizophrenia or a Schizophrenia c Characteristic Inclusion Criter Bipolar Disorder N N Percent N Percent Gender Male 425,462 49,949 11.7 58,946 13.9 Female 593,632 48,462 8.2 71,581 12.1 Age 25 - 30 96,156 10,454 10.9 14,054 14.6 31 - 40 170,421 19,770 11.6 27,620 16.2 41 - 50 298,627 35,211 11.8 46,957 15.7 51 - 60 351,638 27,890 7.9 35,567 10.1 61 - 64 102,281 5,087 5.0 6,331 6.2 Unknown Race/Ethnicity African American 332,190 38,067 11.5 44,169 13.3 Caucasian 473,576 41,105 8.7 62,834 13.3 Hispanic 83,492 7,001 8.4 8,825 10.6 Other 61,492 5,513 9.0 6,329 10.3 Unknown 68,373 6,726 9.8 8,372 12.2 Comorbid Diagnoses d Cardiovascular disease 84,624 4,700 5.6 6,405 7.6 e Diabetes 178,962 17,027 9.5 21,845 12.2 Managed Care Status Enrolled in HMO 126,495 11,273 8.9 16,080 12.7 Enrolled in BHO 14,352 1,372 9.6 1,900 13.2 Enrolled in other MC 78,159 6,605 8.5 8,710 11.1 Total 1,019,123 98,412 9.7 130,529 12.8 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. FFS, non-dual, disabled enrollees with 10 months of eligibility. b. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. c. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia or bipolar disorder. d. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. e. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-90 TABLE E.3a. Use of Antipsychotic Medication by Enrollee Characteristic a Schizophrenia Use of Antipsychotic Medication Characteristic N N Percent Gender Male 48,642 45,704 94.0 Female 47,787 44,458 93.0 Age 25 - 30 10,170 9,639 94.8 31 - 40 19,312 18,212 94.3 41 - 50 34,513 32,345 93.7 51 - 60 27,410 25,326 92.4 61 - 64 5,025 4,641 92.4 Unknown 0 0 0.0 Race/Ethnicity African American 37,041 34,324 92.7 Caucasian 40,491 38,003 93.9 Hispanic 6,898 6,541 94.8 Other 5,412 5,137 94.9 Unknown 6,588 6,158 93.5 Comorbid Diagnoses b Cardiovascular disease 4,683 4,246 90.7 c Diabetes 16,968 15,942 94.0 Managed Care Status Enrolled in HMO 11,018 10,125 91.9 Enrolled in BHO 1,358 1,287 94.8 Enrolled in other MC 6,529 6,108 93.6 Total 96,430 90,163 93.5 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-91 TABLE E.3b. Use of Antipsychotic Medication by State a Schizophrenia Use of Antipsychotic Medication State N N Percent AL 3,997 3,788 94.8 AK 261 242 92.7 CA 35,895 33,664 93.8 CT 2,672 2,566 96.0 DC 1,588 1,426 89.8 GA 5,997 5,618 93.7 ID 772 714 92.5 IL 12,527 11,570 92.4 IN 3,146 2,985 94.9 IA 1,359 1,288 94.8 LA 4,217 4,004 94.9 MD 4,232 3,973 93.9 MO 4,693 4,442 94.7 MS 3,310 2,959 89.4 NH 368 353 95.9 NC 5,561 5,172 93.0 ND 215 198 92.1 NV 737 702 95.3 OK 2,580 2,359 91.4 SD 249 229 92.0 WV 1,915 1,784 93.2 WY 139 127 91.4 Total 96,430 90,163 93.5 SOURCE: 2007 MAX data. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. A-92 TABLE E.4a. Antipsychotic Medication Possession Ratio by Enrollee Characteristic (All States) Antipsychotic Possession Ratio >80% Characteristic Percent Gender Male 64.9 Female 63.7 Age 25 - 30 59.0 31 - 40 60.8 41 - 50 62.8 51 - 60 69.0 61 - 64 74.2 Unknown 0.0 Race/Ethnicity African American 53.0 Caucasian 72.6 Hispanic 64.8 Other 71.1 Unknown 69.3 Comorbid Diagnoses a Cardiovascular disease 62.7 b Diabetes 71.0 Managed Care Status Enrolled in HMO 62.1 Enrolled in BHO 74.7 Enrolled in other MC 60.5 Total 64.3 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. Antipsychotic Possession Ratio = # Days supplied/# Days in treatment period. a. