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  • Measure Summary
  • NQMC:010546
  • Oct 2015
  • NQF-Endorsed Measure

Appropriate treatment for children with upper respiratory infection (URI): percentage of children 3 months to 18 years of age who were given a diagnosis of URI and were not dispensed an antibiotic prescription.

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 children 3 months to 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the Index Episode Start Date (IESD).

Note: This measure is reported as an inverted rate (1 - [numerator/eligible population]). A higher rate indicates appropriate treatment of children with URI (i.e., proportion for whom antibiotics were not prescribed).

Rationale

The common cold (or upper respiratory infection [URI]) is a frequent reason for children visiting the doctor's office. Though existing clinical guidelines do not support the use of antibiotics for the common cold, physicians often prescribe them for this ailment (Rosenstein et al., 1998). Pediatric clinical practice guidelines (Rosenstein et al., 1998) do not recommend antibiotics for a majority of upper respiratory tract infections because of the viral etiology of these infections, including the common cold. A performance measure of antibiotic use for URI sheds light on the prevalence of inappropriate antibiotic prescribing in clinical practice and raises awareness of the importance of reducing inappropriate antibiotic use to combat antibiotic resistance in the community.

Evidence for Rationale

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.

Rosenstein N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF, et al. The common cold--principles of judicious use of antimicrobial agents. Pediatrics. 1998;101(Suppl):181-4.

Primary Health Components

Upper respiratory infection (URI); antibiotic treatment; children

Denominator Description

Children 3 months as of July 1 of the year prior to the measurement year to 18 years as of June 30 of the measurement year, with a Negative Medication History and a Negative Competing Diagnosis, who had an outpatient visit, an observation visit or an emergency department (ED) visit with only a diagnosis of upper respiratory infection (URI) during the Intake Period (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Dispensed prescription for antibiotic medication on or three days after the Index Episode Start Date (IESD) (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

  • Most upper respiratory infections (URIs), also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). Antibiotic resistance is a major health concern in the United States and around the world (Centers for Disease Control and Prevention [CDC], 2013).
  • Children average more than two to three colds each year—colds are the main reason they miss school (CDC, 2014).
  • The total economic impact of treating URIs is close to $17 billion per year in direct costs (Fendrick et al., 2003).
  • Pediatric ambulatory visits to physicians account for nearly 50 million antibiotic prescriptions annually in the United States (Hersh et al., 2011).
  • Recent efforts to decrease unnecessary prescribing have resulted in fewer children receiving antibiotics in recent years, but inappropriate use remains a problem (CDC, 2013). Increased education and awareness of appropriate treatment for URIs can reduce the danger of antibiotic-resistant bacteria.

Evidence for Additional Information Supporting Need for the Measure

Centers for Disease Control and Prevention (CDC). Antibiotics aren’t always the answer. [internet]. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2013 [accessed 2014 Jun 19].

Centers for Disease Control and Prevention (CDC). Common colds: protect yourself and others. [internet]. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2014 [accessed 2014 Jun 19].

Fendrick AM, Monto AS, Nightengale B, Sarnes M. The economic burden of non-influenza-related viral respiratory tract infection in the United States. Arch Intern Med. 2003 Feb 24;163(4):487-94. PubMed External Web Site Policy

Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011 Dec;128(6):1053-61. 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.

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

Pay-for-reporting

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Emergency Department

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

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 3 months to 18 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

Getting Better

IOM Domain

Effectiveness

Case Finding Period

A 12-month window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window brackets index event

Denominator Inclusions/Exclusions

Inclusions
Children 3 months as of July 1 of the year prior to the measurement year to 18 years as of June 30 of the measurement year, with a Negative Medication History and Negative Competing Diagnosis, who had an outpatient visit (Outpatient Value Set), an observation visit (Observation Value Set) or an emergency department (ED) visit (ED Value Set) with only a diagnosis of upper respiratory infection (URI) (URI Value Set) during the Intake Period

Note:

  • Children must have been continuously enrolled 30 days prior to the Episode Date through 3 days after the Episode Date (34 total days) with no gaps in enrollment during the continuous enrollment period.
  • Episode Date: The date of service for any outpatient or ED visit during the Intake Period with only a diagnosis of URI.
  • Negative Medication History: To qualify for Negative Medication History, the following criteria must be met:
    • A period of 30 days prior to the Episode Date when the member had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug.
    • No prescriptions filled more than 30 days prior to the Episode Date that are active on the Episode Date.
  • A prescription is considered active if the "days supply" indicated on the date when the member filled the prescription is the number of days or more between that date and the relevant service date. The 30-day look back period for pharmacy data includes the 30 days prior to the Intake Period.
  • Negative Competing Diagnosis: The Episode Date and three days following the Episode Date when the member had no claims/encounters with a competing diagnosis.
  • Intake Period: A 12-month window that begins on July 1 of the year prior to the measurement year and ends on June 30 of the measurement year. The Intake Period captures eligible episodes of treatment.

Refer to the original measure documentation for steps to identify the eligible population.

Exclusions

  • Exclude claims/encounters with more than one diagnosis code.
  • Exclude ED visits that result in an inpatient admission.
  • Test for Negative Medication History. Exclude Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date (refer to Table CWP-C in the original measure documentation for a list of antibiotic medications).
  • Test for Negative Competing Diagnosis. Exclude Episode Dates where the member had a claim/encounter with a competing diagnosis on or 3 days after the Episode Date. A code from either of the following meets criteria for a competing diagnosis:
    • Pharyngitis Value Set
    • Competing Diagnosis Value Set

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
Dispensed prescription for antibiotic medication on or three days after the Index Episode Start Date (IESD). Refer to Table CWP-C in the original measure documentation for a list of antibiotic medications.

Note:

  • This measure is reported as an inverted rate (1 - [numerator/eligible population]). A higher rate indicates appropriate treatment of children with upper respiratory infection (URI) (i.e., proportion for whom antibiotics were not prescribed).
  • IESD: The earliest Episode Date during the Intake Period that meets all of the following criteria:
    • A 30-day Negative Medication History prior to the Episode Date.
    • A Negative Competing Diagnosis on or 3 days after the Episode Date.
    • The member was continuously enrolled 30 days prior to the Episode Date through 3 days after the Episode Date (34 total days).

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

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

Analysis by subgroup (stratification by individual factors, geographic factors, etc.)

Description of Allowance for Patient or Population Factors

This measure requires that separate rates be reported for commercial and Medicaid product lines.

Standard of Comparison

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

External comparison of time trends

Internal time comparison

Original Title

Appropriate treatment for children with upper respiratory infection (URI).

Measure Collection Name

HEDIS 2016: Health Plan Collection

Measure Set Name

Effectiveness of Care

Measure Subset Name

Overuse/Appropriateness

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.

Endorser

National Quality Forum

NQF Number

0069

Date of Endorsement

2014 Dec 23

Measure Initiative(s)

Physician Quality Reporting System

Adaptation

This measure was not adapted from another source.

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 on April 11, 2005. The information was verified by the measure developer on December 15, 2005.

This NQMC summary was updated by ECRI Institute on November 15, 2007. The information was not verified by the measure developer.

This NQMC summary was updated by ECRI Institute on March 10, 2009. The information was verified by the measure developer on May 29, 2009.

This NQMC summary was updated by ECRI Institute on January 15, 2010 and on February 16, 2011.

This NQMC summary was retrofitted into the new template on June 30, 2011.

This NQMC summary was updated by ECRI Institute on May 16, 2012, April 1, 2013, January 10, 2014, December 9, 2014, and again on February 9, 2016.

Copyright Statement

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