IT-1.28: High Blood Pressure Screening and Follow-Up
Measure Title / IT-1.28 Screening for High Blood Pressure and Follow-Up Documented /Description / Percentage of patients aged 18 years and older seen during the measurement period who were screened for high blood pressure (BP) AND for whom a recommended follow-up plan is documented based on the current blood pressure reading as indicated
NQF Number / Not applicable
Measure Steward / Centers of Medicare and Medicaid Services (GPRO 2014)
Link to measure citation / http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/GPRO_Web_Interface.html
Measure type / Non Stand-Alone (NSA)
Performance and Achievement Type / Pay for Performance (P4P) – Improvement Over Self (IOS)
DY4 / DY5
Achievement Level Calculation / Baseline + 5% *(performance gap)
=
Baseline + 5% *(100% – baseline rate) / Baseline + 10% *(performance gap)
=
Baseline + 10% *(100% – baseline rate)
DSRIP-specific modifications to Measure Steward’s specification / None.
Denominator Description / All patients aged 18 years and older at the beginning of the measurement period
Denominator Inclusions / The Measure Steward does not identify specific denominator inclusions beyond what is described in the denominator description.
Denominator Exclusions / The Measure Steward identifies the following exclusions:
· Documentation of medical reason(s) for not receiving screening for high blood pressure (e.g., patient has an active diagnosis of hypertension, patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status. This may include, but is not limited to severely elevated BP when immediate medical treatment is indicated).
· Documentation of patient reason(s) for not receiving screening for high blood pressure (e.g., patient refuses BP measurement).
Note: Exclusions only applied if patient did not receive screening for high blood pressure during the measurement period.
Denominator Size / Providers must report a minimum of 30 cases per measure during a 12-month measurement period (15 cases for a 6-month measurement period)
· For a measurement period (either 6 or 12 months) where the denominator size is less than or equal to 75, providers must report on all cases. No sampling is allowed.
· For a measurement period (either 6 or 12 months) where the denominator size is less than or equal to 380 but greater than 75, providers must report on all cases (preferred, particularly for providers using an electronic health record) or a random sample of not less than 76 cases.
· For a measurement period (either 6 or 12-months) where the denominator size is greater than 380, providers must report on all cases (preferred, particularly for providers using an electronic health record) or a random sample of cases that is not less than 20% of all cases; however, providers may cap the total sample size at 300 cases.
Numerator Description / Patients who were screened for high blood pressure and a recommended follow-up plan is documented as indicated if the blood pressure is pre-hypertensive or hypertensive
Numerator Inclusions / Definitions:
BP Classification – BP is defined by four BP reading classifications as listed in the “Recommended Blood Pressure Follow-Up” table below including Normal, Pre-Hypertensive, First Hypertensive, and Second Hypertensive Readings.
Recommended BP Follow-Up – The current Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) recommends BP screening intervals, lifestyle modifications and interventions based on BP Classification of the current BP reading as listed in the “Recommended BP Follow-Up” table below.
Lifestyle Modifications – The current JNC report outlines lifestyle modifications and must include one or more of the following as indicated: Weight Reduction, DASH Eating Plan, Dietary Sodium Restriction, Increased Physical Activity, or Moderation in Alcohol Consumption.
Second Hypertensive Reading – Requires both a BP reading of Systolic BP 140 mmHg OR Diastolic BP 90 mmHg during the current encounter AND a most recent BP reading within the last 12 months Systolic BP 140 mmHg OR Diastolic BP 90 mmHg.
Second Hypertensive Reading Interventions – The current JNC report outlines interventions based on BP Readings shown in the “Recommended BP Follow-up” table and must include one or more of the following as indicated: Anti-Hypertensive Pharmacologic Therapy, Laboratory Tests, or Electrocardiogram (ECG).
NUMERATOR NOTE: Although recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, a BP screening must be performed once per measurement period. The intent of this measure is to screen patients for high blood pressure. Normal blood pressure follow-up is not recommended for patients with clinical or symptomatic hypotension.
Numerator Exclusions / The Measure Steward does not identify specific numerator exclusions beyond what is described in the numerator description.
Setting / Ambulatory
Data Source / Electronic Health Record, Administrative Claims, Clinical Data
Allowable Denominator Sub-sets / All denominator subsets are permissible for this outcome
09/24/14