Clinical Quality Measures: Process
Does not apply to this measure
This measure is used to assess the percentage of patients diagnosed with bipolar disorder and treated with an antipsychotic agent who were assessed for the presence of extrapyramidal symptoms (EPS) twice within the first 24 weeks of treatment.
- Extrapyramidal symptoms refer to movement disorders that occur when there is a disruption of the brain's extrapyramidal system. Extrapyramidal Symptoms are referred to as EPS.
- EPS neurological side effects include akathisia, a motor restlessness, and muscle rigidity and tremor, which are sometimes referred to as drug-induced Parkinsonian symptoms.
- EPS also includes tardive dyskinesia and acute dystonia, rare but severe side effects that also relate to disruption of the extrapyramidal system. Sometimes these symptoms are referred to as distinct side effects due to their severity.
Extrapyramidal Symptoms and Antipsychotic Agents
- Typical antipsychotics are associated with significant acute neurologic side effects.
- Tardive dyskinesia (TD) is the principal adverse effect of long-term typical (first generation) antipsychotic treatment; however, studies indicate that TD still occurs with atypical (second generation) antipsychotic agents.
- Atypical (second generation) antipsychotics have been reported to have a lower rate of EPS, particularly acute dystonia and drug-induced Parkinsonism.
Monitoring for Extrapyramidal Symptoms
- Patients with bipolar disorder should be regularly monitored for iatrogenic adverse effects of antipsychotic medication including extrapyramidal symptoms.
- Regular examination for early signs of tardive dyskinesia is an appropriate monitoring plan.
|Keck PE, Perlis R, Otto M, Carpenter D, Ross R, Docherty J. Treatment of bipolar disorder 2004. In: Expert consensus guideline series, postgraduate medicine - a special report. 2004 Dec.|
|Miller DS, Yatham LN, Lam RW. Comparative efficacy of typical and atypical antipsychotics as add-on therapy to mood stabilizers in the treatment of acute mania. J Clin Psychiatry. 2001 Dec;62(12):975-80. PubMed|
|Tarsy D, Baldessarini RJ. Epidemiology of tardive dyskinesia: is risk declining with modern antipsychotics. Mov Disord. 2006 May;21(5):589-98. [117 references] PubMed|
|Wirshing WC. Movement disorders associated with neuroleptic treatment. J Clin Psychiatry. 2001;62 Suppl 2:15-8. [37 references] PubMed|
|Yatham LN, Kennedy SH, O'Donovan C, Parikh S, MacQueen G, McIntyre R, Sharma V, Silverstone P, Alda M, Baruch P, Beaulieu S, Daigneault A, Milev R, Young LT, Ravindran A, Schaffer A, Connolly M, Gorman CP. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord. 2005;7 Suppl 3:5-69. PubMed|
Bipolar disorder; assessment for extrapyramidal symptoms (EPS)
Patients diagnosed and treated for bipolar disorder with an antipsychotic agent (see the related "Denominator Inclusions/Exclusions" field)
Patients assessed for extrapyramidal symptoms (EPS) twice during initial 24 weeks of treatment (see the related "Numerator Inclusions/Exclusions" field)
- A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
- 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
- The STABLE measures were developed using the RAND Appropriateness Method and have been shown to have content validity and face validity.
- Data feasibility testing was performed to determine the availability of the data elements required in the measure numerator and denominator specifications.
- Inter-abstractor reliability testing was performed to assess the data collection strategy. The data collection strategy included data collection forms; data dictionary references and abstractor instructions.
- A field study was conducted to determine measure conformance in an appropriate convenience sample.