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. b. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-93 TABLE E.4b. Antipsychotic Medication Possession Ratio by State Antipsychotic Medication State Possession Ratio >80% Percent AL 59.3 AK 66.5 CA 67.5 CT 72.1 DC 48.3 GA 55.3 ID 78.6 IL 64.2 IN 68.5 IA 74.7 LA 54.7 MD 62.8 MO 66.5 MS 48.9 NH 80.0 NC 64.6 ND 84.6 NV 62.6 OK 62.8 SD 70.9 WV 65.5 WY 65.9 Total 64.3 SOURCE: 2007 MAX data. Antipsychotic Possession Ratio = # Days supplied/# Days in treatment period. A-94 TABLE E.5a. Diabetes Screening Among Enrollees with Schizophrenia or a Bipolar Disorder by Enrollee Characteristics (All States) Denominator Diabetes Screen Characteristic N N Percent Gender Male 40,443 4,118 10.2 Female 43,749 4,760 10.9 Age 25 - 30 10,087 1,096 10.9 31 - 40 18,686 2,083 11.1 41 - 50 30,206 3,104 10.3 51 - 60 21,492 2,199 10.2 61 - 64 3,721 396 10.6 Unknown 0 0 0.0 Race/Ethnicity African American 27,027 2,469 9.1 Caucasian 41,324 4,574 11.1 Hispanic 5,758 728 12.6 Other 4,463 477 10.7 Unknown 5,620 630 11.2 Comorbid Diagnoses b Cardiovascular disease 3,079 384 12.5 c Diabetes N/A N/A N/A Managed Care Status Enrolled in HMO 10,393 1,191 11.5 Enrolled in BHO 1,250 255 20.4 Enrolled in other MC 5,539 695 12.5 Total 84,192 8,878 10.5 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia or bipolar disorder. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-95 TABLE E.5b. Diabetes Screening Among Enrollees with Schizophrenia or a Bipolar Disorder by State Denominator Diabetes Screen State N N Percent AL 3,253 420 12.9 AK 245 21 8.6 CA 31,796 3,758 11.8 CT 2,442 689 28.2 DC 1,284 52 4.0 GA 4,683 148 3.2 ID 824 69 8.4 IL 9,515 562 5.9 IN 3,031 543 17.9 IA 1,251 255 20.4 LA 3,499 382 10.9 MD 4,094 93 2.3 MO 5,030 427 8.5 MS 2,392 232 9.7 NH 377 83 22.0 NC 4,735 452 9.5 ND 171 35 20.5 NV 756 67 8.9 OK 2,318 278 12.0 SD 217 53 24.4 WV 2,148 253 11.8 WY 131 6 4.6 Total 84,192 8,878 10.5 SOURCE: 2007 MAX data. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia or bipolar disorder. A-96 TABLE E.6a. Cardiovascular Health Screening Among Enrollees with Schizophrenia or Bipolar a Disorder by Enrollee Characteristics Denominator Cardiovascular Screen Characteristic N N Percent Gender Male 45,195 19,384 42.9 Female 52,338 23,423 44.8 Age 25 - 30 10,773 3,870 35.9 31 - 40 20,926 8,507 40.7 41 - 50 35,219 15,599 44.3 51 - 60 26,032 12,553 48.2 61 - 64 4,584 2,279 49.7 Unknown 0 0 0.0 Race/Ethnicity African American 32,001 11,752 36.7 Caucasian 46,781 21,525 46.0 Hispanic 7,043 3,657 51.9 Other 5,256 2,732 52.0 Unknown 6,453 3,142 48.7 Comorbid Diagnoses b Cardiovascular disease N/A N/A N/A c Diabetes 16,421 10,173 62.0 Managed Care Status Enrolled in HMO 11,715 3,829 32.7 Enrolled in BHO 1,501 654 43.6 Enrolled in other MC 6,520 2,937 45.0 Total 97,534 42,808 43.9 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia or bipolar disorder. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-97 TABLE E.6b. Cardiovascular Health Screening Among Enrollees with Schizophrenia a or Bipolar Disorder by State Denominator Cardiovascular Screen State N N Percent AL 3,911 1,840 47.0 AK 281 104 37.0 CA 35,706 19,593 54.9 CT 2,985 1,262 42.3 DC 1,488 716 48.1 GA 5,568 547 9.8 ID 994 502 50.5 IL 11,363 2,959 26.0 IN 3,557 1,775 49.9 IA 1,502 654 43.5 LA 3,958 2,002 50.6 MD 4,659 323 6.9 MO 5,770 2,613 45.3 MS 2,880 1,222 42.4 NH 450 285 63.3 NC 5,898 3,313 56.2 ND 210 131 62.4 NV 826 375 45.4 OK 2,651 1,115 42.1 SD 252 118 46.8 WV 2,476 1,311 52.9 WY 149 48 32.2 Total 97,534 42,808 43.9 SOURCE: 2007 MAX data. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia or bipolar disorder. A-98 TABLE E.7a. Diabetes Monitoring Among Enrollees with a Schizophrenia by Enrollee Characteristics (All States) Denominator Diabetes Test Characteristic N N Percent Gender Male 6,919 3,557 51.4 Female 10,107 5,330 52.7 Age 25 - 30 676 347 51.3 31 - 40 2,298 1,226 53.4 41 - 50 6,135 3,195 52.1 51 - 60 6,509 3,398 52.2 61 - 64 1,409 722 51.2 Unknown 0 0 0.0 Race/Ethnicity African American 7,125 3,203 45.0 Caucasian 6,492 3,659 56.4 Hispanic 1,403 801 57.1 Other 904 592 65.5 Unknown 1,103 633 57.4 Comorbid Diagnoses b Cardiovascular disease 1,755 882 50.3 c Diabetes 17,027 8,888 52.2 Managed Care Status Enrolled in HMO 1,486 638 42.9 Enrolled in BHO 263 174 66.2 Enrolled in other MC 1,231 732 59.5 Total 17,027 8,888 52.2 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-99 a TABLE E.7b. Diabetes Monitoring Among Enrollees with Schizophrenia by State Denominator Diabetes Test State N N Percent AL 812 474 58.4 AK 43 11 25.6 CA 5,075 3,376 66.5 CT 566 305 53.9 DC 281 175 62.3 GA 1,118 186 16.6 ID 153 103 67.3 IL 2,958 604 20.4 IN 607 407 67.1 IA 263 174 66.2 LA 651 441 67.7 MD 669 61 9.1 MO 810 460 56.8 MS 640 396 61.9 NH 76 62 81.6 NC 1,294 955 73.8 ND 39 31 79.5 NV 92 68 73.9 OK 432 262 60.6 SD 45 25 55.6 WV 384 301 78.4 WY 19 11 57.9 Total 17,027 8,888 52.2 SOURCE: 2007 MAX data. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia and 1 inpatient or 2 outpatient claims with a primary diagnosis of diabetes. A-100 TABLE E.8a. Cardiovascular Health Monitoring Among Enrollees with a Schizophrenia by Enrollee Characteristics (All States) Denominator Cardiovascular Test Characteristic N N Percent Gender Male 2,218 1,250 56.4 Female 2,482 1,378 55.5 Age 25 - 30 81 45 55.6 31 - 40 333 189 56.8 41 - 50 1,529 852 55.7 51 - 60 2,185 1,234 56.5 61 - 64 572 308 53.8 Unknown 0 0 0.0 Race/Ethnicity African American 2,027 999 49.3 Caucasian 2,028 1,223 60.3 Hispanic 232 160 69.0 Other 136 91 66.9 Unknown 277 155 56.0 Comorbid Diagnoses b Cardiovascular disease 4,700 2,628 55.9 c Diabetes 1,755 1,074 61.2 Managed Care Status Enrolled in HMO 317 121 38.2 Enrolled in BHO 49 29 59.2 Enrolled in other MC 307 180 58.6 Total 4,700 2,628 55.9 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia and 1 inpatient or 2 outpatient claims where the primary diagnosis is cardiovascular disease. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-101 a TABLE E.8b. Cardiovascular Health Monitoring Among Enrollees with Schizophrenia by States Denominator Cardiovascular Test State N N Percent AL 178 99 55.6 AK 12 4 33.3 CA 1,436 1,059 73.7 CT 105 60 57.1 DC 76 36 47.4 GA 260 44 16.9 ID 19 14 73.7 IL 1,147 462 40.3 IN 156 105 67.3 IA 49 29 59.2 LA 222 146 65.8 MD 179 21 11.7 MO 233 136 58.4 MS 107 66 61.7 NH 9 4 44.4 NC 229 158 69.0 ND 5 3 60.0 NV 24 16 66.7 OK 130 82 63.1 SD 7 6 85.7 WV 112 77 68.8 WY 5 1 20.0 Total 4,700 2,628 55.9 SOURCE: 2007 MAX data. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia and 1 inpatient or 2 outpatient claims where the primary diagnosis is cardiovascular disease. A-102 TABLE E.9a. Cervical Cancer Screening Among Enrollees with a Schizophrenia by Enrollee Characteristics (All States) Denominator Cervical Cancer Screen Characteristic N N Percent Gender Male 0 0 0.0 Female 47,800 10,913 22.8 Age 25 - 30 3,347 1,061 31.7 31 - 40 8,549 2,348 27.5 41 - 50 17,433 4,194 24.1 51 - 60 15,313 2,856 18.7 61 - 64 3,158 454 14.4 Unknown 0 0 0.0 Race/Ethnicity African American 18,419 4,182 22.7 Caucasian 20,105 4,723 23.5 Hispanic 3,143 727 23.1 Other 2,753 552 20.1 Unknown 3,380 729 21.6 Comorbid Diagnoses b Cardiovascular disease 2,437 479 19.7 c Diabetes 9,953 2,429 24.4 Managed Care Status Enrolled in HMO 5,753 1,051 18.3 Enrolled in BHO 757 249 32.9 Enrolled in other MC 3,619 799 22.1 Total 47,800 10,913 22.8 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Female enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-103 a TABLE E.9b. Cervical Cancer Screening Among Enrollees with Schizophrenia by States Denominator Cervical Cancer Screen State N N Percent AL 2,271 507 22.3 AK 132 28 21.2 CA 16,773 3,623 21.6 CT 1,388 329 23.7 DC 848 210 24.8 GA 3,411 797 23.4 ID 419 120 28.6 IL 5,519 1,223 22.2 IN 1,604 409 25.5 IA 759 250 32.9 LA 2,269 536 23.6 MD 1,987 157 7.9 MO 2,247 666 29.6 MS 1,821 423 23.2 NH 208 60 28.8 NC 3,018 839 27.8 ND 115 40 34.8 NV 387 83 21.4 OK 1,381 299 21.7 SD 131 32 24.4 WV 1,028 264 25.7 WY 84 18 21.4 Total 47,800 10,913 22.8 SOURCE: 2007 MAX data. a. Female enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. A-104 TABLE E.10a. ED Utilization for Mental Health Conditions Among Enrollees with a Schizophrenia by Enrollee Characteristics (All States) b Denominator ED for Mental Health Conditions Characteristic N N Percent Gender Male 49,949 13,696 27.4 Female 48,462 14,805 30.5 Age 25 - 30 10,454 3,747 35.8 31 - 40 19,770 6,513 32.9 41 - 50 35,211 10,279 29.2 51 - 60 27,890 6,751 24.2 61 - 64 5,087 1,211 23.8 Unknown 0 0 0.0 Race/Ethnicity African American 38,067 12,145 31.9 Caucasian 41,105 11,978 29.1 Hispanic 7,001 1,906 27.2 Other 5,513 902 16.4 Unknown 6,726 1,570 23.3 Comorbid Diagnoses c Cardiovascular disease 4,700 2,170 46.2 d Diabetes 17,027 5,343 31.4 Managed Care Status Enrolled in HMO 11,273 2,879 25.5 Enrolled in BHO 1,372 409 29.8 Enrolled in other MC 6,605 1,995 30.2 Total 98,412 28,501 29.0 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. b. ED use for mental health conditions includes any ED claim with a visit related ICD-9 code of 290, 293, 295-302, 306-316. c. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. d. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-105 TABLE E.10b. ED Utilization for Mental Health Conditions Among Enrollees a with Schizophrenia by State b Denominator SMI ED Use State N N Percent AL 4,071 1,221 30.0 AK 270 97 35.9 CA 36,571 8,168 22.3 CT 2,699 993 36.8 DC 1,716 564 32.9 GA 6,177 2,003 32.4 ID 781 208 26.6 IL 12,781 4,631 36.2 IN 3,198 830 26.0 IA 1,376 409 29.7 LA 4,314 1,485 34.4 MD 4,340 1,487 34.3 MO 4,775 1,607 33.7 MS 3,377 897 26.6 NH 374 125 33.4 NC 5,670 1,981 34.9 ND 219 53 24.2 NV 749 201 26.8 OK 2,600 785 30.2 SD 279 76 27.2 WV 1,933 630 32.6 WY 142 50 35.2 Total 98,412 28,501 29.0 SOURCE: 2007 MAX data. a. Enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. b. ED utilization for mental health conditions includes any ED claim with a visit related ICD-9 code of 290, 293, 295-302, 306-316. A-106 TABLE E.11a. 7-Day Follow-Up After Mental Health Discharge Among Enrollees with a Schizophrenia by Enrollee Characteristics (All States) Denominator 7-Day Follow-Up Characteristic N N Percent Gender Male 19,467 4,842 24.9 Female 19,755 5,731 29.0 Age 25 - 30 5,064 1,338 26.4 31 - 40 9,589 2,459 25.6 41 - 50 14,916 3,998 26.8 51 - 60 8,414 2,402 28.5 61 - 64 1,239 376 30.3 Unknown 0 0 0.0 Race/Ethnicity African American 18,259 4,740 26.0 Caucasian 15,042 4,724 31.4 Hispanic 2,765 466 16.9 Other 1,114 208 18.7 Unknown 2,042 435 21.3 Comorbid Diagnoses b Cardiovascular disease 4,098 1,161 28.3 c Diabetes 7,710 2,464 32.0 Managed Care Status Enrolled in HMO 4,541 939 20.7 Enrolled in BHO 725 272 37.5 Enrolled in other MC 2,337 996 42.6 Total 39,222 10,573 27.0 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Mental health discharges among enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. Mental health discharges include discharges for any of the following visit related ICD-9 codes: 290, 293, 295-302, 306-316. Follow-up services include any outpatient visit; see Appendix F for a listing of codes included. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-107 TABLE E.11b. 7-Day Follow-Up After Mental Health Discharge Among Enrollees with a Schizophrenia by State Denominator 7-Day Follow-Up State N N Percent AL 1,484 650 43.8 AK 32 10 31.3 CA 10,953 908 8.3 CT 1,229 354 28.8 DC 1,303 551 42.3 GA 2,386 843 35.3 ID 72 20 27.8 IL 8,366 2,212 26.4 IN 1,253 656 52.4 IA 725 272 37.5 LA 441 102 23.1 MD 2,864 849 29.6 MO 2,453 832 33.9 MS 1,420 334 23.5 NH 121 80 66.1 NC 2,181 1,123 51.5 ND 79 20 25.3 NV 124 47 37.9 OK 862 349 40.5 SD 106 35 33.0 WV 735 309 42.0 WY 33 17 51.5 Total 39,222 10,573 27.0 SOURCE: 2007 MAX data. a. Mental health discharges among enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. Mental health discharges include discharges for any of the following visit related ICD-9 codes: 290, 293, 295-302, 306-316. Follow-up services include any outpatient visit; see Appendix F for a listing of codes included. A-108 TABLE E.12a. 30-Day Follow-Up After Mental Health Discharge Among Enrollees with a Schizophrenia by Enrollee Characteristics (All States) Denominator 30-Day Follow-Up Characteristic N N Percent Gender Male 14,622 7,340 50.2 Female 15,930 9,277 58.2 Age 25 - 30 3,949 2,047 51.8 31 - 40 7,284 3,771 51.8 41 - 50 11,470 6,213 54.2 51 - 60 6,795 3,948 58.1 61 - 64 1,054 638 60.5 Unknown 0 0 0.0 Race/Ethnicity African American 13,734 7,230 52.6 Caucasian 12,114 7,371 60.8 Hispanic 2,135 883 41.4 Other 924 387 41.9 Unknown 1,645 746 45.3 Comorbid Diagnoses b Cardiovascular disease 