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  • Measure Summary
  • NQMC:010540
  • Oct 2015

Adherence to antipsychotic medications for individuals with schizophrenia: percentage of members 19 to 64 years of age during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80 percent of their treatment period.

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.
National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

This is the current release of the measure.

This measure updates previous versions:

  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of members 19 to 64 years of age during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80 percent of their treatment period.

Rationale

For people with schizophrenia, nonadherence to treatment with antipsychotics is common, and medication nonadherence is a significant cause of relapse (Olfson, Hansell, & Boyer, 1997; Ascher-Svanum et al., 2010). Measuring antipsychotic medication adherence may lead to less relapse and fewer hospitalizations. Additionally, there is potential to lead to interventions to improve adherence and help close the gap in care between people with schizophrenia and the general population.

Evidence for Rationale

Ascher-Svanum H, Zhu B, Faries DE, Salkever D, Slade EP, Peng X, Conley RR. The cost of relapse and the predictors of relapse in the treatment of schizophrenia. BMC Psychiatry. 2010;10:2. PubMed External Web Site Policy

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Olfson M, Hansell S, Boyer CA. Medication noncompliance. New Dir Ment Health Serv. 1997 Spring;(73):39-49. [36 references] PubMed External Web Site Policy

Primary Health Components

Schizophrenia; antipsychotic medication; treatment adherence

Denominator Description

Medicaid members 19 to 64 years of age as of December 31 of the measurement year with schizophrenia (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

The number of members who achieved a proportion of days covered (PDC) of at least 80 percent for their antipsychotic medications during the measurement year (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • Schizophrenia is a chronic and disabling psychiatric disorder that requires ongoing treatment and monitoring. Symptoms include hallucinations, illogical thinking, memory impairment and incoherent speech (American Psychiatric Association [APA], n.d.). Medication nonadherence is common and a major concern in the treatment of schizophrenia. Using antipsychotic medications as prescribed reduces the risk of relapse or hospitalization (Busch et al., 2009).
  • In 2002, the overall economic burden of schizophrenia was estimated to be $62.7 billion (Wu et al., 2005).
  • The cost of care for people with schizophrenia and a history of prior relapse is three times higher than it is for people without a history of prior relapse (Ascher-Svanum et al., 2010).
  • 1.1 percent of adults in the United States have schizophrenia (Wu et al., 2005).
  • Approximately 40 percent of hospital readmissions for patients with schizophrenia are attributed to nonadherence to antipsychotic medications (Weiden & Olfson, 1995).
  • Nearly half of people with schizophrenia take less than 70 percent of prescribed medication doses (Goff, Hill, & Freudenreich, 2010).
  • People with schizophrenia who discontinue their medications are twice as likely to experience a relapse in symptoms than those who continue their prescribed doses (Wunderink et al., 2007).
  • Schizophrenia is a life-long mental illness that can be tough to treat and manage. Continuation of medication is important to reduce the number of relapse episodes and the need for hospitalization.

Evidence for Additional Information Supporting Need for the Measure

American Psychiatric Association (APA). Schizophrenia fact sheet. [internet]. Arlington (VA): American Psychiatric Association (APA); [accessed 2014 Jun 19].

Ascher-Svanum H, Zhu B, Faries DE, Salkever D, Slade EP, Peng X, Conley RR. The cost of relapse and the predictors of relapse in the treatment of schizophrenia. BMC Psychiatry. 2010;10:2. PubMed External Web Site Policy

Busch AB, Lehman AF, Goldman H, Frank RG. Changes over time and disparities in schizophrenia treatment quality. Med Care. 2009 Feb;47(2):199-207. PubMed External Web Site Policy

Goff DC, Hill M, Freudenreich O. Strategies for improving treatment adherence in schizophrenia and schizoaffective disorder. J Clin Psychiatry. 2010;71 Suppl 2:20-6. PubMed External Web Site Policy

National Committee for Quality Assurance (NCQA). The state of health care quality 2015. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. 205 p.

