DARTNet Institute Informing Practice Improving Care
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Prevention

Diabetes Management

Chronic Kidney Disease Management

Other Chronic Conditions Management

 

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

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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

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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)