Improving Evidence-Based Primary Care for Chronic Kidney Disease | Research

Prevention

metric_label	Measure Guideline Description	Exclusions	Guideline Source
AAA Screening	Men, age 65-75 years, and current or past smoker with AAA Screening since age 63.	Dx: AAA	USPSTF (B) NQF 0629
Alcohol Screening	Age 18-75 with alcohol screening in the prior 12 months. If alcohol screen found positive, needs alcohol education / intervention	None	USPSTF (B) NQF 2152
ASCVD Screening	Adults 18+ yrs with Lipid panel in prior 5 years.	Dx: ASCVD Current Lipid Lowering medication	AAFP
Blood Pressure Control	Age 18-59 / DM / CKD and last blood pressure taken in prior 12 mos with result < 140/90. Age 60+ (no DM or CKD) and last blood pressure taken in prior 12 months with result <150/90.	ESRD Pregnancy	JNC8
CKD Screening	Age 18+ with CKD Risk (Microalb / Cr Ratio > 30 x 2 with at least 90 days between 2 results), consider Dx of CKD Age 18+ with CKD Risk (eGFR < 60 x 2 with at least 90 days between the 2 results), consider Dx of CKD	Dx: Renal Disease	KDOQI
Depression Screening and Mgmt	Age 12+ years with Depression screening documented in prior 12 months. If last PHQ9 >= 10, must have depression plan q 12 months.	None	NQF 0418 USPSTF (B)
Diabetes Screening	Age 18+ with DM Risk (BMI >= 30 or Obesity or HTN) with A1c in prior 60 days	Dx: Diabetes	ADA
Osteoporosis Screening	Females, age 65+ and Bone Mineral Density scan documented	Dx: Osteoporosis	USPSTF (B) NQF 0046
Tobacco Use Screening	Age 18+ years with tobacco screening documented in prior 24 months. If tobacco user, must have cessation plan q 24 months.	None	USPSTF (A) NQF 0028
Weight Mgmt Screening	Age 18-64 yrs with BMI in prior 12 months and falling into normal parameters (18.5-25) OR BMI outside of normal paramenters and weight mgmt plan documented in prior 12 mos Age 65+ yrs with BMI in prior 12 months and falling into normal parameters (23-30) OR BMI outside of normal paramenters and weight mgmt plan documented in prior 12 mos	Current Pregnancy	NQF 0421 CDC
Breast Cancer Screening	Females, Age 50-74 with a breast cancer screening in the prior 24 months	Double Mastectomy	USPSTF (B) CDC NQF 2372
Cervical Cancer Screening	Female, Age 21-64 with Pap Smear in prior 3 years OR Female, Age 30-64 with Pap Smear + HPV lab in prior 5 years	Total Abdominal Hysterectomy	USPSTF (A) HEDIS (CCS) NQF 0032
Chlamydia Screening	Female, Age 15-25 and sexually active, with Chlamydia screen in prior 12 months	None	USPSTF (B) HEDIS (CHL) NQF 0033
Colon Cancer Screening	Age 50-74 with Colon Cancer Screening meeting frequency dates per screen type: Colonoscopy q 10 yrs OR Flex Sigmoidoscopy q 5 yrs OR Genetic stool testing q 3 yrs OR FIT / FOBT q 12 mos.	Total Colectomy	USPSTF (A) HEDIS (COL) NQF 0034
Gonorrhea Screening	Female, Age 15-25 and sexually active, with Gonorrhea screen in prior 12 months	None	USPSTF (B)
Hepatitis C Screening	Patients born from 1945-1965 with Hepatitis C screened at any time.	Dx: Hep C	USPSTF (B)
HIV Screening	Age 15-65 and pregnant in prior 7 months with HIV screen in prior 12 months Age 15-65 (no pregnancy in prior 7 months) with HIV screen at any time prior	Dx: HIV	USPSTF (A) CDC
HPV Vaccine	Age 15-26 with HPV2 or HPV4 3-dose vaccine series: --Dose 1-2 interval: min 30 days --Dose 2-3 interval: min 90 days --Dose 1-3 interval: min 180 days Age 9-14 with HPV9 2-dose vaccine series (minimum of 6 mos between doses)	Vaccine Allergy	NQF 1959 CDC / ACIP
Influenza Vaccine	Age 6 months and up with a Flu Vaccine during the Flu Season (Sept-March)	Flu Vaccine Allergy	NQF 0041 CDC / ACIP
Pneumococcal Vaccine	Age 65+: with PCV13 x1 and PPSV23 x1 (following CDC dosing schedule) Age 19-64 + Moderate Risk (Smoker; Asthma / COPD; DM; CHF; Liver Dz; Alcoholism) with PPSV23 x1 Age 19-64 + High Risk (Sickle Cell Dz; Asplenia / splenectomy; Renal Dz; Dialysis; HIV, Lymphoma / Hodgkins Dz, Leukemias, Genl malignancy; CSF Leaks; Cochlear Implant) with PCV13 x1 and PPSV23 q 5 years	Vaccine Allergy	CDC / ACIP NQF 0043 NQF 0617
Tetanus Vaccine	Age 13-64 with Tetanus vaccine in prior 10 years	Vaccine Allergy	CDC / ACIP
Zoster Vaccine	Age 60+ with Zoster vaccine x1	Vaccine Allergy	CDC / ACIP (2014)
Zoster Vaccine 2 dose	Age 50+ with inflammatory / immunocompromised condition (RA M05 / psor Arth L40.5 / Crohns K50 / ulcerative collitis K51 / lupus M32 / M45 / IBD? / M04), consider Shingrix but note potential contraindication Age 50+ (no risk condition) , consider RZV (2 dose) at least 2 mos apart	Vaccine Allergy	CDC / ACIP (2018)
Older Adult Advanced Directives	Age 65+ with Advanced Directive or Care Plan documented	None	NCQA / HEDIS (COA) NQF 0326
Older Adult Avoiding High Risk Meds	Age 66+ with Avoidance of High Risk Meds documented in prior 12 mos	None	NCQA NQF 0022
Older Adult Fall Risk Screening	Age 65+ and Fall Risk Screen in prior 12 months and with fall count / injury documented in record. If 2+ falls or injury, at high risk for future fall.	None	NQF 0101 AGS (Amer Geriatrics Soc)
Older Adult Functional Status	Age 66+ with Functional Status assessed in prior 12 mos	None	NCQA / HEDIS (COA)
Older Adult Medication Review	Age 65+ with medications reviewed or reconciled q 12 months	None	NCQA / HEDIS (COA) NQF 0553 (65+)
Older Adult Pain Assessment	Age 66+ with Pain Assessment in prior 12 mos	None	NCQA / HEDIS (COA)
Older Adults Annual Wellness Visit	Patients with Medicare Part B who have had an Annual Wellness Visit coded in the prior 12 months (codes = G0438, G0439, G0468)	None	CMS

