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  • Measure Summary
  • NQMC:010633
  • Oct 2015

Utilization of the PHQ-9 to monitor depression symptoms for adolescents and adults: percentage of members 12 and older with a diagnosis of major depression or dysthymia who are covered by an electronic clinical data system (ECDS) who have either a PHQ-9 or PHQ-A score present in their record.

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.

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 12 years of age and older with a diagnosis of major depression or dysthymia who are covered by an electronic clinical data system (ECDS) and, if they had an outpatient encounter, have either a Patient Health Questionnaire (PHQ-9) or PHQ-9 Modified for Adolescents (PHQ-A) score present in their record.

See the related National Quality Measures Clearinghouse (NQMC) summary of the National Committee for Quality Assurance (NCQA) measure Utilization of the PHQ-9 to monitor depression symptoms for adolescents and adults: percentage of members 12 and older with a diagnosis of major depression or dysthymia who are included in an electronic clinical data system (ECDS).

Rationale

Major depressive disorder (MDD) is a leading cause of disability worldwide, affecting an estimated 120 million people (Murray et al., 2012). The lifelong prevalence is estimated to range from 10 to 15 percent (Lépine & Briley, 2011). In the United States (U.S.), 15.7 percent of people report that at some point in their lifetime they were told by a health care professional that they had depression (Centers for Disease Control and Prevention [CDC], 2009).

Depression is also associated with other chronic medical conditions and increased morbidity and mortality. The mortality risk for suicide in depressed patients is more than 20-fold greater than in the general population (Bostwick & Pankratz, 2000). In terms of other chronic conditions, depression is associated with a 60 percent increased risk of type 2 diabetes (Mezuk et al., 2008) and has been identified as a risk factor for development of cardiovascular disease (Van der Kooy et al., 2007).

In adolescents, depression can also result in serious long-term morbidities such as generalized anxiety disorder and panic disorder or lead to engagement in risky behaviors such as substance use (Taylor et al., 1996; Foley, Carlton, & Howell, 1996; Friedman et al., 1996). Adolescent-onset depression increases the risk of attempted suicide by five-fold, compared with nondepressed adolescents (Garber et al., 2009). Most adolescents who commit suicide - the third leading cause of death among 15 to 24 year olds - have a previous history of depression (Williams et al., 2009).

Depression has large effects on both health care costs and lost productivity. Adolescents with depression have higher medical expenditures, including those related to general and mental health care, than adolescents without a diagnosis of depression (O'Connor et al., 2009). A recent study showed a relationship between the severity of depression symptoms and work function in working-age adults, and found that for every 1-point increase in the Patient Health Questionnaire (PHQ-9) score (a measure of depression severity), patients experienced an additional mean productivity loss of 1.65 percent. In a survey study, Birnbaum et al. (2010) found that major depressive disorder severity is significantly associated with increased treatment usage and costs, unemployment, disability and reduced work performance. When the results of the study were projected to the U.S. workforce, it was estimated that monthly depression-related worker productivity losses had human capital costs of nearly $2 billion.

Numerous studies have found that patient outcomes improve when there is collaboration between a primary care doctor, case manager and a mental health specialist to screen for depression, monitor symptoms, provide treatment and refer to specialty care as needed (Von Korff & Goldberg, 2001; Gilbody et al., 2006; Thota et al., 2012; Katon & Seelig, 2008; Unützer et al., 2002). Standardized instruments are useful in identifying meaningful change in clinical outcomes over time. Guidelines recommend that providers establish and maintain regular follow-up with patients diagnosed with depression and use a standardized tool to track symptoms (Mitchell et al., 2013; Cheung et al., 2007).

Evidence for Rationale

Birnbaum HG, Kessler RC, Kelley D, Ben-Hamadi R, Joish VN, Greenberg PE. Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance. Depress Anxiety. 2010;27(1):78-89. PubMed External Web Site Policy

Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry. 2000 Dec;157(12):1925-32. PubMed External Web Site Policy

Centers for Disease Control and Prevention (CDC). Anxiety and depression effective treatments exist: people with depression and anxiety should seek help as early as possible to reduce health effects and improve quality of life. Based on 2006 Behavior Risk Factor Surveillance System. [internet]. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2009. 

Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE, GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007 Nov;120(5):e1313-26. [91 references] PubMed External Web Site Policy

Foley HA, Carlton CO, Howell RJ. The relationship of attention deficit hyperactivity disorder and conduct disorder to juvenile delinquency: legal implications. Bull Am Acad Psychiatry Law. 1996;24(3):333-45. PubMed External Web Site Policy

Friedman RM, Katz-Levey JW, Manderscheid RW, Sondheimer DL. Prevalence of serious emotional disturbance in children and adolescents. In: Manderscheid RW, Sonnenschein MA, editor(s). Mental health, United States. Rockville (MD): Substance Abuse and Mental Health Services Administration; 1996. p. 71-8.

Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA, Gladstone TR, DeBar LL, Lynch FL, D'Angelo E, Hollon SD, Shamseddeen W, Iyengar S. Prevention of depression in at-risk adolescents: a randomized controlled trial. JAMA. 2009 Jun 3;301(21):2215-24. PubMed External Web Site Policy

Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006 Nov 27;166(21):2314-21. [72 references] PubMed External Web Site Policy

Katon WJ, Seelig M. Population-based care of depression: team care approaches to improving outcomes. J Occup Environ Med. 2008 Apr;50(4):459-67. PubMed External Web Site Policy

Lépine JP, Briley M. The increasing burden of depression. Neuropsychiatr Dis Treat. 2011;7(Suppl 1):3-7. PubMed External Web Site Policy

Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care. 2008 Dec;31(12):2383-90. PubMed External Web Site Policy

Mitchell J, Trangle M, Degnan B, Gabert T, Haight B, Kessler D, Mack N, Mallen E, Novak H, Rossmiller D, Setterlund L, Somers K, Valentino N, Vincent S. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Sep. 129 p. [334 references]

Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basáñez MG, Baxter A, Bell ML, Benjamin EJ, Bennett D, Bernabé E, Bhalla K, Bhandari B, Bikbov B, Bin Abdulhak A, Birbeck G, Black JA, Blencowe H, Blore JD, Blyth F, Bolliger I, Bonaventure A, Boufous S, Bourne R, Boussinesq M, Braithwaite T, Brayne C, Bridgett L, Brooker S, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2197-223. 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.

O'Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: A systematic evidence review. Ann Intern Med. 2009 Dec 1;151(11):793-803. PubMed External Web Site Policy

Taylor E, Chadwick O, Heptinstall E, Danckaerts M. Hyperactivity and conduct problems as risk factors for adolescent development. J Am Acad Child Adolesc Psychiatry. 1996 Sep;35(9):1213-26. PubMed External Web Site Policy

Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight-Eily LR, Chapman DP, Abraido-Lanza AF, Pearson JL, Anderson CW, Gelenberg AJ, Hennessy KD, Duffy FF, Vernon-Smiley ME, Nease DE Jr, Williams SP, Community Preventive Services Task Force. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med. 2012 May;42(5):525-38. PubMed External Web Site Policy

Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, Arean PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002 Dec 11;288(22):2836-45. PubMed External Web Site Policy

Van der Kooy K, van Hout H, Marwijk H, Marten H, Stehouwer C, Beekman A. Depression and the risk for cardiovascular diseases: systematic review and meta analysis. Int J Geriatr Psychiatry. 2007 Jul;22(7):613-26. [45 references] PubMed External Web Site Policy

Von Korff M, Goldberg D. Improving outcomes in depression. BMJ. 2001 Oct 27;323(7319):948-9. PubMed External Web Site Policy

Williams SB, O'Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009 Apr;123(4):e716-35. [88 references] PubMed External Web Site Policy

Primary Health Components

Major depression; dysthymia; Patient Health Questionnaire (PHQ-9); PHQ-9 Modified for Adolescents (PHQ-A); electronic clinical data system (ECDS); adolescents

Denominator Description

Members age 12 years and older as of January 1 of the measurement year with an active diagnosis of major depression or dysthymia for whom a plan can receive HEDIS measure electronic clinical data system (ECDS) data (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

A Patient Health Questionnaire (PHQ-9) or PHQ-9 Modified for Adolescents (PHQ-A) total score in the patient's record during the same assessment period in which an Index Episode Start Date (IESD) occurred (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • 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
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

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

External oversight/Medicaid

External oversight/Medicare

External oversight/State government program

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Behavioral Health Care

Managed Care Plans

Professionals Involved in Delivery of Health Services

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 12 years and older

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 is divided into three assessment periods with specific dates of service:

  • Assessment Period One. January 1 to April 30 of the measurement year
  • Assessment Period Two. May 1 to August 31 of the measurement year
  • Assessment Period Three. September 1 to December 31 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
The sum of all Index Episode Start Dates (IESD) for members age 12 years and older as of January 1 of the measurement year with an active diagnosis of major depression or dysthymia for whom a plan can receive HEDIS measure electronic clinical data system (ECDS) data