2,804 1,728 61.6 c Diabetes 5,852 3,807 65.1 Managed Care Status Enrolled in HMO 3,582 1,634 45.6 Enrolled in BHO 597 470 78.7 Enrolled in other MC 2,033 1,472 72.4 Total 30,552 16,617 54.4 SOURCE: 2007 MAX data. HMO = health maintenance organization; BHO = behavioral healthcare organization; MC = managed care. a. Mental health discharges among enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. Mental health discharges include discharges for any of the following visit related ICD-9 codes: 290, 293, 295-302, 306-316. Follow-up services include any outpatient visit; see Appendix F for a listing of codes included. b. Refer to Appendix F for all CPT, HCPC, and ICD9 codes used to identify cardiovascular disease. c. Diabetes identified using ICD-9 diagnoses of 250, 357.2, 362.0, 366.41, 648.0. A-109 TABLE E.12b. 30-Day Follow-Up After Mental Health Discharge Among Enrollees with a Schizophrenia by State Denominator 30-Day Follow-Up State N N Percent AL 1,329 950 71.5 AK 27 21 77.8 CA 8,498 2,172 25.6 CT 1,008 602 59.7 DC 941 613 65.1 GA 2,008 1,349 67.2 ID 66 48 72.7 IL 5,601 3,119 55.7 IN 1,091 897 82.2 IA 597 470 78.7 LA 412 247 60.0 MD 2,195 1,348 61.4 MO 1,938 1,226 63.3 MS 1,257 770 61.3 NH 96 85 88.5 NC 1,881 1,471 78.2 ND 69 55 79.7 NV 107 81 75.7 OK 713 530 74.3 SD 83 57 68.7 WV 605 480 79.3 WY 30 26 86.7 Total 30,552 16,617 54.4 SOURCE: 2007 MAX data. a. Mental health discharges among enrollees with 1 inpatient or 2 outpatient claims where the primary diagnosis is schizophrenia. Mental health discharges include discharges for any of the following visit related ICD-9 codes: 290, 293, 295-302, 306-316. Follow-up services include any outpatient visit; see Appendix F for a listing of codes included. A-110 TABLE E.13. Distributions of Measures at the State Level (N=22) 25th 75th Measure Minimum Median Mean Maximum Percentile Percentile Schizophrenia Use of Antipsychotic 89.4 92.1 93.4 93.3 94.8 96.0 Medications Antipsychotic Medication 48.3 62.6 65.7 65.7 70.9 84.6 Possession Ratio Diabetes 9.1 55.6 62.1 57.3 67.7 81.6 Monitoring Cardiovascular 11.7 44.4 59.6 54.5 67.3 85.7 Health Monitoring Cervical Cancer 7.9 21.7 23.7 24.4 27.8 34.8 Screening ED Utilization For Mental Health 22.3 26.8 32.5 31.0 34.4 36.8 Conditions Follow-up After Mental Health 8.3 27.8 34.6 36.0 42.3 66.1 Discharge (7-day) Follow-up After Mental Health 25.6 61.4 72.1 69.7 78.7 88.5 Discharge (30-day) Schizophrenia or Bipolar Disorder Diabetes Screening 2.3 8.4 10.3 12.1 17.9 28.2 Cardiovascular 6.9 42.1 46.1 43.4 50.6 63.3 Health Screening SOURCE: 2007 MAX data. A-111 TABLE E.14. Utilization by Measure Performance Quartile Enrollees Hospitalized for Enrollees Hospitalized for Schzophrenia (Percentage) Schzophrenia (Percentage) Measure States in States in States in States in Bottom 25% Top 25% Bottom 25% Top 25% Schizophrenia Use of antipsychotic medications 18.5 10.5 21.2 22.3 Antipsychotic possession ratio 14.0 15.5 23.4 23.3 Diabetes monitoring 23.7 14.3 26.7 24.2 Cardiovascular health monitoring 24.2 17.1 26.6 16.1 Cervical cancer screen 17.9 18.4 15.8 21.2 Mental health follow-up (7 day) 19.4 16.3 18.1 23.0 Mental health follow-up (30 day) 19.3 16.0 18.6 19.1 Schizophrenia or Bipolar Disorder