Table.

Selected Quality Measures That Encourage Different Levels of Accountable Prescribing.^*

Measure	Goal	Comment
Measures encouraging underaccountable prescribing
Controlling high blood pressure (HEDIS, PQRS)	Blood pressure of <140/90 mm Hg in patients 18 to 85 yr of age	Reward a trial of diet and exercise for newly diagnosed high blood pressure. Use evidence-based guidelines to assign drug classes as first-line, second-line, or third-line treatment, accounting for coexisting conditions (e.g., diabetes or heart failure). Modify treatment goals to patient age (e.g., <150/80 for age ≥80 yr)
Cholesterol management for patients with cardiovascular conditions (HEDIS, PQRS)	LDL cholesterol control (<100 mg/dl)	Reward first-line use of statins over other lipid-lowering drugs. Penalize initial use of ezetimibe products or other drugs that do not have proven clinical (vs. surrogate) benefit.
Comprehensive adult diabetes care (HEDIS)	Glycated hemoglobin control (<8.0%) Glycated hemoglobin control (<7.0%) for a selected population	Reward a trial of diet and exercise for newly diagnosed diabetes. Reward first-line use of metformin. Penalize initial or disproportionate use of drugs that do not have proven clinical benefit or drugs with black-box warnings.
Use of aspirin or another antithrombotic in ischemic vascular disease: (ACO, PQRS)	Documented use of aspirin or other antithrombotic agent	Reward first-line use of aspirin over other antithrombotic agents (e.g., clopidogrel).
Measures encouraging partially accountable prescribing
Lipid control in coronary artery disease (ACO, PQRS)	Either LDL cholesterol level of <100 mg/dl or both LDL cholesterol level of ≥100 mg/dl and a documented plan to achieve LDL cholesterol level of <100 mg/dl, including, at a minimum, the prescription of a statin; plan may include documentation of a discussion of lifestyle modifications	Reward first-line use of statins that have been shown to reduce mortality.
Measures encouraging fully accountable prescribing
Persistence of beta-blocker treatment after myocardial infarction (HEDIS)	Prescription for nonselective or cardioselective beta-blocker, or both, at discharge (at least a 135-day supply in the 180 days after discharge)	Evidence-based prescription of any beta-blocker has been proven to reduce mortality after myocardial infarction; the measure accounts for persistence, not just initiation.
Beta-blocker therapy for left ventricular systolic dysfunction (ACO)	Prescription for beta-blocker (bisoprolol, carvedilol, or sustained-release metoprolol)	Evidence-based prescription of specific medications has been proven to reduce mortality among patients with congestive heart failure.
Avoidance of antibiotic treatment in adults with acute bronchitis (HEDIS, PQRS)	No antibiotic prescription on, or within 3 days after, the episode start date	This is an evidence-based approach to acute bronchitis (e.g., the avoidance of antibiotic treatment for viral infections). Flexibility allows for revision of the plan after 3 days.
Avoidance of potentially harmful drug–disease interactions in the elderly (HEDIS, PQRS)	No tricyclic antidepressants, antipsychotics, or sleep agent prescription for patients with history of falls No tricyclic antidepressant or anticholinergic agent prescription for patients with dementia No NSAID or COX-2 selective NSAID prescription for patients with chronic renal failure	This measure illustrates the level of detail achievable in quality measures, for both specific drugs and specific patient populations.

^*COX-2 denotes cyclooxygenase 2, LDL low-density lipoprotein, and NSAID nonsteroidal antiinflammatory drug. Accountable Care Organization (ACO) 2012 Program Analysis Quality Performance Standards measures are available at www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/downloads/aco_qualitymeasures.pdf. Healthcare Effectiveness Data and Information Set (HEDIS) measures are available at www.ncqa.org/tabid/1415/Default.aspx. Physician Quality Reporting System (PQRS) measures are available at www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2013_PQRS_MeasuresList_ImplementationGuide_12192012.zip.