Diabetes Management

metric_label	Measure Guideline Description	Exclusions	Guideline Source
A1c Control	Age 18+ with Diabetes Mellitus and an A1c completed in the prior 6 months with result < 8.0% (If DM + CKD, A1c goal < 7.0%)	None	ADA NQF 0575
ACEi ARB	Age 18+ with Diabetes Mellitus and currently on ACEi/ARB. Consider dc'ing ACEi/ARB if Last potassium >= 5.5	ACEi/ARB allergy Last Potassium >= 5.5	AAFP / ADA NQF 2467
Albumin Creatinine	Age 18+ with Diabetes Mellitus and an Albumin/Cr urine lab performed in prior 12 mos with result < 30.	None	ADA NQF 0062
Blood Pressure Control	Age 18+ with Diabetes Mellitus and blood pressure taken in prior 12 mos with result < 140/90.	ESRD Pregnancy	JNC8 NQF 0061
Eye Exam	Age 18+ with Diabetes Mellitus and an Eye Exam in prior 12 months	None	NQF 0055
Foot Exam	Age 18+ with Diabetes Mellitus and a foot exam in prior 12 months	None	NQF 0056
Hep B Vaccine	Age 18-60 yrs with Diabetes Mellitus and a complete Hep B vaccine series.	Hep B Vaccine refused	CDC
Lipids	Age 18+ with Diabetes Mellitus and an Lipid panel performed in prior 12 mos with LDL < 100 (or Non-HDL < 130).	None	NQF 0064

Chronic Kidney Disease Management

metric_label	Measure Guideline Description	Exclusions	Guideline Source
A1c Control	Age 18+ with CKD and Diabetes Mellitus and an A1c completed in the prior 6 months with result < 7.0%)	ESRD	NKF / KDOQI
ACEi ARB	Age 18+ with CKD and currently on ACEi/ARB. Consider dc'ing ACEi/ARB if Last potassium >= 5.5	ESRD ACEi/ARB allergy Last Potassium >= 5.5	NKF / KDOQI
Albumin Cr	Age 18+ with CKD and an Albumin/Cr urine lab performed in prior 12 mos with result < 30.	ESRD	NKF / KDOQI
Anemia Screening	Age 18+ with CKD and Anemia and Hgb completed in the prior 3 months with Hgb >= 12 Age 18+ with CKD (no Anemia Dx) and Hgb completed in the prior 12 months with Hgb >= 12	ESRD	NKF / KDOQI
Blood Pressure Control	Age 18+ with CKD and blood pressure taken in prior 12 mos with result < 140/90.	ESRD	JNC8
Calcium	Age 18+ with CKD Stage 3-5 and Calcium in the prior 12 months.	ESRD	NKF / KDOQI NQF 0574
eGFR Control	Age 18+ with CKD and GFR calculated in the prior 6 months with result >= 30.	ESRD	NKF / KDOQI
iPTH	Age 18+ with CKD Stage 3-5 and iPTH in the prior 12 months.	ESRD	NKF / KDOQI NQF 0571
Lipids	Age 18+ with CKD and an Lipid panel performed in prior 12 mos.	ESRD	NKF / KDOQI NQF 1668
Phosphorus	Age 18+ with CKD Stage 3-5 and Phosphorus in the prior 12 months.	ESRD	NKF / KDOQI NQF 0570
Vitamin D	Age 18+ with CKD Stage 3-5 and Vitamin D in the prior 12 months with result > 30. If Vit D < 30, supplementation with vitamin D2 (ergocalciferol) should be initiated	ESRD	NKF / KDOQI

