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  • Measure Summary
  • NQMC:010524
  • Oct 2015
  • NQF-Endorsed Measure

Comprehensive diabetes care: percentage of members 18 to 75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed.

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 18 to 75 years of age with diabetes (type 1 and type 2) who had an eye screening for diabetic retinal disease.

This measure is a component of the Comprehensive Diabetes Care composite measure—one of 7 different rates—looking at how well an organization cares for the common and serious chronic disease of diabetes.

The denominator for all rates must be the same, with the exception of HbA1c control (less than 7.0%) for a selected population.

Note from the National Quality Measures Clearinghouse (NQMC): For this measure, there are both Administrative and Hybrid Specifications. This NQMC measure summary is based on the Administrative Specification. Refer to the original measure documentation for details pertaining to the Hybrid Specification.

Rationale

Diabetes is one of the most costly and highly prevalent chronic diseases in the United States (U.S.). Approximately 26.5 million Americans have diabetes, and seven million of these cases are undiagnosed. Complications from the disease cost the country nearly $245 billion annually. In addition, diabetes is the seventh leading cause of death in the U.S. (American Diabetes Association, 2013). Many complications, such as amputation, blindness, and kidney failure, can be prevented if detected and addressed in the early stages.

Evidence for Rationale

American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013 Apr;36(4):1033-46.

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.

Primary Health Components

Diabetes; retinopathy; retinal eye exam; dilated eye exam

Denominator Description

Members 18 to 75 years of age as of December 31 of the measurement year with diabetes (type 1 and type 2) (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

An eye screening for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following:

  • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year, or
  • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to 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

  • Diabetes is a complex group of diseases marked by high blood glucose (blood sugar) due to the body's inability to make or use insulin. Left unmanaged, diabetes can lead to serious complications, including heart disease, stroke, hypertension, blindness, kidney disease, diseases of the nervous system, amputations, and premature death (Centers for Disease Control and Prevention [CDC], 2014).
  • Diabetes cost the nation $245 billion in 2012: $176 billion in direct medical expenses and $69 billion in disability, unemployment and premature deaths (CDC, 2014).
  • Diabetes is the seventh leading cause of death in the United States (CDC, 2014).
  • In 2012, approximately 29 million Americans had diabetes (CDC, 2014), an increase of nearly 3 million people from 2010 (CDC, 2011).
  • Proper diabetes management is essential to control blood glucose, reduce risks of complications and prolong life. With support from health care providers, patients can manage their diabetes with self-care, taking medications as instructed, eating a healthy diet, being physically active and quitting smoking (CDC, 2014).

Evidence for Additional Information Supporting Need for the Measure

Centers for Disease Control and Prevention (CDC). National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta (GA): U.S Department of Health and Human Services, Centers for Disease Control and Prevention (CDC); 2011. 12 p.

Centers for Disease Control and Prevention (CDC). National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014. Atlanta (GA): U.S. Department of Health and Human Services (DHHS), Centers for Disease Control and Prevention (CDC); 2014.

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/Medicare

External oversight/State government program

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Emergency Department

Hospital Inpatient

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Optometrists

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age 18 to 75 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 and the year prior to the measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Institutionalization

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Time window brackets index event

Denominator Inclusions/Exclusions

Inclusions
Members 18 to 75 years of age as of December 31 of the measurement year with diabetes (type 1 and type 2)

  • There are two ways to identify members with diabetes: by claim/encounter data and by pharmacy data. The organization must use both to identify the eligible population, but a member only needs to be identified by one method to be included in the measure. Members may be identified as having diabetes during the measurement year or the year prior to the measurement year.
    • Claim/Encounter Data: Members who met any of the following criteria during the measurement year or the year prior to the measurement year (count services that occur over both years):
      • At least two outpatient visits (Outpatient Value Set), observation visits (Observation Value Set), emergency department (ED) visits (ED Value Set) or nonacute inpatient encounters (Nonacute Inpatient Value Set) on different dates of service, with a diagnosis of diabetes (Diabetes Value Set). Visit type need not be the same for the two visits.
      • At least one acute inpatient encounter (Acute Inpatient Value Set) with a diagnosis of diabetes (Diabetes Value Set).
    • Pharmacy Data: Members who were dispensed insulin or hypoglycemics/antihyperglycemics on an ambulatory basis during the measurement year or the year prior to the measurement year (refer to Table CDC-A in the original measure documentation for a list of prescriptions to identify members with diabetes).

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
Members who do not have a diagnosis of diabetes (Diabetes Value Set), in any setting, during the measurement year or year prior to the measurement year and who had a diagnosis of gestational diabetes or steroid-induced diabetes (Diabetes Exclusions Value Set), in any setting, during the measurement year or the year prior to the measurement year. (Optional)

Note: Organizations that apply optional exclusions must exclude members from the denominator for all indicators in the composite measure.

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
An eye screening for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following:

  • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year
  • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year

Any of the following meet criteria:

  • Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the measurement year.
  • Any code in the Diabetic Retinal Screening Value Set billed by an eye care professional (optometrist or ophthalmologist) during the year prior to the measurement year, with a negative result (negative for retinopathy).
  • Any code in the Diabetic Retinal Screening With Eye Care Professional Value Set billed by any provider type during the measurement year.
  • Any code in the Diabetic Retinal Screening With Eye Care Professional Value Set billed by any provider type during the year prior to the measurement year, with a negative result (negative for retinopathy).
  • Any code in the Diabetic Retinal Screening Negative Value Set billed by any provider type during the measurement year.

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

Fixed time period or point in time

Data Source

Administrative clinical data

Paper medical record

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, Medicaid, and Medicare plans.

Standard of Comparison

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

External comparison of time trends

Internal time comparison

Original Title

Comprehensive diabetes care (CDC): eye exam (retinal) performed.

Measure Collection Name

HEDIS 2016: Health Plan Collection

Measure Set Name

Effectiveness of Care

Measure Subset Name

Diabetes

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

0055

Date of Endorsement

2014 Sep 2

Core Quality Measures

Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), and Primary Care

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 July 18, 2003. The information was verified by the measure developer on August 29, 2003.

This NQMC summary was updated by ECRI on March 22, 2005 and on September 29, 2005. The information was verified by the measure developer on December 2, 2005.

This NQMC summary was updated by ECRI Institute on February 19, 2008. The information was verified by the measure developer on April 24, 2008.

This NQMC summary was updated by ECRI Institute on March 12, 2009. The information was verified by the measure developer on May 29, 2009.

This NQMC summary was updated by ECRI Institute on January 25, 2010 and on February 22, 2011.

This NQMC summary was retrofitted into the new template on June 29, 2011.

This NQMC summary was updated by ECRI Institute on August 10, 2012, April 1, 2013, January 10, 2014, January 14, 2015, and again on January 18, 2016.

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