Table 3.
HEDIS Quality of Care Measure Specifications
| Quality of care measures | Population (denominator) | Receipt of guideline-concordant care (numerator) |
|---|---|---|
| Population with diabetes | ||
| Annual receipt of: | ||
| Diabetic eye exam |
Prior to the study period: I. Any inpatient claim with any diagnosis code from HEDIS “Diabetes Value Set” or II. At least two uniquely dated claims with any diagnosis code from HEDIS “Diabetes Value Set” or III. Any dispensation of insulin or hypoglycemics/antihyperglycemics (HEDIS Table CDC-A) or metformin |
Any code from HEDIS “Diabetic Retinal Screening Value Set” or “Diabetic Retinal Screening with Eye Care Professional Value Set” or “Diabetic Retinal Screening Negative Value Set” during the measurement year |
| Diabetic foot exam | Procedure code G9224, G9225, or G9226 during the measurement year | |
| Hemoglobin A1c test | Any code from HEDIS “HbA1c Tests Value Set” during the measurement year | |
|
Diabetic nephropathy test |
Any code from HEDIS “Urine Protein Tests Value Set” during the measurement year | |
| Cholesterol test | Any code from HEDIS “LDL-C Tests Value Set” or “Cholesterol Tests other than LDL-C Value Set” during the measurement year | |
| Any statin therapy |
I. Population with diabetes (see above) and II. Aged 40–67 and not (excluding): - Population with CVD (see below) - Any dispensation for clomiphene (HEDIS Table SPC-A) - Any code from HEDIS “Pregnancy Value Set” - Any code from HEDIS “IVF Value Set” - Any code from HEDIS “ESRD Value Set” - Any code from HEDIS “Cirrhosis Value Set” |
At least one dispensation for a statin medication of any intensity (HEDIS Table SPD-A) during the measurement year |
|
> 80% statin therapy adherence |
At least 80% proportion of days covered from initial statin therapy dispensation to end of measurement year | |
| Population with cardiovascular disease | ||
| Annual receipt of: | ||
|
Cardiovascular monitoring |
Prior to the study period: I. Any inpatient claim with code from HEDIS “AMI Value Set” or II. Any inpatient claim with code from HEDIS “MI Value Set” or III. Any code from HEDIS “CABG Value Set” or IV. Any code from HEDIS “PCI Value Set” or V. Any code from HEDIS “Other Revascularization Value Set” or VI. Any diagnosis code from HEDIS “IVD Value Set” |
Any code from HEDIS “LDL-C Tests Value Set” or “Cholesterol Tests other than LDL-C Value Set” during the measurement year |
| Any statin therapy |
I. Population with CVD and II. Male aged 21–75 or III. Female aged 40–75 and not (excluding): - Any dispensation for clomiphene (HEDIS Table SPC-A) - Any code from HEDIS “Pregnancy Value Set” - Any code from HEDIS “IVF Value Set” - Any code from HEDIS “ESRD Value Set” - Any code from HEDIS “Cirrhosis Value Set” |
At least one dispensation for a statin medication of any intensity (HEDIS Table SPD-A) during the measurement year |
|
> 80% statin therapy adherence |
At least 80% proportion of days covered from initial statin therapy dispensation to end of measurement year | |