PQRI: E-Prescribing by Group Practices

2010 Physician Quality Reporting Initiative (PQRI)

Group Practice Reporting Option
(GPRO)
Narrative Measure Specifications

GPRO v1.0

Page 1 of 38

11/10/09

2010 Physician Quality Reporting Initiative (PQRI)
Group Practice Reporting Option (GPRO)
Narrative Measure Specifications

Table of Contents
Introduction .................................................................................................................................................................. 3
Diabetes Mellitus (DM) Disease Module ..................................................................................................................... 4
Heart Failure (HF) Disease Module ........................................................................................................................... 15
Coronary Artery Disease (CAD) Disease Module .................................................................................................... 23
Hypertension (HTN) Disease Module ....................................................................................................................... 28
Preventive (Prev) Care Measures ............................................................................................................................. 31
Symbol and Copyright Information .......................................................................................................................... 38

GPRO v1.0

Page 2 of 38

11/10/09

2010 Physician Quality Reporting Initiative (PQRI)
Group Practice Reporting Option (GPRO)
Narrative Measure Specifications
Introduction
The GPRO is a reporting option for PQRI that incorporates some characteristics and methods from the
demonstration projects, Medicare Care Management Performance (MCMP) and Physician Group Practice
(PGP). In order to participate in the 2010 GPRO, practices are required to complete a self-nomination
process and meet certain technical and other requirements.
For the purposes of 2010 PQRI, a “group practice” consists of a physician group practice as defined by a
Tax Identification Number (TIN) with at least 200 or more individual eligible professionals [or as identified
by individual National Provider Identifier (NPI)] who have reassigned their billing rights to the TIN. The initial
implementation of the GPRO will be limited to practices with 200 or more individual eligible professionals.
There are a total of 26 NQF-endorsed quality measures included in GPRO targeting high-cost chronic
conditions and preventive care. The measure specifications are grouped into four disease modules:
diabetes mellitus (8 measures); heart failure (7 measures); coronary artery disease (4 measures), and
hypertension (3 measures). In addition, there are 4 preventive care measures.
A database pre-populated with an assigned beneficiary sample and the quality measures will serve as a
data collection tool for groups to use in collecting and submitting data to CMS. The data collected will be
based on services furnished during the January 1, 2010 through December 31, 2010 reporting period.
Group practices who satisfactorily submit data on PQRI quality measures via GPRO are eligible to earn an
incentive of 2% of the group practice’s Medicare Part B PFS total estimated allowed charges for covered
services furnished by the group during the reporting period. This incentive is in lieu of PQRI individual NPI’s
incentive payments.
Narrative measure specifications are being provided to allow group practices an opportunity to have a
better understanding of each of the 26 quality measures included in the 2010 GPRO. Once a group
practice is selected to participate in 2010 PQRI using this reporting option, additional detailed information
will be provided.
Each Measure Specification includes the following information:
• Measure title
• Measure description
• Numerator statement
• Denominator statement
• Exclusions applicable to measure
• Rationale statement for measure
• Clinical recommendations or evidence forming the basis or supporting criteria for the measure
• Measure developer

GPRO v1.0

Page 3 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-1: Diabetes Mellitus: Hemoglobin A1c Testing
DESCRIPTION:
Percentage of patients aged 18 through 75 years of age with diabetes mellitus who had hemoglobin A1c
(HbA1c) testing
NUMERATOR:
Patients with one or more HbA1c test(s) performed during the measurement period
DENOMINATOR:
Patients aged 18 through 75 years with a diagnosis of diabetes
WITHOUT

Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Diabetes is a group of diseases characterized by high blood glucose levels caused by the body's inability to
correctly produce or use the hormone insulin. It is one of the leading causes of death and disability in the
U.S. More than 20 million Americans live with diabetes today. One-third of people with diabetes are not
diagnosed. Much of the burden of illness and cost of diabetes treatment is attributed to potentially
preventable long-term complications including heart disease, blindness, kidney disease and stroke. Timely
screening and treatment can significantly reduce the disease burden. Prolonged hyperglycemia causes
nonenzymatic glycosylation of proteins in tissue and blood, including hemoglobin in erythrocytes. Similar
glycosylation of tissue proteins may be involved in pathologic processes which occur in the
microvasculature in diabetes. Measurement of glycated proteins such as hemoglobin or other serum
proteins can quantify average levels of blood glucose over a period of weeks to months depending on the
component measured. In the case of glycosylated hemoglobin, this corresponds to about the life cycle of a
red blood cell, or 120 days (3 months). Other glycated serum proteins, such as fructosamine, represent
short term changes in glycemia on the order of one to two weeks. The relationship of glucose levels over
time to glycohemoglobin makes it a convenient long-term measure of glycemic control. Considering the
interval during which glycosylation of hemoglobin occurs, the American Diabetes Association (ADA)
recommends testing frequency from one to four times a year depending on the stability of control (ADA,
1997a).
CLINICAL RECOMMENDATION STATEMENTS:
American Association of Clinical Endocrinologist/American College of Endocrinology (AACE/ACE):
Recommend that a glycosylated hemoglobin be performed during an initial assessment and during followup assessments, which occur at no longer than three-month intervals.