Diabetes screening 24.3 18.1 26.6 24.5 Cardiovascular health screening 24.2 17.4 26.6 16.2 SOURCE: 2007 MAX data. NOTES: Lower rates of hospitalization and ED use hypothesized for enrollees in the top 25% for each measure. Hospitalization percentages significantly different at p<0.01 except Cervical Cancer Screen. ED percentages significantly different at p<0.01 except Use of Antipsychotic Medications, Antipsychotic Possession Ratio, and Mental Health Follow-up (30-day). A-112 TABLE E.15. Enrollee Level Correlation Matrix (2007) Antipsychotic Cervical ED Antipsychotic Diabetes Diabetes Cardiovascular Cardiovascular Follow-Up Possession Cancer Utilization Use Screening Monitoring Screening Monitoring (7-Day) Ratio Screen (MH) Antipsychotic Use Antipsychotic Possession 0.000 Ratio Diabetes 0.000 0.063 Screening Diabetes 0.013 0.073 0.000 Monitoring Cardiovascular 0.000 0.116 0.276 0.908 Screening Cardiovascular 0.039 0.073 0.198 0.888 0.000 Monitoring Cervical -0.008 0.028 0.050 0.082 0.112 0.104 Cancer Screen ED Utilization 0.031 -0.138 0.013 -0.038 -0.026 -0.033 -0.013 (MH) MH Follow-up 0.092 0.103 0.014 0.081 0.068 0.095 0.051 0.060 (7-day) MH Follow-up 0.105 0.153 0.007 0.092 0.063 0.069 0.081 0.019 0.495 (30-day) SOURCE: 2007 MAX data. A-113 TABLE E.16. State Measure Correlations, 2007-2008 (N=16) 2007-2008 Correlation Use of Antipsychotic Medications 0.252 Antipsychotic Medication Possession Ratio 0.550 Diabetes Screening 0.330 Diabetes Monitoring 0.453 Cardiovascular Health Screening 0.426 Cardiovascular Health Monitoring 0.403 Cervical Cancer Screen 0.314 ED Utilization for Mental Health Conditions 0.416 Follow-up after Mental Health Discharge (7-day) 0.173 Follow-up: after Mental Health Discharge (30-day) 0.202 SOURCE: 2007 and 2008 MAX data. A-114 APPENDIX F. SCHIZOPHRENIA QUALITY MEASURES: NUMERATOR, DENOMINATOR AND EXCLUSION CRITERIA A-115 TABLE F.1. Measure Criteria: Numerators, Denominators and Exclusions Measure Title Numerator Denominator Exclusions Use of Antipsychotic Individuals with schizophrenia prescribed Adults age 25-64 with a diagnosis of None. Medications any antipsychotic medication during the schizophrenia during the measurement year. year. a Antipsychotic Medication Individuals who achieved a PDC of at least Adults age 25-64 with a diagnosis of Individuals with fewer than 90 Possession Ratio 80% for their antipsychotic medications schizophrenia with a claim for any days in observation period. during the measurement year. antipsychotic medication during the measurement year. b Diabetes Screening Individuals with a CPT code for glucose Adults age 25-64 with a diagnosis of Individuals with diabetes . screening: 82947, 82950, 82951, or ICD9 schizophrenia or bipolar disorder during the DX code V77.1. measurement year who received at least 2 months of an antipsychotic medication. Diabetes Monitoring Individuals with a CPT code for HbA1c Adults age 25-64 with a diagnosis of None. b testing: 83036, 83037, 3044F, 3045F, schizophrenia and diabetes during the 3046F, and any CPT code for LDL-C measurement year. screening: 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F. Cardiovascular Health Individuals with a CPT code for LDL-C Adults age 25-64 