Count the IESD from each of the three assessment periods (members may have an IESD in any or all the three assessment periods, thus members may appear in the denominator 1 to 3 times based on the presence of an IESD in each of the different assessment periods). Members need only have one event in any assessment period to be counted. To determine denominator events:

  • Identify all members in claims with an active diagnosis of major depression or dysthymia (Major Depression and Dysthymia Value Set) that starts before the beginning of the measurement year or during the measurement year.
  • Identify all members from the previous step with an active diagnosis of depression that starts before or occurs during an outpatient encounter (Depression Encounter Value Set) during the measurement year.
  • Identify all members for whom a plan can receive HEDIS measure ECDS data.
  • Identify all outpatient encounters (Depression Encounter Value Set) during the measurement year where an active diagnosis of depression starts before or during the encounter.
  • For each outpatient encounter, identify the date of service and classify each encounter in one of the three assessment periods.
  • For each assessment period, count only the first qualifying encounter for each member. These are the IESD. Each member may have up to three IESDs (one from each assessment period) for the measurement year.
  • Count the number of IESDs for each member. The denominator is the sum of all IESDs across all of the members.

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.
  • Index Episode Start Date (IESD): The first date of an outpatient encounter in each assessment period, where an active diagnosis of depression starts before or occurs during the encounter.
  • ECDS: A structured, electronic version of a patient's comprehensive medical experiences, maintained over time, that may include some or all key administrative clinical data relevant to care (e.g., demographics, progress notes, problems, medications, vital signs, past medical history, social history, immunizations, laboratory data, radiology reports). The ECDS provides automated access to comprehensive information and can create data files for quality reporting. The ECDS may also support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management and outcome reporting. To qualify for this measure, ECDS data must be automated data that is accessible by the healthcare team at the point of care (e.g., electronic health records, registries and case management or disease management systems to which any provider interacting with the member has access to the clinical interface).

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

Exclusions
Exclude members with an active diagnosis from any of the following value sets, at any time during the measurement year:

  • Bipolar disorder (Bipolar Disorder Value Set; Bipolar Disorder ECDS Value Set; Other Bipolar Disorder Value Set)
  • Personality disorder (Personality Disorder Value Set)
  • Psychotic disorder (Psychotic Disorders Value Set)
  • Autism spectrum disorder (Pervasive Developmental Disorder 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

Unspecified

Numerator Inclusions/Exclusions

Inclusions
A Patient Health Questionnaire (PHQ-9) or PHQ-9 Modified for Adolescents (PHQ-A) total score in the patient's record during the same assessment period in which an Index Episode Start Date (IESD) occurred

To determine numerator events:

  • For each IESD, identify if a PHQ questionnaire was completed during the same assessment period as the IESD. The presence of a PHQ total score indicates completion of a PHQ assessment tool and counts as a qualifying PHQ. In addition, completion of a PHQ can be identified by codes in the PHQ Administered Value Set. The PHQ assessment does not need to occur during an encounter; for example, it can be completed over the telephone or through a Web-based portal.
  • For each assessment period where a member had an IESD, count only the first qualifying PHQ. Each member may have up to three qualifying PHQs (one from each assessment period) for the measurement year.
  • Sum the qualifying PHQs across the three periods. To calculate the performance rate, divide the sum of the qualifying PHQs across the three assessment periods by the sum of the IESDs across the three assessment periods.

Note: IESD: The first date of an outpatient encounter in each assessment period, where an active diagnosis of depression starts before or occurs during the encounter.

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

Electronic health/medical record

Registry data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Patient Health Questionnaire (PHQ-9)
  • PHQ-9 Modified for Adolescents (PHQ-A)

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, Medicare, and Medicaid product lines.

Report four age stratifications and a total rate:

  • 12 to 17 years
  • 18 to 44 years
  • 45 to 64 years
  • 65+ years
  • Total

The total rate is the sum of the age stratifications.

Standard of Comparison

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

External comparison of time trends

Internal time comparison

Original Title

Utilization of the PHQ-9 to monitor depression symptoms for adolescents and adults (DMS): utilization of PHQ-9 rate.

Measure Collection Name

HEDIS 2016: Health Plan Collection

Measure Set Name

Measures Collected Using Electronic Clinical Data Systems

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 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.

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 is available:

  • 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 April 14, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

Content adapted and reproduced with permission from the National Committee for Quality Assurance (NCQA). HEDIS® is a registered trademark of NCQA. HEDIS measures and specifications were developed by and are owned and copyrighted by NCQA. HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. NCQA disclaims all liability for use or accuracy of any coding contained in the specifications.

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