Other Chronic Conditions Management

metric_label	Measure Guideline Description	Exclusions	Guideline Source
ACEi/ARB Medication Mgmt	Patient currently on ACEi/ARB who had potassium check q 2 yrs Consider dc'ing ACEi/ARB if Last potassium >= 5.5	Last Potassium >= 5.5	AAFP
Asthma Medication Mgmt	Patients 5 years and older with diagnosis of persistent asthma who were prescribed long-term control medication Medications may include: --inhaled corticosteroid (ICS) --long acting beta-agonist (LABA) --alternative long term control medication (non-ICS) -- (inhaled steroid combinations, antiasthmatic combinations, antibody inhibitor, leukotriene modifiers, mast cell stabilizers, methylxanthines)	Note contraindication may exist	NQF 0047 AAAAI
Atrial Fibrillation Mgmt	Percentage of patients aged 18 years and older with a diagnosis of atrial fibrillation (AF) or atrial flutter with appropriate medication therapy according to the following scores: ---If Score 0-1: ASA therapy current ---If Score 2+: Anticoagulation Therapy current - warfarin [Coumadin] OR rivaroxaban [Xarelto]; dabigatran [Pradaxa]; apixaban [Eliquis]	ASA contraindication mitral stenosis prostethic heart valve current pregnancy current pneumonia current hyperthyroidism	NQF 1525
COPD Asthma Spirometry	Percentage of patients aged 18 years and older with a diagnosis of COPD (or persistent asthma, emphysema, chronic bronchitis) who had spirometry results documented in prior 12 months	None	NHLBI NQF 0091
COPD Medication Mgmt	Patients with Dx COPD and FEV1 < 60% and are prescribed a current inhaled bronchodilator	Note contraindication may exist	NQF 0102 ATS (Amer. Thoracic Society)
Heart Dz Mgmt ACEi/ARB	Patients with HF, ASCVD, CAD, or LVSD / CHF and on current ACEi/ARB. Patient currently on ACEi/ARB, potassium check q 2 yrs Consider dc'ing ACEi/ARB if Last potassium >= 5.5	ACEi/ARB allergy Last Potassium >= 5.5	NQF 0081 (HF / LVSD) NQF 0066 (CAD) AAFP (potassium lab)
HF Beta Blocker	Patient with prior AMI, LVSD (LVEF < 40%), HF with current beta blocker therapy For MI - Any Beta Blocker For HF / LVSD / LVEF <40% - Bisoprolol, Carvediol, or sustained-release metoprolol succinate * For HF - If current beta blocker therapy is Atenolol: Consider changing to bisoprolol, carvedilol, or sustained release metoprolol succinate.	Note contraindication may exist	HEDIS (PBH) (MI) NQF 2438 (HF / LVSD) NQF 0083 (HF / LVSD) NQF 0070 (MI / LVSD)
HF Mgmt Echo	Patient with current dx: Heart Failure with Echocardiogram performed q 12 months	None	ACC / ASA
HTN Blood Pressure Control	Age 18+ with HTN and blood pressure taken in prior 12 mos with result < 140/90. ACEi/ARB current if last BP >= 140/90	ESRD Pregnancy	JNC8 AAFP NQF 0018
HTN Lipids	Age 18+ with HTN and an Lipid panel performed in prior 12 mos with LDL < 100 (or Non-HDL < 130). If LDL goal not met, needs Statin tx		PQRS 296
IVD CAD Mgmt Antiplatelet / ASA	Patients with Dx CAD, Ischemic Vascular Disease (IVD) OR Evidence of prior AMI, CABG, PTCA/PCI who are on current Aspirin or other antiplatelet therapy.	Antiplatelet allergy	NQF 0068 (IVD) NQF 0067 (CAD)
IVD or Risk Blood Pressure Control	Patients age 18 to 75 years with a diagnosis of ischemic vascular disease (IVD) or any previous acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) and had a blood pressure taken in prior 12 mos with result < 140/90. ACEi/ARB current if last BP >= 140/90	None	NQF 0073
RA DMARD	Age 18+ with Dx Rheumatoid Arthritis with current DMARD or DMARD in prior 12 months	Dx HIV, Dx Pregnancy	HEDIS (ART) NQF 0054
Statin Management	Patient on current statin if one of the following: - Age 21+ years with ASCVD or LDL-C >= 190 - Age 40-75 years with 1 CVD Risk Factor and LDL-C 70-189 - Last LDL-C >= 100 (or Last Non-HDL >= 130) -- also include note about lifestyle mgmt ***CVD Risk Factors: Dyslipidemia, Smoking, HTN, DM, or Last BP >/= 140/90	Note contraindication may exist	USPSTF ACC / AHA HEDIS (SPD) (DM)