GPRO v1.0

Page 4 of 38

11/10/09

American Diabetes Association (ADA): Recommends obtaining a glycosylated hemoglobin during an initial
assessment and then routinely as part of continuing care. In the absence of well-controlled studies that
suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at
least twice a year in patients who are meeting treatment goals and who have stable glycemic control and
more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting
glycemic goals.
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 5 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-2: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin
A1c greater than 9.0%
NUMERATOR:
Patients with most recent hemoglobin A1c level > 9.0%
DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
WITHOUT
Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Intensive therapy of glycosylated hemoglobin (A1c) reduces the risk of microvascular complications.
CLINICAL RECOMMENDATION STATEMENTS:
A glycosylated hemoglobin should be performed during an initial assessment and during follow-up
assessments, which should occur at no longer than three-month intervals. (AACE/ACE)
The A1c should be universally adopted as the primary method of assessment of glycemic control. On the
basis of data from multiple interventional trials, the target for attainment of glycemic control should be A1c
values ≤6.5%. (AACE/ACE)
Obtain a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing
care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion
recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting
treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in
patients whose therapy was changed or who are not meeting glycemic goals. (Level of Evidence: E) (ADA)
Because different assays can give varying glycated hemoglobin values, the ADA recommends that
laboratories only use assay methods that are certified as traceable to the Diabetes Control and
Complications Trial A1c reference method. The ADA’s goal for glycemic control is A1c <7%. (Level of
Evidence: B) (ADA)
Monitor and treat hyperglycemia, with a target A1c of 7%, but less stringent goals for therapy may be
appropriate once patient preferences, diabetes severity, life expectancy and functional status have been
considered. (AGS)
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 6 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood
pressure in control (less than 140/80 mmHg)
NUMERATOR:
Patients whose most recent blood pressure < 140/80 mmHg
DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
WITHOUT
Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Intensive control of blood pressure in patients with diabetes reduces diabetes complications, diabetesrelated deaths, strokes, heart failure, and microvascular complications.
CLINICAL RECOMMENDATION STATEMENTS:
Recommends that a blood pressure determination during the initial evaluation, including orthostatic
evaluation, be included in the initial and every interim physical examination. (AACE/ACE)
Blood pressure control must be a priority in the management of persons with hypertension and type 2
diabetes. (ACP)
Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood
pressure >130 mmHg or diastolic >80 mmHg should have blood pressure confirmed on a separate day.
Orthostatic measurement of blood pressure should be performed to assess for the presence of autonomic
neuropathy. (Level of Evidence: E) (ADA)
Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore
monitor and treat hypertension and dyslipidemias. (AGS)
Measurement of blood pressure in the standing position is indicated periodically, especially in those at risk
for postural hypotension. At least two measurements should be made and the average recorded. After BP
is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals. Comorbidities such as heart
failure, associated diseases such as diabetes, and the need for laboratory tests influence the frequency of
visits. (JNC)
All individuals should be evaluated during health encounters to determine whether they are at increased
risk of having or of developing chronic kidney disease. This evaluation of risk factors should include blood
pressure measurement. (NKF)
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 7 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-5: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level
in control (less than 100 mg/dl)
NUMERATOR:
Patients with most recent LDL-C < 100 mg/dL
DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
WITHOUT
Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Persons with diabetes are at increased risk for coronary heart disease (CHD). Lowering serum cholesterol
levels can reduce the risk for CHD events.
CLINICAL RECOMMENDATION STATEMENTS:
A fasting lipid profile should be obtained during an initial assessment, each follow-up assessment, and
annually as part of the cardiac-cerebrovascular-peripheral vascular module. (AACE/ACE)
A fasting lipid profile should be obtained as part of an initial assessment. Adult patients with diabetes
should be tested annually for lipid disorders with fasting serum cholesterol, triglycerides, HDL cholesterol,
and calculated LDL cholesterol measurements. If values fall in lower-risk levels, assessments may be
repeated every two years. (Level of Evidence: E) (ADA)
Patients who do not achieve lipid goals with lifestyle modifications require pharmacological therapy.
Lowering LDL cholesterol with a statin is associated with a reduction in cardiovascular events. (Level of
Evidence: A)
Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity
for all patients with known coronary artery disease and type 2 diabetes. (ACP)
Statins should be used for primary prevention against macrovascular complications in patients with type 2
diabetes and other cardiovascular risk factors.
Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least
moderate doses of a statin.
Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore
monitor and treat hypertension and dyslipidemias. (AGS)
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 8 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-6: Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for
Nephropathy in Diabetic Patients
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein
screening or medical attention for nephropathy during at least one office visit within 12 months
NUMERATOR:
Patients who have a nephropathy screening during at least one office visit within 12 months
DENOMINATOR:
All patients aged 18 through 75 years with the diagnosis of diabetes
WITHOUT
Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Nephropathy is a frequent complication of renal disease for both type 1 and type 2 diabetes and often ends
in end-stage renal disease (ESRD) (ADA, 2002). Of all people with diabetes, 10-21% have nephropathy
(ADA 2002).
CLINICAL RECOMENNDATION STATEMENTS:
American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE):
Recommends that the initial assessment should include a urinalysis, test for microalbuminuria and
creatinine clearance. The renal complication module should be performed annually and includes a test for
microalbuminuria and creatinine clearance (AACE/ACE, 2002).
American Diabetes Association (ADA): A test for the presence of microalbumin should be performed at
diagnosis in patients with type 2 diabetes. Microalbuminuria rarely occurs with short duration of type 1
diabetes; therefore, screening in individuals with type 1 diabetes should begin after 5 years' disease
duration (Level of Evidence: E). However, some evidence suggests that the prepubertal duration of
diabetes may be important in the development of microvascular complications; therefore, clinical judgment
should be exercised when individualizing these recommendations. Because of the difficulty in precise
dating of the onset of type 2 diabetes, such screening should begin at the time of diagnosis. After the initial
screening and in the absence of previously demonstrated microalbuminuria, a test for the presence of
microalbumin should be performed annually (ADA, 2004).
Screening for microalbuminuria can be performed by three methods:
1) measurement of the albumin-to-creatinine ratio in a random spot collection
2) 24-h collection with creatinine, allowing the simultaneous measurement of creatinine clearance
3) timed (e. g. 4-h or overnight) collection – the analysis of a spot sample for the albumin-tocreatinine ratio is strongly recommended.
The role of annual microalbuminuria assessment is less clear after diagnosis of microalbuminuria and
institution of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
GPRO v1.0

Page 9 of 38

11/10/09

and blood pressure control. Many experts recommend continued surveillance to assess both response to
therapy and progression of disease.
National Kidney Foundation (NKF): Individuals at increased risk, but found not to have chronic kidney
disease, should be advised to follow a program of risk factor reduction, if appropriate, and undergo repeat
periodic evaluation (NKF, 2003).
A comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries
(including the American Diabetes Association and Canadian Medical Association) found there was
agreement among the guidelines that ACE inhibitors should be recommended to patients with hypertension
and renal disease (Burgers, 2002).
The ADA also recommends that for the treatment of both micro- and macroalbuminuria, ARBs should be
used except during pregnancy (ADA, 2005).
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 10 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-7: Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
DESCRIPTION:
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated
eye exam
NUMERATOR:
Patients who had a dilated eye exam for diabetic retinal disease at least once within 12 months
DENOMINATOR:
All patients aged 18 through 75 years with a diagnosis of diabetes
WITHOUT
Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Examination of the eyes is the first step in the treatment of any existing or developing conditions related to
retinopathy and the first step in the prevention of blindness.
CLINICAL RECOMMENDATION STATEMENTS:
AACE/ACE, ADA, and American Academy of Ophthalmology (AAO): Recommend that a dilated eye
examination be performed on patients with diabetes during an initial assessment and at least annually
thereafter. (AACE/ACE, 2002; ADA, 2004; AAO, 1998; Hammond, 1998)
American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE):
Recommend that the annual eye examination be performed as part of a retinal module. The module
includes test of visual acuity (Snellen chart); funduscopic examination and intraocular pressure (IOP) test.
The AACE/ACE recommends that diabetic patients should be under the care of an ophthalmologist
experienced in the management of diabetic retinopathy. AACE/ACE further believes that a dilated eye
exam should only be done by an MD/DO. (AACE/ACE, 2002)
American Diabetes Association (ADA): Patients with type 1 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist or optometrist within 3-5 years after the onset of
diabetes. In general evaluation for diabetic eye disease is not necessary before 10 years of age. However,
some evidence suggests that the prepubertal duration of diabetes may be important in the development of
microvascular complications; therefore, clinical judgment should be used when applying these
recommendations to individual patients. (Level of Evidence: B)
Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an
ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the presence of
diabetic retinopathy and is aware of its management. Examination will be required more frequently if
retinopathy is progressing. This follow-up interval is recommended recognizing that there are limited data
addressing this issue. (Level of Evidence: B)

