Adult major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.

Date Reviewed: November 19, 2017

Measure Info

MIPS 107 NQF 0104 CMS 107 NQF Endorsed
Measure Type
Measure Steward
Physician Consortium for Performance Improvement
Clinical Topic Area

Care Setting
Data Source
Electronic Health Records

ACP supports QPP measure 107: "Adult Major Depressive Disorder: Suicide Risk Assessment” because it is clinically important to assess for suicide risk in patients with MDD. While we support this measure, we note several recommendations that could improve the measure quality. First, the measure is close to being topped out. The measure developers cite a 96% compliance rate. However, this data only represents clinicians who chose to report on the measure for the 2010 PQRS reporting year and therefore, may inaccurately represent nationwide performance levels. Developers should include current, national performance data in the updated measure report. Second, the numerator is not clearly specified. In particular, it is not well defined what constitutes a “recurrent” episode. Developers should consider revising the specifications to stipulate that this is an episode associated with the initiation of new treatment for depression. As currently stated, the measure could apply to all follow-up visits with the mention of even well-controlled depression. Third, this is a “check the box measure” with little potential to shift the quality needle as evidenced by the small performance gap. Lastly, the measure poses significant burden.