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 lithium who have evidence of a lithium serum medication level within 12 weeks of beginning treatment.
Side Effects of Lithium
- Up to 75% of patients on lithium experience some side effects, but most are minor (polyuria; polydipsia, weight gain, cognitive problems, sedation or lethargy) and can be reduced or eliminated by dose adjustment or dosage schedule.
- Tremor affects up to 65% of patients treated with lithium and a severe tremor may be a sign of toxicity. Nausea and diarrhea or blurred vision may also be side effects of toxicity.
- Target lithium levels are generally 0.8-1.1 mmol/L.
- Serum concentrations of 0.5 to 1.2 meq/L may be therapeutic according to individual patient response and side effects.
- Patients can experience toxic effects with levels above 1.5 meq/L such as marked tremor, nausea and diarrhea, or blurred vision; levels above 2.0 meq/L have been associated with life-threatening side effects, such as neurotoxicity, delirium and encephalopathy.
Monitoring of Serum Lithium Levels
- Lithium level monitoring is required due to the medication's narrow therapeutic index.
- Check lithium level after initial dosage and after each dosage increase.
- It is recommended to obtain serum levels approximately 5 days after a dosage adjustment as this is when the steady state is reached.
- Long-term monitoring recommendations are to check every 3 to 6 months in patients with stable lithium levels and whenever the clinical status changes.
|Freeman MP, Freeman SA. Lithium: clinical considerations in internal medicine. Am J Med. 2006 Jun;119(6):478-81. [70 references] PubMed|
|Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002 Apr;159(4 Suppl):1-50. [472 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; lithium serum level monitoring
Patients diagnosed and treated for bipolar disorder with a lithium agent (see the related "Denominator Inclusions/Exclusions" field)
Patients with a serum medication level within 12 weeks of beginning treatment with lithium (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
Making Care Safer
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 a lithium (lithium carbonate; lithium citrate)
Exclude case from denominator population if clinician requests patient to obtain serum lithium level but then subsequently documents that the patient failed to comply with clinician request.
Documentation of reference to serum blood levels in chart must include:
- Documentation that serum blood levels were requested
- Results, or information about results, were obtained and placed/documented in the patient record
Documented results or narrative reference to results are recorded within 12 weeks of date of first order for lithium.
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 lithium serum levels.
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.
The STABLE materials published on this Web site are copyrighted by CQAIMH. They may be used for research, teaching, and quality measurement/improvement activities – provided the following:
- The materials are not sold, distributed or licensed for commercial purposes.
- CQAIMH's copyright is acknowledged in reproductions of these materials.
- Modifications to the materials are not made without CQAIMH's permission.
The National Quality Measures Clearinghouse™ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.
All measures summarized by NQMC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public and private organizations, other government agencies, health care organizations or plans, individuals, and similar entities.
Measures represented on the NQMC Web site are submitted by measure developers, and are screened solely to determine that they meet the NQMC Inclusion Criteria.
NQMC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or its reliability and/or validity of the quality measures and related materials represented on this site. Moreover, the views and opinions of developers or authors of measures represented on this site do not necessarily state or reflect those of NQMC, AHRQ, or its contractor, ECRI Institute, and inclusion or hosting of measures in NQMC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding measure content are directed to contact the measure developer.