Improving Quality
NCQHA
Diabetes | Asthma | Congestive Heart Failure | Hypertension | Post-MI

The following slides reflect data collected from NCHQA practices through August 2009 (click on thumbnail for a larger image).




Quality Measures

The use of evidence-based treatment and measures of care are essential to improve healthcare quality. The N.C. Healthcare Quality Alliance (NCHQA) was established to improve health care for North Carolinians through promotion of evidence-based practice in primary care and measurement of health care quality using nationally recognized standards for care for specific health conditions.

There is considerable scientific research into the design of measures to capture health care quality and numerous national organizations have developed and endorsed measures for preventive and acute care. Providers across North Carolina currently report data for quality measures as part of their participation in Community Care of North Carolina (CCNC) and/or as part of their agreements with state insurers. The implementation of the NCHQA will expand current reporting statewide and represents a significant initiative that can serve as a model to other states seeking to improve the health of their citizens through improved health care quality.

Measures of quality have been chosen by the NCHQA partners to assess quality of care in the following five areas which represent a significant portion of health problems and health care expenditures among North Carolinians: diabetes, asthma, congestive heart failure, hypertension, and post-MI care. Selection of measures for these conditions was guided by the following principles:
  • Measures used in the NCHQA are based on nationally recognized evidence-based standards such as those developed by the National Committee for Quality Assurance (NCQA) and endorsed by the National Quality Forum (NQF) and which have been widely accepted in the North Carolina provider community.
  • Whenever possible, NCHQA measures will build on existing reporting systems, particularly the CCNC measures, to assess quality. Building on existing systems will reduce burden and ensure the most comparable results across time.
  • Assessment in progress regarding quality of care will be regularly conducted and will include critical review of the measures being used and the need to adjust them. Changes in measures will be linked to the release of new national standards and improvements in the measurement process suggested by evidence-based practice. Expansion of NCHQA to measures for other conditions and across the continuum of care is a long-term goal.
Data to calculate measures will be obtained both through claims data and chart audits. Collection of data will consider the privacy concerns of providers and patients and every effort will be made to reduce the cost and administrative burden on practitioners of additional data collection activities. Other NCHQA activities to assist practices in improving quality will provide support for provider-based data collection for short-term assessment of improvement.

A detailed description of specific measures proposed for the initial five NCHQA diseases/conditions follows.


DIABETES

Eligible Patients:

  • 18-75 years old
  • Diagnosis of diabetes based on:
    • ICD-9 or DRG codes for outpatient, nonacute inpatient, acute inpatient or emergency department visits (specific CPT or revenue codes)
    • pharmacy data indicating prescription for insulin or oral hypoglycemics/antihyperglycemics
    • exclude patients with polycystic ovaries, gestational diabetes, steroid-induced diabetes

Quality Measures (endorsing organizations):

  1. One hemoglobin A1c measurement in past year (NCQA¹ and Alliance²)
  2. Most recent HbA1c is >9.0% (NCQA)
  3. One LDL-C test in past year (NCQA)
  4. Most recent LDL-C is <100mg/dl (NCQA)
  5. Documented retinal or dilated eye exam by an eye care professional (NCQA)
  6. Any documented foot exam (visual inspection, sensory exam with monofilament, pulse exam) in past year
  7. Most recent BP is <130 systolic and <80 diastolic³
  8. Any nephropathy screening in past year – urine microalbumin screen or + result, diagnosis of or treatment for nephropathy, nephrologist visit, ACE inhibitor/ARB therapy (NCQA)
  9. Flu vaccine in past year (CCNC4)5
  10. Pneumococcal vaccine ever (CCNC)²

Data Collection:

Claims data used to identify a panel of eligible patients for each practice. Chart audit at practice to confirm diagnosis and exclude those without diabetes and to obtain information for measures.


ASTHMA

Eligible Patients:

  • 5-40 years old
  • Diagnosis of asthma based on:
    • ICD-9 or DRG codes for outpatient, nonacute inpatient, acute inpatient or emergency department visits (specific CPT or revenue codes)
    • Specific subsets of patients for measures applicable to patients with mild, moderate or severe asthma

Quality Measures (endorsing organizations):

  1. Patients evaluated during at least one office visit for frequency of symptoms (AMA6)
  2. Patients with mild, moderate or severe (stages II-IV) asthma on preferred long-term control medication (AMA)
  3. Patients with mild, moderate or severe (stages II-IV) asthma have asthma action plan in chart or documented that was given to patient (AMA)

Data Collection:

Claims data used to identify a panel of eligible patients for each practice.
Chart audit at practice to:
  • Confirm diagnosis and exclude those without asthma
  • Determine subset of patients for measures 2 and 3, i.e., patients with >Stage I asthma
  • Obtain information for measures

CONGESTIVE HEART FAILURE

Eligible Patients:

  • ≥18 years old
  • Diagnosis of congestive heart failure (CHF) based on:
    • ICD-9 or DRG codes for outpatient, nonacute inpatient, acute inpatient or emergency department visits (specific CPT or revenue codes)
    • subsets of patients for measures applicable to patients with EF<40%

Quality Measures (endorsing organizations):

  1. a and b below will allow comparison of methods and test accuracy of claims data to verify that LVF assessment was done.
    1. Patients with left ventricular function assessment in past 3 years (CCNC) – FROM CLAIMS DATA
    2. Patients with quantitative results of LVF assessment recorded (AMA) – FROM CHART REVIEW
  2. Patients with EF <40% who were prescribed ACEI or ARB therapy (AMA)
  3. Patients with EF <40% who were prescribed beta blocker therapy (AMA)

Data Collection:

Claims data used to identify a panel of eligible patients for each practice.
Claims data also used to identify receipt of LVF assessment by eligible patients. Chart audit at practice to:
  • Confirm diagnosis and exclude those without CHF
  • Determine patients with EF <40% for measures 2 and 3
  • Obtain information for measures

HYPERTENSION

Eligible Patients:

  • ≥18 years old
  • Diagnosis of hypertension based on ICD-9 codes:
    • ICD-9 or DRG codes for outpatient, nonacute inpatient, acute inpatient or emergency department visits (specific CPT or revenue codes)

Quality Measures (endorsing organizations):

  1. Patients with most recent BP reading <140/90 (NCQA)

Data Collection:

Claims data used to identify a panel of eligible patients for each practice.
Claims data also used to identify receipt of LVF assessment by eligible patients. Chart audit at practice to:
  • Confirm diagnosis and exclude those without hypertension
  • Obtain values for most recent BP

POST-MI

Eligible Patients:

  • ≥18 years old
  • Diagnosis of coronary artery disease with prior MI
    • ICD-9 or DRG codes for outpatient, nonacute inpatient, acute inpatient or emergency department visits (specific CPT or revenue codes)
  • Pharmacy data are available

Quality Measures (endorsing organizations):

  1. Patients filling prescriptions for lipid-lowering medications (AMA)
  2. Patients filling prescriptions for beta blockers (AMA)

Data Collection:

These measures will be community-level measures and not specific to individual practices or physicians. Data will be obtained from administrative insurance and pharmacy benefit databases.


1 National Committee for Quality Assurance
2 National Diabetes Quality Improvement Alliance
3 If feasible, BP of 140/90 will also be collected and reported only to the practice
4 Community Care of North Carolina
5 National measures for flu and pneumococcal vaccines are not disease-specific
6 American Medical Association Physician Consortium for Performance Improvement

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