Retired Measures

Rheumatoid Arthritis: Assessment of Disease Activity

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) and >=50% of total number of outpatient RA encounters in the measurement year with assessment of disease activity using a standardized measure.

Date Reviewed: April 27, 2015

Colonoscopy Interval for Patients with a History of Adenomatous Polyps-Avoidance of Inappropriate Use

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.

Date Reviewed: January 27, 2022

Dementia: Screening for Depressive Symptoms

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period

Date Reviewed: April 7, 2014

Rheumatoid Arthritis: Tuberculosis Screening

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who have documentation of a tuberculosis (TB) screening performed within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).

Date Reviewed: April 27, 2015

Asthma Medication Ratio

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of patients who have a medication ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

Date Reviewed: July 26, 2015

Sleep Apnea: Positive Airway Pressure Therapy Prescribed

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Patients who were prescribed positive airway pressure therapy as a proportion of all patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea

Date Reviewed: April 8, 2013

Pharmacologic Therapy for Persistent Asthma

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patient aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication Three rates are reported for this measure:

1. Patients prescribed inhaled corticosteroids (ICS) as their long term control medication
2. Patients prescribed other alternative long term control medications (non-ICS)
3. Total patients prescribed long-term control medication

Date Reviewed: July 26, 2015

Hypertension Improvement in Blood Pressure

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

Date Reviewed: November 19, 2017

HIV/AIDS: CD4 Cell Count or Percentage Performed

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged six months and older with a diagnosis of HIV/AIDS, with at least two CD4 cell counts or percentages performed during the measurement year at least 3 months apart

Date Reviewed: July 26, 2014

Hepatitis C: Antiviral Treatment Prescribed

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Date Reviewed: July 26, 2014

Controlling High Blood Pressure for People with Serious Mental Illness

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of patients 18-85 years of age with serious mental illness who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled during the measurement year.
Note: This measure is adapted from an existing health plan measure used in a variety of reporting programs for the general population (NQF #0018: Controlling High Blood Pressure). It was originally endorsed in 2009 and is owned and stewarded by NCQA. The specifications for the existing measure (Controlling High Blood Pressure NQF #0018) have been updated based on 2013 JNC-8 guideline. NCQA will submit the revised specification for Controlling High Blood Pressure NQF #0018 in the 4th quarter 2014 during NQF’s scheduled measure update period. This measure uses the new specification to be consistent with the current guideline.

Date Reviewed: July 21, 2018

HIV/AIDS: Medical Visit

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS, with at least two medical visits during the measurement year, with a minimum of 90 and 180 days between each visit

Date Reviewed: July 26, 2014

Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge

Date Reviewed: April 7, 2014

HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, who had at least two medical visits during the measurement year, with at least 90 days between each visit, who are receiving potent antiretroviral therapy, who have a viral load < 200 copies/mL after at least 6 months of potent antiretroviral therapy

Date Reviewed: July 26, 2014

HIV/AIDS: Screening for High Risk Sexual Behaviors

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients, aged 13 years and older, who were screened for high risk sexual behaviors at least once within 12 months.

Date Reviewed: November 7, 2015

Chlamydia Screening and Follow-up

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up

Date Reviewed: November 7, 2015

Gap in HIV Medical Visits

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.

Date Reviewed: November 7, 2015

Hepatitis C: Hepatitis B Vaccination

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B

Date Reviewed: July 26, 2014

Total Cost of Care Population-Based PMPM Index (Cost/Resource use Measure)

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Total Cost of Care reflects a mix of complicated factors such as patient illness burden, service utilization and negotiated prices.

Total Cost Index (TCI) is a measure of a primary care provider's risk adjusted cost effectiveness at managing the population they care for. TCI includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.

A Total Cost of Care Index when viewed together with a Resource Use measure provides a more complete picture of population based drivers of health care costs.

Date Reviewed: November 7, 2015

HIV medical visit frequency

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.