GPRO v1.0

Page 11 of 38

11/10/09

Seven standard field stereoscopic 30° fundus photography is an accepted method for examining diabetic
retinopathy. (ADA, 2004)
American Academy of Ophthalmology (AAO): Recommends that diabetic patients should be under the care
of an ophthalmologist experienced in the management of diabetic retinopathy. Ophthalmologists with
specialized knowledge and experience in managing the disease are best able to detect and treat serious
disease. Stereoscopic photographs offer an advantage over nonstereoscopic photographs, and the
traditional “seven stereo fields” provide the most complete coverage. (AAO, 1998; Hammond, 1996)
American Geriatrics Society (AGS): Dilated eye examinations should be performed every two years at a
minimum, and more often if there are additional risk factors for diabetic eye disease or evidence of agerelated eye disease. (CHF/AGS, 2003)
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 12 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-8: Diabetes Mellitus: Foot Exam
DESCRIPTION:
The percentage of patients aged 18 through 75 years with diabetes who had a foot examination
NUMERATOR:
Patients who received a foot exam (visual inspection, sensory exam with monofilament, or pulse exam)
DENOMINATOR:
Patients aged 18 through 75 years with a diagnosis of diabetes
WITHOUT
Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusion only applied if
patient did not receive a foot examination)
•

Documentation of medical reason for not receiving foot exam (i.e. patient with bilateral foot/leg
amputation)

RATIONALE:
The most common consequences of diabetic neuropathy are amputation and foot ulceration (ADA, 2006).
In developed countries, up to five percent of diabetic patients have foot ulcers (IDF, 2005). One in every six
diabetics will have an ulcer during their lifetime (IDF, 2005). Amputation and foot ulceration are also major
causes of morbidity and mortality. One half to 80% of all amputations are diabetes-related (Mayfield, 1998;
Reiber, 1995; ADA, 2001; Unwin, 2000). The risk of ulcers or amputations increases the longer someone
has diabetes. Early recognition and management of risk factors can prevent or delay adverse outcomes
(ADA, 2006).
CLINICAL RECOMMENDATION STATEMENTS:
American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) and
American Diabetes Association (ADA) recommend that a foot examination (visual inspection, sensory
exam, and pulse exam) be performed during an initial assessment.
AACE/ACE (2002) recommends that a foot examination be a part of every follow-up assessment visit,
which should occur quarterly.
ADA (2004) recommends that all individuals with diabetes should receive an annual foot examination to
identify high-risk foot conditions. This examination should include assessment of protective sensation, foot
structure and biomechanics, vascular status, and skin integrity.
The ADA (2004) recommends that people with one or more high-risk foot conditions should be evaluated
more frequently for the development of additional risk factors. People with neuropathy should have a visual
inspection of their feet at every contact with a health care professional.
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 13 of 38

11/10/09

Diabetes Mellitus Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO DM-9: Diabetes Mellitus: Lipid Profile
DESCRIPTION:
Percentage of patients aged 18 through 75 years of age with diabetes who received at least one lipid profile
within 12 months
NUMERATOR:
Patients who received at least one lipid profile (or ALL component tests)
DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
WITHOUT
Diagnosis of polycystic ovaries, gestational diabetes or steroid induced diabetes
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Studies indicate that diabetes is associated with a higher risk of coronary heart disease (CHD) (Kannel,
1979 and Wingard, 1995). CHD is the most common cause of death among adults with diabetes. The
increased risk of coronary heart disease in people with Type 2 diabetes (95% of all diabetics) has been
linked with dyslipidemia, hypertension, obesity, and smoking (Pyorala, 1987 and Bierman, 1992). The
relative risk in diabetic women is greater than in diabetic men, but the absolute risk is greater in men than in
women. Diabetic patients are more likely to have small, dense form of LDL (pattern B), which is more
atherogenic than normal LDL. Because of this, diabetics may be at a greater risk of CHD at LDL levels
considered to be within the normal range for non-diabetics.
In the 4S, CARE, and Post-CABG trials, reductions in LDL levels led to decreases in coronary events
(Bloomgarden, 1997). The 4S showed reductions of 55% in the number of events in diabetics compared to
32% in non-diabetics. In the CARE study, both diabetic and non-diabetic subjects showed a 25% reduction
in coronary events. The combination of data from these two studies produces a near linear relationship
between cholesterol and the risk of coronary events. The Post-CABG study also showed benefits from
reducing cholesterol from 130 to 95 mg/dL (Bloomgarden, 1997).
CLINICAL RECOMMENDATION STATEMENTS:
The American Diabetes Association (ADA) recommends that a fasting lipid profile be obtained as part of an
initial assessment. Adult patients with diabetes should be tested annually for lipid disorders with fasting
serum cholesterol, triglycerides, HDL cholesterol, and calculated LDL cholesterol measurements. If values
fall in lower-risk levels, assessments may be repeated every two years. (Level of evidence: E) (ADA, 2004).
Patients who do not achieve lipid goals with lifestyle modifications require pharmacological therapy.
Lowering LDL cholesterol with a statin is associated with a reduction in cardiovascular events. (Level of
evidence: A) (ADA, 2004).
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 14 of 38

11/10/09

Heart Failure Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
▲GPRO HF-1: Heart Failure: Left Ventricular Function (LVF) Assessment
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who have quantitative or
qualitative results of LVF assessment recorded
NUMERATOR:
Patients with quantitative or qualitative results of LVF assessment recorded
DENOMINATOR:
All patients aged ≥ 18 years and older with a diagnosis of heart failure
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Evaluation of LVEF in patients with heart failure provides important information that is required to
appropriately direct treatment. Several pharmacologic therapies have demonstrated efficacy in slowing
disease progression and improving outcomes in patients with left ventricular systolic dysfunction. LVEF
assessed during the initial evaluation of patients presenting with heart failure can be considered valid
unless the patient has demonstrated a major change in clinical status, experienced or recovered from a
clinical event, or received therapy that might have a significant effect on cardiac function. A comprehensive
2-dimensional echocardiogram with Doppler flow studies has been identified as the single most useful
diagnostic test in the evaluation of patients with heart failure.
CLINICAL RECOMMENDATION STATEMENTS:
Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients
presenting with HF to assess LVEF, LV size, wall thickness, and valve function. Radionuclide
ventriculography can be performed to assess LVEF and volumes. adionuclide ventriculography can be
performed to assess LVEF and volumes. (Class I, Level of Evidence: C) (ACC/AHA, 2009)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 15 of 38

11/10/09

Heart Failure Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO HF-2: Heart Failure: Left Ventricular Function (LVF) Testing
DESCRIPTION:
Percentage of patients with LVF testing during the current year for patients hospitalized with a principal
diagnosis of heart failure (HF) during the measurement period
NUMERATOR:
Patients with LVF testing during the measurement period
DENOMINATOR:
All patients with a principal diagnosis of HF ≥ 18 years of age hospitalized during the measurement period
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient did not receive LVF testing during the measurement period if patient was hospitalized for HF)
Documentation of medical reason(s) for not obtaining LVF testing during the measurement period if
patient was hospitalized for HF
• Documentation of patient reason(s) for not obtaining LVF testing during the measurement if patient
was hospitalized for HF
RATIONALE:
Appropriate selection of medications to reduce morbidity and mortality in heart failure requires the
identification of patients with impaired left ventricular systolic function. National guidelines advocate the
evaluation of left ventricular systolic function as the single most important diagnostic test in the
management of all patients with heart failure (Hunt, 2005). Despite these recommendations, left ventricular
systolic function is not evaluated in a substantial proportion of eligible older patients hospitalized with heart
failure (Jencks, 2000).
•

