As part of our commitment to quality, Optima Health voluntarily participates in the accreditation process administered by the National Committee for Quality Assurance (NCQA). NCQA is an independent, not for profit organization whose mission is to improve health care quality everywhere. HEDIS® (Healthcare Effectiveness Data and Information Set) performance measures are an important part of the accreditation process. These measures tell the story of how well health plans perform in key areas: quality of care, access to care, and use of services.
HEDIS Definitions
Adolescent Well-Care Visits – The percentage of enrolled members 12-21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN during the measurement year.
Adult BMI Assessment -The percentage of members18–74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior the measurement year.
Appropriate Treatment for Children with Pharyngitis – The percentage of children 2–18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic, and received a group A streptococcus (strep) test for the episode. This measure assesses the adequacy of clinical management of pharyngitis episodes for members who received an antibiotic prescription. A higher rate represents better performance (i.e., appropriate testing).
Appropriate Treatment for Children with Upper Respiratory Infection –The percentage of children 3 months–18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. This process measure assesses if antibiotics were inappropriately prescribed for children with URI. A higher rate represents better performance.
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis – The percentage of members 18–64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. A higher rate represents better performance.
Breast Cancer Screening – The percentage of women age 42-69 continuously enrolled during the reporting year and the preceding year, who had a mammogram during the previous 2 calendar years.
Cervical Cancer Screening – The percentage of women age 21 – 64, continuously enrolled during the reporting year, and 2 years prior, and received one or more Pap tests during the reporting year or 2 years prior.
Childhood Immunization Status (Combo 2) – The percentage of children who received: 1) Four diphtheria/pertussis/tetanus (DTaP) vaccinations; 2) Three polio virus (IPV) vaccinations; 3) One mumps/measles/rubella (MMR) vaccination; 4) Two hemophilus influenza type B (HiB) vaccinations; 5) Three hepatitis B (Hep B) vaccinations; and 6) At least one chicken pox (VZV) vaccination on or before the child's second birthday.
Cholesterol Management for Patients With Cardiovascular Conditions – The percentage of members age 18-75 years who were discharged alive in the year prior to the reporting year for acute myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty or who had a diagnosis of Ischemic Vascular Disease (IVD), who had each of the following during the measurement year: LDL-C screening performed, LCL-C controlled (<100 mg/dl)
Colorectal Cancer Screening – Percentage of members 50 – 80 years of age who had one or more of the following colorectal screening: fecal occult blood test during; flexible sigmoidoscopy; double contrast barium enema or air barium air; colonoscopy
Comprehensive Diabetes Care – This set of indicators estimates the percentage of diabetic patients with Type 1 or Type 2 diabetes and are between the ages of 18 and 75, who received each of the following: Hemoglobin A1c testing; LDL-C screening; eye exam; medical attention for nephropathy; and monitoring of blood pressure.
Controlling High Blood Pressure – The percentage of enrolled members 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year. Adequately control is define as BP <140/90.
Follow-Up After Hospitalization for Mental Illness – The percentage of members who were hospitalized for treatment of selected mental health disorders, who were 6 years of age or older at the time of discharge, who were continuously enrolled (without gaps), who were on an outpatient basis or who were in day (or night) treatment with a licensed mental health practitioner within 7 days or within 30 days after discharge from a hospital.
Postpartum Care – Percentage of women who delivered a live birth during the reporting year and received a postpartum visit between 21 and 56 days after delivery.
Timeliness of Prenatal Care – The percentage of deliveries that received a prenatal care visit as a member of the MCO in the first trimester or within 42 days of enrollment in the MCO.
Use of Appropriate Medications for People with Asthma –Percentage of members ages 5-56 who were identified as having persistent asthma during the year prior to the measurement year and who were appropriately prescribed medication during the measurement year.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents -The percentage of members 2–17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.
Well Child Visits in the First 15 Months of Life – Percentage of members who turned 15 months old in the measurement year, were continuously enrolled with the health plan from 31 days of age and received either 0, 1, 2, 3, 4, 5, 6 or more visits with a primary care practitioner during their first 15 months of life. The child should be counted only once.
Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life – Percentage of members who were 3, 4, 5, or 6 years of age during the measurement year, who were continuously enrolled during the measurement year and who received one or more well-child visits with a primary care practitioner during the measurement year.
Based on HEDIS 2009 Technical Standards and Quality Compass