Weiden PJ, Olfson M. Cost of relapse in schizophrenia. Schizophr Bull. 1995;21(3):419-29. PubMed External Web Site Policy

Wu EQ, Birnbaum HG, Shi L, Ball DE, Kessler RC, Moulis M, Aggarwal J. The economic burden of schizophrenia in the United States in 2002. J Clin Psychiatry. 2005 Sep;66(9):1122-9. PubMed External Web Site Policy

Wunderink L, Nienhuis FJ, Sytema S, Slooff CJ, Knegtering R, Wiersma D. Guided discontinuation versus maintenance treatment in remitted first-episode psychosis: relapse rates and functional outcome. J Clin Psychiatry. 2007 May;68(5):654-61. PubMed External Web Site Policy

Extent of Measure Testing

All HEDIS measures undergo systematic assessment of face validity with review by measurement advisory panels, expert panels, a formal public comment process and approval by the National Committee for Quality Assurance's (NCQA's) Committee on Performance Measurement and Board of Directors. Where applicable, measures also are assessed for construct validity using the Pearson correlation test. All measures undergo formal reliability testing of the performance measure score using beta-binomial statistical analysis.

Evidence for Extent of Measure Testing

Rehm B. (Assistant Vice President, Performance Measurement, National Committee for Quality Assurance, Washington, DC). Personal communication. 2015 Mar 16.  1 p.

State of Use

Current routine use

Current Use

Accreditation

Decision-making by businesses about health plan purchasing

Decision-making by consumers about health plan/provider choice

External oversight/Medicaid

External oversight/State government program

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Behavioral Health Care

Emergency Department

Hospital Inpatient

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Pharmacists

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age 19 to 64 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

The measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window brackets index event

Denominator Inclusions/Exclusions

Inclusions
Medicaid members 19 to 64 years of age as of December 31 of the measurement year with schizophrenia.

  • Identify members with schizophrenia as those who met at least one of the following criteria during the measurement year:
    • At least one acute inpatient encounter with any diagnosis of schizophrenia. Either of the following code combinations meets criteria:
      • BH Stand Alone Acute Inpatient Value Set with Schizophrenia Value Set
      • BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Schizophrenia Value Set
    • At least two visits in an outpatient, intensive outpatient, partial hospitalization, emergency department (ED) or nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia. Any two of the following code combinations meet criteria:
      • BH Stand Alone Outpatient/PH/IOP Value Set with Schizophrenia Value Set
      • BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Schizophrenia Value Set
      • ED Value Set with Schizophrenia Value Set
      • BH ED Value Set with BH ED POS Value Set and Schizophrenia Value Set
      • BH Stand Alone Nonacute Inpatient Value Set with Schizophrenia Value Set
      • BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Schizophrenia Value Set

Note:

  • Members must have been continuously enrolled during the measurement year.
  • Allowable Gap: No more than one gap in enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage.

Exclusions
Exclude members who met at least one of the following during the measurement year:

  • A diagnosis of dementia (Dementia Value Set)
  • Did not have at least two antipsychotic medication dispensing events. There are two ways to identify dispensing events: by claim/encounter data and by pharmacy data. The organization must use both methods to identify dispensing events but an event need only be identified by one method to be counted.
    • Claim/Encounter Data. An antipsychotic medication (Long-Acting Injections 14 Days Supply Value Set or Long-Acting Injections 28 Days Supply Value Set)
    • Pharmacy Data. Dispensed an antipsychotic medication (refer to Table SAA-A in the original measure documentation for a list of antipsychotic medications) on an ambulatory basis

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
The number of members who achieved a proportion of days covered (PDC) of at least 80 percent for their antipsychotic medications (refer to table SAA-A in the original measure documentation for a list of antipsychotic medications; Long-Acting Injections 14 days Supply Value Set; Long-Acting Injections 28 Days Supply Value Set) during the measurement year

To identify numerator compliance:

  • Identify the Index Prescription Start Date (IPSD). The IPSD is the earliest dispensing event for any antipsychotic medication during the measurement year.
  • To determine the treatment period, calculate the number of days beginning on the IPSD through the end of the measurement year.
  • Count the days covered by at least one antipsychotic medication during the treatment period. To ensure that days supply that extend beyond the measurement year are not counted, subtract any days supply that extends beyond December 31 of the measurement year.
  • Calculate the member's PDC using the following equation. Round to two decimal places using the .5 rule.