CLINICAL RECOMMENDATION STATEMENTS:
In patients with HF, an assessment of left ventricular systolic function with 2-dimensional
echocardiography or radionuclide ventriculography is recommended. (Class 1 Recommendation, Level-C
Evidence) (ACC/AHA)
In patients with a change in clinical status or clinical event/treatment with significant effect on
cardiac function, repeat measurement of ejection fraction is recommended. (Level-C Evidence) (ACC/AHA)
MEASURE DEVELOPER: CMS-QIP

GPRO v1.0

Page 16 of 38

11/10/09

Heart Failure Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO HF-3: Heart Failure: Weight Measurement
DESCRIPTION:
Percentage of patient visits for patients aged 18 years and older with a diagnosis of heart failure with
weight measurement recorded
NUMERATOR:
Patient visits with weight measurement recorded
DENOMINATOR:
All patient visits for patients with heart failure (HF) ≥ 18 years of age
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusion only applied if
patient did not receive weight measurement)
•

Documentation of medical reason(s) for not receiving weight measurement

RATIONALE:
Weight and fluid monitoring is essential for heart failure patients. Significant changes in weight are often
indications that the patient is in fluid overload. A thorough physical examination is recommended to identify
cardiac and non-cardiac disorders that may accelerate the progression of HF. A careful history of heart
failure patients focused on volume status plays a pivotal role in determining the need for or adjustment of
diuretic therapy and in detecting sodium excesses or deficiencies that may limit efficacy and decrease the
tolerability of drugs used to treat HF. Short-term changes in fluid status are best assessed by measuring
changes in body weight. However, changes in body weight may be less reliable during long periods of
follow-up, because many patients lose skeletal muscle mass and body fat as the disease progresses due to
the development of cardiac cachexia. (ACC/AHA)
CLINICAL RECOMMENDATION STATEMENTS:
A thorough physical examination is recommended to identify cardiac and noncardiac disorders that may
accelerate the progression of HF. This physical examination may include initial and ongoing assessments
of the patient’s volume status. (Class 1 Recommendation Level-C Evidence)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 17 of 38

11/10/09

Heart Failure Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
▲GPRO HF-5: Heart Failure: Patient Education
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who were provided with
patient education on disease management and health behavior changes during one or more visit(s) within
12 months
NUMERATOR:
Patients who were provided with patient education on disease management and health behavior changes*
during one or more visits within 12 months
Definition: *Patient education should include one or more of the following: Weight monitoring; Diet
(sodium restriction); Symptom management; Physical activity; Smoking cessation; Medication
instruction; Minimizing or avoiding use of NSAIDs; Referral for visiting nurse, or specific educational or
management programs; Prognosis/end-of-life issues
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of heart failure who were seen at least twice for any
visits within 12 months
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Patient education is an essential nonpharmacological component to heart failure care. It may reduce the
likelihood of noncompliance with recommended therapeutic strategies and lead to early identification of
worsening clinical status and subsequent treatment. Heart failure disease management programs, in which
patient education is an integral component, have been shown to be effective in improving self-care and
reducing readmissions.
CLINICAL RECOMMENDATION STATEMENTS:
Patients at high risk for developing HF should be counseled to avoid behaviors that may increase the risk of
HF (e.g., smoking, excessive alcohol consumption, and illicit drug use). (Class I, Level of Evidence: C)
(ACC/AHA, 2009).
It is recommended that patients with HF and their family members or caregivers receive individualized
education and counseling that emphasizes self-care. (Strength of Evidence=B) (HFSA, 2006).

GPRO v1.0

Page 18 of 38

11/10/09

Essential Elements of Patient Education With Associated Skills and Target Behaviors (HFSA, 2006).
Elements of Education

Skill Building and Critical Target Behaviors

Definition of HF (linking disease,
Discuss basic HF information, cause of patient's HF, and how
symptoms, and treatment) and cause symptoms are related
of patient's HF
Recognition of escalating symptoms • Monitor for specific signs and symptoms (e.g., increasing fatigue
and selection of appropriate
doing usual activities, increasing shortness of breath with
treatments in response to particular
activity, shortness of breath at rest, need to sleep with
symptoms
increasing number of pillows, waking at night with shortness of
breath, edema)
• Perform and document daily weights
• Develop action plan for how and when to notify the provider
• Institute flexible diuretic regimen, if appropriate
Indications and use of each
medication

• Reiterate medication dosing schedule, basic reason for specific
medications, and what to do if a dose is missed

Importance of risk factor modification • Smoking cessation
• State blood pressure goal and know own blood pressure from
recent measurement
• Maintain normal HgA1c, if diabetic
• Maintain specific body weight
Specific diet recommendations:
individualized low-sodium diet;
recommendation for alcohol intake

Specific activity/exercise
recommendations

• Reiterate recommended sodium intake
• Demonstrate how to read a food label to check sodium amount
per serving and sort foods into high- and low-sodium groups
• Reiterate limits for alcohol consumption or need for abstinence if
history of alcohol abuse
• Reiterate goals for exercise and plan for achieving
• Reiterate ways to increase activity level

Importance of treatment adherence • Plan and use a medication system that promotes routine
and behavioral strategies to promote
adherence
• Plan for refills
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 19 of 38

11/10/09

Heart Failure Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO HF-6: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD
(LVEF < 40%) and who were prescribed beta-blocker therapy
NUMERATOR:
Patients who were prescribed beta-blocker therapy
DENOMINATOR:
Patients aged 18 years and older with a diagnosis of heart failure with left ventricular ejection fraction
(LVEF) < 40% or with moderately or severely depressed left ventricular systolic function
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient was not prescribed beta-blocker therapy)
•
•
•

Documentation of medical reason(s) for not prescribing beta-blocker therapy
Documentation of patient reason(s) for not prescribing beta-blocker therapy
Documentation of system reason(s) for not prescribing beta-blocker therapy

RATIONALE:
Beta-blockers are recommended for all patients with symptoms of heart failure and left ventricular systolic
dysfunction, unless contraindicated. Treatment with beta-blockers has been shown to provide multiple
benefits to the patient, including reducing the symptoms of heart failure, improving the clinical status of
patients, and decreasing the risk of mortality and hospitalizations.
CLINICAL RECOMMENDATION STATEMENTS:
Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release
metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and
reduced LVEF, unless contraindicated. (Class I Recommendation, Level of Evidence: A) (ACC/AHA)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 20 of 38

11/10/09

Heart Failure Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO HF-7: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF < 40%)
who were prescribed ACE inhibitor or ARB therapy
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
DENOMINATOR:
Heart failure patients aged 18 years and older with LVEF < 40% or with moderately or severely depressed
left ventricular systolic function
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient was not prescribed ACE or ARB therapy)
•
•
•

Documentation of medical reason(s) for not prescribing ACE or ARB therapy
Documentation of patient reason(s) for not prescribing ACE or ARB therapy
Documentation of system reason(s) for not prescribing ACE or ARB therapy