Refer to the references listed below for further information.
|STABLE performance measures: data feasibility testing & results. Boston (MA): Center for Quality Assessment and Improvement in Mental Health; 2007. 2 p.|
|STABLE performance measures: development process & validity ratings. Boston (MA): Center for Quality Assessment and Improvement in Mental Health; 2007. 3 p.|
|STABLE performance measures: field study process & conformance findings. Boston (MA): Center for Quality Assessment and Improvement in Mental Health; 2007. 3 p.|
|STABLE performance measures: inter-abstractor reliability testing & results. Boston (MA): Center for Quality Assessment and Improvement in Mental Health; 2007. 2 p.|
Behavioral Health Care
Advanced Practice Nurses
Psychologists/Non-physician Behavioral Health Clinicians
Individual Clinicians or Public Health Professionals
Age greater than or equal to 18 years
Either male or female
Prevention and Treatment of Leading Causes of Mortality
Patients associated with provider
Patient/Individual (Consumer) Characteristic
Does not apply to this measure
Patients 18 years of age or older with an initial or new episode of bipolar disorder
Documentation of a diagnosis involving bipolar disorder; to include at least one of the following:
- Codes 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.81; 296.82; 296.89; 301.13 documented in body of chart, such as, a pre-printed form completed by a clinician and/or codes documented in chart notes/forms
- Diagnosis or impression documented in chart indicating bipolar disorder
- Use of a screening/assessment tool for bipolar disorder with a score or conclusion that patient has bipolar disorder and indication that this information is used to establish or substantiate the diagnosis
Documentation of treatment with an antipsychotic agent (Refer to the "Data Dictionary Reference" in the original measure documentation for specified medications.)
Assessment of extrapyramidal symptoms (EPS) to include a documented reference of at least one of the following (Refer to the "Data Dictionary Reference" in the original measure documentation for EPS definitions):
- Clinician narrative information concerning patient's EPS symptoms documented in chart
- Clinician scored EPS tool is present in chart
- Patient's self-reported symptoms (may be included on an assessment tool or preprinted form) are documented in chart
Documentation must include at least two recordings within the first 24 weeks of treatment.
Fixed time period or point in time
Administrative clinical data
Paper medical record
Does not apply to this measure
Does not apply to this measure
Desired value is a higher score
Internal time comparison
Bipolar disorder: monitoring for extrapyramidal symptoms.
Standards for Bipolar Excellence (STABLE) Performance Measures
Center for Quality Assessment and Improvement in Mental Health - Clinical Specialty Collaboration
STABLE Project National Coordinating Council - Clinical Specialty Collaboration
AstraZeneca LLP, Wilmington, Delaware, provided financial sponsorship for the STABLE Project. They did not otherwise participate in the development of either the measures or toolkit.
The STABLE National Coordinating Council (NCC) was comprised of national experts in bipolar disorder, psychiatry, primary care, and performance improvement. The NCC guided and directed the STABLE Project. NCC members agreed to serve with the understanding that the STABLE Performance Measures and Resource Toolkit would be fully transparent and available without cost in the public domain.
EPI-Q, Inc. , is a consulting company providing practice-based outcomes research, pharmacoeconomic studies, and quality improvement services. EPI-Q managed the STABLE Project.
This measure was not adapted from another source.
This is the current release of the measure.
The measure developer reaffirmed the currency of this measure in September 2015.
|STABLE (STAndards for BipoLar Excellence) performance measures. Boston (MA): Center for Quality Assessment and Improvement in Mental Health; 2007. various p.|
Source available from the Center for Quality Assessment and Improvement in Mental Health (CQAIMH) Web site .
The following is available:
- STABLE National Coordinating Council Resource Toolkit Workgroup. STABLE resource toolkit. Boston (MA): Center for Quality Assessment and Improvement in Mental Health; 2007 Mar. 67 p. This document is available in Portable Document Format (PDF) from the Center for Quality Assessment and Improvement in Mental Health (CQAIMH) Web site .
This NQMC summary was completed by ECRI Institute on January 10, 2008. The information was verified by the measure developer on April 14, 2008.
This NQMC summary was retrofitted into the new template on June 27, 2011.
The information was reaffirmed by the measure developer on September 30, 2015.
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