Date Reviewed: November 7, 2015

Hepatitis C Ribonucleic Acid (RNA) Testing Before Initiating Treatment

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment (paired with NQF 0396)

Date Reviewed: July 26, 2014

GERD - Upper Gastrointestinal Study in Adults with Alarm Symptoms

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of adult patients with gastroesophageal reflux disease (GERD) with alarm symptoms who have had an upper gastrointestinal study

Date Reviewed: November 18, 2013

Annual cervical cancer screening or follow-up in high-risk women

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

This measure identifies women age 12 to 65 diagnosed with cervical dysplasia (CIN 2), cervical carcinoma-in-situ, or HIV/AIDS prior to the measurement year, and who still have a cervix, who had a cervical CA screen during the measurement year.

Date Reviewed: November 7, 2015

Hepatitis C: Testing for Chronic Hepatitis C - Confirmation of Hepatitis C Viremia

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed

Date Reviewed: July 26, 2014

Stroke and Stroke Rehabilitation: Thrombolytic Therapy

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

This measure captures the proportion of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well for whom IV t-PA was initiated at this hospital within 3 hours of time last known well

Date Reviewed: April 7, 2014

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.

Date Reviewed: April 27, 2015

Use of Appropriate Medications for People with Asthma

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year

Date Reviewed: July 26, 2015

Stroke and Stroke Rehabilitation: Screening for Dysphagia

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care

Date Reviewed: April 7, 2014

Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified.

Date Reviewed: April 27, 2015

Adult Kidney Disease: Laboratory Testing (Lipid Profile)

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of CKD (stage 3, 4 or 5, not receiving Renal Replacement Therapy (RRT)) who had a fasting lipid profile performed at least once within a 12-month period

Date Reviewed: November 23, 2013

Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge

Date Reviewed: April 7, 2014

Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.

Date Reviewed: November 19, 2017

Non-Diabetic Nephropathy - Use of ACE Inhibitor or ARB Therapy

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of patients aged 18 years and older with proteinuria who are taking an ACE inhibitor or ARB

Date Reviewed: November 23, 2013

Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered DVT prophylaxis by the end of hospital day two

Date Reviewed: April 7, 2014

Adult Major Depressive Disorder: Coordination of Care of Patients with Specific Comorbid Conditions

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.

Date Reviewed: November 19, 2017

Adult Kidney Disease: Blood Pressure Management

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care.

Date Reviewed: November 19, 2017

Assessment and Classification of Disease Prognosis

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months.

Date Reviewed: April 27, 2015

Chronic Liver Disease: Hepatitis A Vaccination

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

The percentage of adult patients with chronic liver disease who have received a hepatitis A vaccine.

Date Reviewed: November 7, 2015

Dementia: Counseling Regarding Risks of Driving

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period

Date Reviewed: April 7, 2014

Rheumatoid Arthritis (RA): Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who are newly prescribed disease modifying anti-rheumatic drug therapy within 12 months.

Date Reviewed: April 27, 2015

Adults with Diabetes Mellitus That Had a Serum Creatinine in the Last 12 Reported Months

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

This measure identifies adults with diabetes mellitus that had a serum creatinine test in last 12 reported months

Date Reviewed: November 23, 2013

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 05)

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 100,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions. (NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population)

Date Reviewed: July 26, 2015

Rheumatoid Arthritis: Functional Status Assessment

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis for whom a functional status assessment was performed at least once during the measurement period.

Date Reviewed: April 27, 2015

Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent-Hemoglobin Level > 12.0 g/dL

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of calendar months within a 12-month period during which a Hemoglobin is measured for patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT) or ESRD (who are on hemodialysis or peritoneal dialysis) who are also receiving ESA therapy and have a Hemoglobin Level > 12.0 g/dL

Date Reviewed: November 23, 2013

Staging of Dementia

RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.

Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period

Date Reviewed: April 7, 2014