RATIONALE:
In the absence of contraindications, ACE Inhibitors or ARBs are recommended for all patients with
symptoms of heart failure and reduced left ventricular systolic function, as measured by left ventricular
ejection fraction (LVEF). Both drugs have been shown to decrease mortality and hospitalizations.
CLINICAL RECOMMENDATION STATEMENTS:
Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior symptoms
of HF and reduced LVEF, unless contraindicated. (Class I Recommendation, Level of Evidence: A)
(ACC/AHA)
Angiotensin II receptor blockers approved for the treatment of HF are recommended in patients with current
or prior symptoms of HF and reduced LVEF who are ACEI-intolerant. (Class I Recommendation, Level of
Evidence: A) (ACC/AHA)
Angiotensin II receptor blockers are reasonable to use as alternatives to ACEIs as first-line therapy for
patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other
indications. (Class IIa Recommendation, Level of Evidence: A) (ACC/AHA)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 21 of 38

11/10/09

Heart Failure Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
▲GPRO HF-8: Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation
DESCRIPTION:
Percentage of all patients aged 18 and older with a diagnosis of heart failure and paroxysmal or chronic
atrial fibrillation who were prescribed warfarin therapy
NUMERATOR:
Patients who were prescribed warfarin therapy
DENOMINATOR:
All heart failure patients aged 18 years and older with paroxysmal or chronic atrial fibrillation
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient was not prescribed warfarin therapy)
• Documentation of medical reason(s) for not prescribing warfarin therapy
• Documentation of patient reason(s) for not prescribing warfarin therapy
• Documentation of system reason(s) for not prescribing warfarin therapy
RATIONALE:
Adjusted-dose warfarin is highly efficacious in preventing thromboembolism in patients with AF and should
be prescribed for all patients with AF and heart failure except those with contraindications to
anticoagulation.
CLINICAL RECOMMENDATION STATEMENTS:
Physicians should prescribe anticoagulants in patients with HF who have paroxysmal or persistent atrial
fibrillation or a previous thromboembolic event. (Class I, Level of Evidence: A)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 22 of 38

11/10/09

Coronary Artery Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO CAD-1: Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients
with CAD
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral
antiplatelet therapy
NUMERATOR:
Patients who were prescribed oral antiplatelet therapy
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of coronary artery disease
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient was not prescribed antiplatelet therapy)
•
•
•

Documentation of medical reason(s) for not prescribing oral antiplatelet therapy
Documentation of patient reason(s) for not prescribing oral antiplatelet therapy
Documentation of system reason(s) for not prescribing oral antiplatelet therapy

RATIONALE:
Oral antiplatelet therapy, preferably aspirin unless contraindicated, is recommended for all patients with
coronary artery disease. By limiting the ability of clots to form in the arteries, antiplatelet agents have
proven benefits in reducing the risk of non-fatal myocardial infarction, non-fatal stroke and death.
CLINICAL RECOMMENDATION STATEMENTS:
Chronic Stable Angina: Class I – Aspirin 75-325 mg daily should be used routinely in all patients with acute
and chronic ischemic heart disease with or without manifest symptoms in the absence of contraindications.
Class IIa – Clopidogrel is recommended when aspirin is absolutely contraindicated. Class III –
Dipyridamole. Because even the usual oral doses of dipyridamole can enhance exercise-induced
myocardial ischemia in patients with stable angina, it should not be used as an antiplatelet agent.
(ACC/AHA/ACP-ASIM)
Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Class I – Aspirin 75 to 325 mg/dl in
the absence of contraindications. Class I – Clopidogrel 75 qd for patients with a contraindication to ASA.
(ACC/AHA)
Acute Myocardial Infarction (AMI): Class I – A dose of aspirin, 160 to 325 mg, should be given on day one
of AMI and continued indefinitely on a daily basis thereafter. Trials suggest long-term use of aspirin in the
postinfarction patient in a dose as low as 75 mg per day can be effective, with the likelihood that side
effects can be reduced. Class IIb – Other antiplatelet agents such as dipyridamole, ticlopidine or clopidogrel
may be substituted if true aspirin allergy is present or if the patient is unresponsive to aspirin. (ACC/AHA)
Coronary Artery Bypass Graft Surgery: Aspirin is the drug of choice for prophylaxis against early
saphenous graft thrombotic closure and should be considered a standard of care for the first postoperative
year. In general, patients are continued on aspirin indefinitely, given its benefit in the secondary prevention
GPRO v1.0

Page 23 of 38

11/10/09

of AMI. Ticlopidine is efficacious but offers no advantage over aspirin except as an alternative in the truly
aspirin-allergic patient. Clopidogrel offers the potential of fewer side effects compared with ticlopidine as an
alternative to aspirin for platelet inhibition. Indobufen appears to be as effective as aspirin for saphenous
graft patency over the first postoperative year but with fewer gastrointestinal side effects. Current evidence
suggests that dipyridamole adds nothing to the aspirin effect for saphenous graft patency. (ACC/AHA)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 24 of 38

11/10/09

Coronary Artery Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO CAD-2: Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipidlowering therapy (based on current ACC/AHA guidelines)
NUMERATOR:
Patients who were prescribed lipid-lowering therapy
DENOMINATOR:
All patients aged 18 years and older with CAD
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient was not prescribed lipid-lowering therapy)
•
•
•

Documentation of medical reason(s) for not prescribing lipid-lowering therapy
Documentation of patient reason(s) for not prescribing lipid-lowering therapy
Documentation of system reason(s) for not prescribing lipid-lowering therapy

RATIONALE:
Studies have demonstrated that active treatment with lipid-lowering therapy is associated with stabilization
and regression of coronary atherosclerotic plaques and decreased incidence of clinical events. Recent
clinical trials have further documented that LDL-lowering agents can decrease the risk of adverse ischemic
events in patients with established CAD.
CLINICAL RECOMMENDATION STATEMENTS:
The LDL-C treatment goal is <100 mg/dl. Persons with established coronary heart disease (CHD) who have
a baseline LDL-C 130 mg/dl should be started on a cholesterol-lowering drug simultaneously with
therapeutic lifestyle changes and control of nonlipid risk factors (National Cholesterol Education Program
(NCEP).
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 25 of 38

11/10/09

Coronary Artery Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO CAD-3: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior
Myocardial Infarction (MI)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed
beta-blocker therapy
NUMERATOR:
Patients who were prescribed beta-blocker therapy
DENOMINATOR:
Patients aged 18 years and older with a diagnosis of coronary artery disease who also have prior myocardial
infarction (MI) at any time
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient was not prescribed beta-blocker therapy)
•
•
•

Documentation of medical reason(s) for not prescribing beta-blocker therapy
Documentation of patient reason(s) for not prescribing beta-blocker therapy
Documentation of system reason(s) for not prescribing beta-blocker therapy