with a diagnosis of Individuals who had diagnoses Screening screening: 80061, 83700, 83701, 83704, schizophrenia or bipolar disorder during the or CPT, HCPCS codes 83721, 3048F, 3049F, 3050F. measurement year who received at least 2 indicating CABG, PCI, CHF, months of an antipsychotic medication. IVD or MI during the measurement year. Cardiovascular Health Individuals with a CPT code for LDL-C Adults age 25-64 with a diagnosis of None. Monitoring testing: 80061, 83700, 83701, 83704, schizophrenia and any codes indicating 83721, 3048F, 3049F, 3050F. CABG, CHF, PCI, IVD or MI during the measurement year. Cervical Cancer Screening Individuals with a CPT code for cervical Female adults age 25-64 with a diagnosis of Hysterectomy. cancer screen. schizophrenia. ED Utilization for Mental ED visit with a visit related diagnosis of Adults age 25-64 with a diagnosis of None. Health Conditions 290, 293, 295-302, 306-316. schizophrenia during the measurement year. A-116 TABLE F.1 (continued) Measure Title Numerator Denominator Exclusions Follow-up after Mental Any CPT, HCPCs or POS codes to Inpatient mental health discharges None. Health Discharge (7 days) identify follow-up visit within 7 days of (ICD-9 diagnosis=290, 293, 295-302, discharge date. 306-316) among adults age 25-64 with a diagnosis of schizophrenia. CPT=90804-90815, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341- 99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510. [90801, 90802, 90816-90819, 90821- 90824, 90826-90829, 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875, 90876 (required POS=03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72)] [99221-99223, 99231-99233, 99238, 99239, 99251-99255 (require POS=52, 53)] HCPS=G0155, G0176, G0177, G0409- G0411, H0002, H0004, H0031, H0034- H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485. Follow-up after Mental Any CPT, HCPCs or POS codes to Inpatient mental health discharges None. Health Discharge (30 days) identify follow-up visit within 30 days of (ICD-9 diagnosis=290, 293, 295-302, discharge date. (See 7-day measure for 306-316) among adults age 25-64 with listing of codes to identify outpatient a diagnosis of schizophrenia. follow-up visit). NOTE: Schizophrenia identified by any inpatient primary diagnosis ICD-9 code of 295 or 2 primary outpatient ICD-9 codes of 295 observed on different days. a. Proportion of days covered (PDC) = number of days filled divided by days in observation period. b. Diabetes identified by the following ICD-9 diagnoses: 250, 357.2, 362.0, 366.41, 648.0. A-117 To obtain a printed copy of this report, send the full report title and your mailing information to: U.S. Department of Health and Human Services Office of Disability, Aging and Long-Term Care Policy Room 424E, H.H. Humphrey Building 200 Independence Avenue, S.W. Washington, D.C. 20201 FAX: 202-401-7733 Email: webmaster.DALTCP@hhs.gov NOTE: All requests must be in writing. RETURN TO: Office of Disability, Aging and Long-Term Care Policy (DALTCP) Home http://aspe.hhs.gov/_/office_specific/daltcp.cfm Assistant Secretary for Planning and Evaluation (ASPE) Home http://aspe.hhs.gov U.S. Department of Health and Human Services (HHS) Home http://www.hhs.gov