    Total Days Covered by an Antipsychotic Medication in the Treatment Period
    Total Days in the Treatment Period

  • Sum the number of members whose PDC is greater than or equal to 80% for their treatment period.

Note:

  • PDC: The number of days a member is covered by at least one antipsychotic medication prescription, divided by the number of days in the treatment period.
  • Treatment Period: The period of time beginning on the IPSD through the last day of the measurement year.
  • Oral Medication Dispensing Event: One prescription of an amount lasting 30 days or less. To calculate dispensing events for prescriptions longer than 30 days, divide the days supply by 30 and round down to convert. Multiple prescriptions for different medications dispensed on the same day are counted as separate dispensing events. If multiple prescriptions for the same medication are dispensed on the same day, use the prescription with the longest days supply. Use the drug ID to determine if the prescriptions are the same or different.
  • Long-acting Injections Dispensing Event: Injections count as one dispensing event. Multiple J codes or National Drug Codes (NDCs) for the same or different medication on the same day are counted as a single dispensing event.
  • Calculating Number of Days Covered for Oral Medications: If multiple prescriptions for the same or different oral medications are dispensed on the same day, calculate number of days covered by an antipsychotic medication (for the numerator) using the prescription with the longest days supply. If multiple prescriptions for different oral medications are dispensed on different days, count each day within the treatment period only once toward the numerator. If multiple prescriptions for the same oral medication are dispensed on different days, sum the days supply and use the total to calculate the number of days covered by an antipsychotic medication (for the numerator). Use the drug ID provided on the NDC list to determine if the prescriptions are the same.
  • Calculating Number of Days Covered for Long-acting Injections: Calculate number of days covered (for the numerator) for long-acting injections using the days supply specified for the medication in Table SAA-A in the original measure documentation or in the value set name. For multiple J Codes or NDCs for the same or different medications on the same day, use the medication with the longest days supply. For multiple J Codes or NDCs for the same or different medications on different days with overlapping days supply, count each day within the treatment period only once towards the numerator.

Exclusions
Unspecified

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Numerator Search Strategy

Episode of care

Data Source

Administrative clinical data

Pharmacy data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Adherence to antipsychotic medications for individuals with schizophrenia (SAA).

Measure Collection Name

HEDIS 2016: Health Plan Collection

Measure Set Name

Effectiveness of Care

Measure Subset Name

Behavioral Health

Submitter

National Committee for Quality Assurance - Health Care Accreditation Organization

Developer

National Committee for Quality Assurance - Health Care Accreditation Organization

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

National Committee for Quality Assurance's (NCQA's) Measurement Advisory Panels (MAPs) are composed of clinical and research experts with an understanding of quality performance measurement in the particular clinical content areas.

Financial Disclosures/Other Potential Conflicts of Interest

In order to fulfill National Committee for Quality Assurance's (NCQA's) mission and vision of improving health care quality through measurement, transparency and accountability, all participants in NCQA's expert panels are required to disclose potential conflicts of interest prior to their participation. The goal of this Conflict Policy is to ensure that decisions which impact development of NCQA's products and services are made as objectively as possible, without improper bias or influence.

Adaptation

This measure was adapted from the Centers for Medicare & Medicaid Services (CMS).

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates previous versions:

  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

Source(s)

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Measure Availability

Source available for purchase from the National Committee for Quality Measurement (NCQA) Web site External Web Site Policy.

For more information, contact NCQA at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

Companion Documents

The following are available:

  • National Committee for Quality Assurance (NCQA). The state of health care quality 2015. Washington (DC): National Committee for Quality Assurance (NCQA); 2015 Oct. 205 p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical update. Washington (DC): National Committee for Quality Assurance (NCQA); 2015 Oct 1. 12 p.

For more information, contact the National Committee for Quality Assurance (NCQA) at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on July 25, 2013.

This NQMC summary was updated by ECRI Institute on January 22, 2014, April 10, 2015, and again on January 29, 2016.

Copyright Statement

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