RATIONALE:
In the absence of contraindications, beta-blocker therapy has been shown to reduce the risk of a recurrent MI
and decrease mortality for those patients with a prior MI.
CLINICAL RECOMMENDATION STATEMENTS:
Chronic Stable Angina: Class I – Beta-blockers as initial therapy in the absence of contraindications in patients
with prior MI. Class I – Beta-blockers as initial therapy in the absence of contraindications in patients without
prior MI. (ACC/AHA/ACP-ASIM)
Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Class I – Drugs required in the hospital
to control ischemia should be continued after hospital discharge in patients who do not undergo coronary
revascularization, patients with unsuccessful revascularization, or patients with recurrent symptoms after
revascularization. Upward or downward titration of the doses may be required. Class I – Beta-blockers in the
absence of contraindications. (ACC/AHA)
Acute Myocardial Infarction: Class I – All but low-risk patients without a clear contraindication to ß-adrenoceptor
blocker therapy. Treatment should begin within a few days of the event (if not initiated acutely) and continue
indefinitely. Class IIa – Low-risk patients without a clear contraindication to ß-adrenoceptor blocker therapy.
Survivors of non-ST-elevation MI. Class IIb – Patients with moderate or severe LV failure or other relative
contraindications to ß-adrenoceptor blocker therapy, provided they can be monitored closely. (ACC/AHA)
Although no study has determined if long-term ß-adrenoceptor blocker therapy should be administered to
survivors of MI who subsequently have satisfactorily undergone revascularization, there is no reason to believe
that these agents act differently in coronary patients who have undergone revascularization. (ACC/AHA)
MEASURE DEVELOPER: AMA-PCPI
GPRO v1.0

Page 26 of 38

11/10/09

Coronary Artery Disease Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO CAD-7: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor
or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left
Ventricular Systolic Dysfunction (LVSD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who also have diabetes mellitus
and/or LVSD (LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of CAD who also have a diagnosis of LVSD (LVEF
< 40%)
OR
All patients aged 18 years and older with a diagnosis of CAD who also have a diagnosis of diabetes
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient was not prescribed ACE or ARB therapy)
•
•
•

Documentation of medical reason(s) for not prescribing ACE or ARB therapy
Documentation of patient reason(s) for not prescribing ACE or ARB therapy
Documentation of system reason(s) for not prescribing ACE or ARB therapy

RATIONALE:
In the absence of contraindications, ACE inhibitors or ARBs are recommended for patients with coronary
artery disease; especially those with diabetes and /or left ventricular systolic dysfunction. ACE inhibitors
and ARBs have shown to decrease morbidity and mortality, including significant reductions in the
occurrence of myocardial infarction, stroke, and diabetic complications.
CLINICAL RECOMMENDATION STATEMENTS:
ACE inhibitor use is recommended in all patients with CAD who also have diabetes and/or left ventricular
systolic dysfunction. (ACC/AHA)
ACE inhibitor use is also recommended in patients with CAD or other vascular disease. (ACC/AHA)
In ST elevation myocardial infarction (STEMI) patients who tolerate ACE inhibitors, an angiotensin receptor
blocker (ARB) can be useful as an alternative to ACE inhibitors in the long-term management of STEMI
patients, provided there are either clinical or radiological signs of heart failure or LVEF less than 0.40.
(ACC/AHA)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 27 of 38

11/10/09

Hypertension Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO HTN-1: Hypertension (HTN): Blood Pressure Measurement
DESCRIPTION:
Percentage of patient visits with blood pressure measurement recorded among all patient visits for patients
aged ≥ 18 years with diagnosed hypertension
NUMERATOR:
Patient visits with blood pressure measurement recorded
DENOMINATOR:
All patient visits for patients aged ≥ 18 years with hypertension
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Data from the National Health and Nutrition Examination Survey (NHANES) have indicated that 50 million
or more Americans have high blood pressure (BP) warranting some form of treatment. Worldwide
prevalence estimates for hypertension may be as much as 1 billion individuals, and approximately 7.1
million deaths per year may be attributable to hypertension. The World Health Organization reports that
suboptimal BP (>115 mm Hg SBP) is responsible for 62% of cerebrovascular disease and 49% of ischemic
heart disease, with little variation by sex. In addition, suboptimal blood pressure is the number one
attributable risk for death throughout the world. (JNC 7: Complete Report)
Hypertension is an increasingly important medical and public health issue. The prevalence of hypertension
increases with advancing age to the point where more than half of people aged 60 to 69 years old and
approximately three-fourths of those aged 70 years and older are affected. The age-related rise in SBP is
primarily responsible for an increase in both incidence and prevalence of hypertension with increasing age.
(JNC 7: Complete Report)
CLINICAL RECOMMENDATION STATEMENTS:
Obtaining proper blood pressure (BP) measurements at each health care encounter is recommended for
hypertension detection. Repeated BP measurements (≥ 2 per patient visit) will determine if initial elevations
persist and require prompt attention (Level 1 Recommendation, Level-C Evidence)
Classification of adult BP (including stages 1-3 of hypertension) is useful for making treatment decisions
and is based on the average of ≥ 2 readings taken at each of 2 or more visits after an initial screening.
Hypertension is defined as systolic BP of 140 mm Hg or greater, diastolic BP of 90 mm Hg or greater or
taking antihypertensive medication.
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 28 of 38

11/10/09

Hypertension Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO HTN-2: Hypertension (HTN): Blood Pressure Control
DESCRIPTION:
Percentage of patients with last BP < 140/90 mmHg
NUMERATOR:
Patients with last systolic blood pressure measurement < 140 mmHg and a diastolic blood pressure
< 90 mmHg
DENOMINATOR:
All patients with HTN ≥ 18 years of age who had a blood pressure measurement during the last office visit
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION (exclusion only applied if last
blood pressure ≥ 140/90)
•

Documentation of medical reason(s) for not recording a blood pressure measurement (diagnosis
for ESRD and pregnancy are the only acceptable exclusions)

RATIONALE:
Hypertension is a very significant health issue in the United States. Fifty million or more Americans have
high blood pressure that warrants treatment, according to the NHANES survey (JNC-7, 2003). The
USPSTF recommends that clinicians screen adults aged 18 and older for high blood pressure (USPSTF,
2007).
The most frequent and serious complications of uncontrolled hypertension include coronary heart disease,
congestive heart failure, stroke, ruptured aortic aneurysm, renal disease, and retinopathy. The increased
risks of hypertension are present in individuals ranging from 40 to 89 years of age. For every 20 mmHg
systolic or 10 mmHg diastolic increase in BP, there is a doubling of mortality from both IHD and stroke
(JNC-7, 2003).
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in
adults age 18 years and older.
JNC-7: Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD
complications.
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 29 of 38

11/10/09

Hypertension Module
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO HTN-3: Hypertension (HTN): Plan of Care
DESCRIPTION:
Percentage of patient visits for patients aged 18 years and older with a diagnosis of HTN with either systolic
blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg with documented plan of care for
hypertension
NUMERATOR:
Patient visits with a documented plan of care for hypertension
Definition:
Plan of Care - Plan of Care should include one or more of the following: Recheck blood pressure
at specified future date, initiate or alter pharmacologic therapy, initiate or alter non-pharmacologic
therapy
DENOMINATOR:
All visits for patients aged 18 years and older with a diagnosis of HTN with either systolic blood pressure ≥
140 mmHg or diastolic blood pressure ≥ 90 mmHg
THERE ARE NO PERFORMANCE EXCLUSIONS FOR THIS MEASURE
RATIONALE:
Effective management of blood pressure in patients with hypertension can help prevent cardiovascular
events, including myocardial infarction, stroke, and the development of heart failure.
Reference: National Institutes of Health, National Heart, Lung, and Blood Institute, National High Blood
Pressure Education Program. The seventh report of the Joint National Committee on Prevention, Detection,
and Treatment of High Blood Pressure. NIH Publication No. 04-5230. September 2004.
CLINICAL RECOMMENDATION STATEMENTS:
Nonpharmacological therapy is recommended and may include weight reduction, decreased sodium
and alcohol intake and exercise.
Selection of pharmacological therapy should be based on the presence of comorbidities, severity of
hypertension, presence of risk factors, and target organ damage.
Frequent follow-up visits are recommended.
After initiation of the initial therapy, a follow-up visit is recommended within 1-2 months, to assess
hypertension control, patient compliance to treatment, and adverse effects. (Level 1Recommendation,
Level-C Evidence)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 30 of 38

11/10/09

Preventive Care Measure
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO Prev-5: Preventive Care and Screening: Screening Mammography
DESCRIPTION:
Percentage of women aged 40 through 69 years who had a mammogram to screen for breast cancer within
24 months
NUMERATOR:
Patients who had a mammogram at least once within 24 months
DENOMINATOR:
All female patients aged 40 through 69 years
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusion only applied if
mammogram not performed within 24 months)
•

Documentation of medical reason(s) for not performing a mammogram within 24 months (i.e.,
women who had a bilateral mastectomy or two unilateral mastectomies)

RATIONALE:
Breast cancer ranks as the second leading cause of death in women. For women 40 to 49 years of age
mammography can reduce mortality by 17 percent. (AMA, 2003)
CLINICAL RECOMMENDATION STATEMENT:
The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or
without clinical breast examination (CBE), every 1-2 years for women aged 40 and older. (USPSTF, 2002)
The USPSTF found fair evidence that mammography screening every 12-33 months significantly
reduces mortality from breast cancer. Evidence is strongest for women aged 50-69, the age group
generally included in screening trials. (USPSTF, 2002)
• For women aged 40-49, the evidence that screening mammography reduces mortality from breast
cancer is weaker, and the absolute benefit of mammography is smaller, than it is for older women.
Most, but not all, studies indicate a mortality benefit for women undergoing mammography at ages
40-49, but the delay in observed benefit in women younger than 50 makes it difficult to determine
the incremental benefit of beginning screening at age 40 rather than at age 50. (USPSTF, 2002)
• The absolute benefit is smaller because the incidence of breast cancer is lower among women in
their 40s than it is among older women. (USPSTF, 2002)
The USPSTF concluded that the evidence is also generalizable to women aged 70 and older (who face a
higher absolute risk for breast cancer) if their life expectancy is not compromised by comorbid disease. The
absolute probability of benefits of regular mammography increases along a continuum with age, whereas
the likelihood of harms from screening (false-positive results and unnecessary anxiety, biopsies, and cost)
diminishes from ages 40-70. The balance of benefits and potential harms, therefore, grows more favorable
as women age. The precise age at which the potential benefits of mammography justify the possible harms
is a subjective choice. (USPSTF, 2002)
•

GPRO v1.0

Page 31 of 38

11/10/09

American Cancer Society: Yearly Mammograms starting at age 40 and continuing for as long as a woman
is in good health. (Smith, 2003)
American College of Preventative Medicine (ACPM):
Low-risk women (no family history, familial cancer syndrome, or prior cancer). There is inadequate
evidence for or against mammography screening of women under the age of 50. Women between
the ages of 50-69 should have annual or biennial, high-quality, two-view mammography. Women
aged 70 and older should continue undergoing mammography screening provided their health
status permits breast cancer treatment. (Ferrini, 1996)
• Higher-risk women: Women with a family history of pre-menopausal breast cancer in a first-degree
relative or those with a history of breast and/or gynecologic cancer may warrant more aggressive
screening. Women with these histories often begin screening at an earlier age, although there is no
direct evidence of effectiveness to support this practice. The future availability of genetic screening
may define new recommendations for screening high-risk women. (Ferrini, 1996)
The American Medical Association (AMA), the American College of Obstetricians and Gynecologists
(ACOG), and the American College of Radiology (ACR), all support screening with mammography and
CBE beginning at age 40. (AMA, 1999; ACOG, 2000; Feig, 1998)
•

The Canadian Task Force on Preventive Health Care (CTFPHC), and the American Academy of Family
Physicians (AAFP), recommends beginning mammography for average-risk women at age 50. (Canadian
Task Force on the Periodic Health Examination, 1999; AAFP, 2005)
AAFP recommends that mammography in high-risk women begin at age 40, and recommends that all
women aged 40-49 be counseled about the risks and benefits of mammography before making decisions
about screening. (AAFP, 2005)
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 32 of 38

11/10/09

Preventive Care Measure
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO Prev-6: Preventive Care and Screening: Colorectal Cancer Screening
DESCRIPTION:
Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening
NUMERATOR:
Patients who had at least one or more screenings for colorectal cancer during or prior to the reporting
period
DENOMINATOR:
All patients aged 50 through 75 years
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusion only applied if
colorectal cancer screening not performed)
•

Documentation of medical reason(s) for not performing colorectal cancer screening

RATIONALE:
Colorectal cancer is the second leading cause of cancer-related death in the United States. There were an
estimated 135,400 new cases and 56,700 deaths from the disease during 2001. Colorectal cancer (CRC)
places significant economic burden on the society as well with treatment costs over $6.5 billion per year
and, among malignancies, is second only to breast cancer at $6.6 billion per year (Schrag, 1999).
Colorectal cancer screening can detect pre-malignant polyps and early stage cancers. Unlike other
screening tests that only detect disease, colorectal cancer screening can guide removal of pre-malignant
polyps, which in theory can prevent development of colon cancer. Three tests are currently recommended
for screening: fecal occult blood testing (FOBT), flexible sigmoidoscopy, and colonoscopy.
CLINICAL RECOMMENDATION STATEMENTS:
During the past decade, compelling evidence has accumulated that systematic screening of the population
can reduce mortality from colorectal cancer. Three randomized, controlled trials demonstrated that fecal
occult blood testing (FOBT), followed by complete diagnostic evaluation of the colon for a positive test,
reduced colorectal cancer mortality (Hardcastle et al., 1996; Mandel & Oken, 1998; Kronborg; 1996). One
of these randomized trials (Mandel et al., 1993) compared annual FOBT screening to biennial FOBT
screening, and found that annual screening resulted in greater reduction in colorectal cancer mortality. Two
case control studies have provided evidence that sigmoidoscopy reduces colorectal cancer mortality (Selby
et al., 1992; Newcomb et al., 1992). Approximately 75% of all colorectal cancers arise sporadically
(Stephenson et al., 1991). Part of the effectiveness of colorectal cancer screening is mediated by the
removal of the precursor lesion—an adenomatous polyp (Vogtelstein et al., 1988). It has been shown that
removal of polyps in a population can reduce the incidence of colorectal cancer (Winawer, 1993). Colorectal
screening may also lower mortality by allowing detection of cancer at earlier stages, when treatment is
more effective (Kavanaugh, 1998).
The U.S. Preventive Services Task Force (USPSTF) published an updated recommendation for colorectal
cancer screening in 2008. The guideline strongly recommends that clinicians screen men and women ages
50 to 75 years of age for colorectal cancer (A recommendation). The USPSTF recommends not screening
GPRO v1.0

Page 33 of 38

11/10/09

adults age 85 and older due to possible harms (D recommendation). The appropriateness of colorectal
cancer screening for men and women aged 76 to 85 years old should be considered on an individual basis
(C recommendation). While the approved modalities vary for patients 50 to 75 years old, the USPSTF
found there is insufficient evidence to assess the benefits and harms of computed tomographic
colonography (CTC) and fecal DNA (fDNA) testing as screening modalities for colorectal cancer for all
patients (I statement).
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 34 of 38

11/10/09

Preventive Care Measure
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO Prev-7: Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years
Old
DESCRIPTION:
Percentage of patients aged 50 years and older who received an influenza immunization during the flu
season (September through February)
NUMERATOR:
Patients who received an influenza immunization during the flu season (September through February)
DENOMINATOR:
All patients aged 50 years and older
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusions only applied if
patient did not receive influenza immunization during the flu season)
•
•
•

Documentation of medical reason(s) for not receiving an influenza immunization during the flu
season
Documentation of patient reason(s) for not receiving an influenza immunization during the flu
season
Documentation of system reason(s) for not receiving an influenza immunization during the flu
season

RATIONALE:
Influenza vaccination has shown to decrease hospitalizations for influenza, especially for those with risk
factors, however annual influenza vaccination rates remain low.
CLINICAL RECOMMENDATION STATEMENTS:
Annual influenza immunization is recommended for all groups who are at increased risk for complications
from influenza including persons aged ≥ 50 years. (CDC, USPSTF)
MEASURE DEVELOPER: AMA-PCPI

GPRO v1.0

Page 35 of 38

11/10/09

Preventive Care Measure
2010 Physician Quality Reporting Initiative
Narrative Measure Specification for GPRO USE ONLY
GPRO Prev-8: Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and
Older
DESCRIPTION:
Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine
NUMERATOR:
Patients who have ever received a pneumococcal vaccination
DENOMINATOR:
All patients 65 years and older
EXCLUDED FROM PERFORMANCE DENOMINATOR POPULATION: (exclusion only applied if
patient did not ever receive a pneumococcal immunization)
•

Documentation of medical reason(s) for not ever receiving pneumococcal vaccination

RATIONALE:
The elderly have a much higher mortality from community-acquired pneumonia due to increased risk
factors such as comorbidities, an increase in the number of medications taken and weaknesses or disease
of lung tissue. Pneumonia accounts for an estimated 20 percent of nosocomial infections among the
elderly, second only to urinary tract infections. The disease burden is large for older adults and the potential
for prevention is high. (Ely, E., 1997)
Drugs such as penicillin were once effective in treating these infections; but the disease has become more
resistant, making treatment of pneumococcal infections more difficult. This makes prevention of the disease
through vaccination even more important. (CDC. National Immunization Program—Pneumococcal
Disease., 2005)
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services recommends
pneumococcal vaccine for all immunocompetent individuals who are 65 and older or otherwise at increased
risk for pneumococcal disease. Routine revaccination is not recommended, but may be appropriate in
immunocompetent individuals at high risk for morbidity and mortality from pneumococcal disease (e.g.,
persons ≥ 75 years of age or with severe chronic disease) who were vaccinated more than five years
previously. Medicare Part B fully covers the cost of the vaccine and its administration every five years.
(United States Preventive Services Task Force, 1998) Pneumococcal infection is a common cause of
illness and death in the elderly and persons with certain underlying conditions. In 1998, an estimated 3,400
adults aged ≥ 65 years died as a result of invasive pneumococcal disease. Pneumococcal infection
accounts for more deaths than any other vaccine-preventable bacterial disease. (CDC, 2002;
Pneumococcal Pneumonia, NIAID Fact Sheet, December 2004.)
One of the Healthy People 2010 objectives is to increase pneumococcal immunization levels for the noninstitutionalized, high-risk populations to at least 90 percent (objective no. 14.29). While the percent of
persons 65 years and older receiving the pneumococcal vaccine has increased, it still remains considerably
below the Health People 2010 objective. According to the National Health Interview Survey (NHIS), which
GPRO v1.0

Page 36 of 38

11/10/09

is used to track performance on year 2010 objectives, in 1998 only 46 percent of adults age 65 years and
older report receiving the vaccine. The figure was 45 percent based on the 1997 Behavioral Risk Factor
Surveillance System (BRFSS) survey. (National Center for Health Statistics., 2005; CDC, 1997)
A particular strength of this measure is that it provides an opportunity to compare performance against
national, state and/or regional benchmarks, which are collected through nationally organized and
administered surveys.
At the physician practice level where a patient survey may not be feasible, data collection on pneumonia
vaccination status through chart abstraction is a viable option.
MEASURE DEVELOPER: NCQA

GPRO v1.0

Page 37 of 38

11/10/09

Symbol and Copyright Information
The following notice applies to each of the measures that contain a triangle (

) before the title:

Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium for
Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician
who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical guidelines
and do not establish a standard of medical care. The Consortium has not tested its Measures for all potential applications. The
Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not be altered
without the prior written approval of the Consortium. Measures developed by the Consortium, while copyrighted, can be reproduced
and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their
practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the
Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures
require a license agreement between the user and American Medical Association, on behalf of the Consortium. Neither the
Consortium nor its members shall be responsible for any use of these Measures.

THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

© 2007 American Medical Association. All Rights Reserved
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. The AMA, the Consortium and its members disclaim all liability for
use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

CPT® contained in the Measures specifications is copyright 2006 American Medical Association.

The following notice applies to each of the measures that contain a diamond (

) before the title:

NCQA Notice of Use. Broad public use and dissemination of these measures is encouraged and the measure developers have
agreed with NQF that noncommercial uses do not require the consent of the measure developer. Use by health care providers in
connection with their own practices is not commercial use. Commercial use of a measure does require the prior written consent of
the measure developer. As used herein, a "commercial use" refers to any sale, license, or distribution of a measure for commercial
gain, or incorporation of a measure into any product or service that is sold, licensed, or distributed for commercial gain, (even if
there is no actual charge for inclusion of the measure.)
These performance measures were developed and are owned by the National Committee for Quality Assurance ("NCQA"). These
performance measures 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. NCQA holds a copyright in this measure and can
rescind or alter this measure at any time. Users of the measure shall not have the right to alter, enhance, or otherwise modify the
measure and shall not disassemble, recompile, or reverse engineer the source code or object code relating to the measure. Anyone
desiring to use or reproduce the measure without modification for a noncommercial purpose may do so without obtaining any
approval from NCQA. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA.
©2004 National Committee for Quality Assurance, all rights reserved.
Performance measures developed by NCQA for CMS may look different from the measures solely created and owned by NCQA.

The following notice applies to each of the measures that contain a spade ( ) before the title:
These measures were developed by Quality Insights of Pennsylvania as a special project under the Quality Insights' Medicare
Quality Improvement Organization (QIO) contract HHSM-500-2005-PA001C with the Centers for Medicare & Medicaid Services.
These measures are in the public domain.
GPRO v1.0

Page 38 of 38

11/10/09