To ensure that all members with diabetes receive a diabetic retinopathy that in patients with type 1 diabetes, annual screening (ophthalmoscopy …
Health Benchmarks Clinical Quality Indicator Specification 2007
Client HCSC STANDARD ALGORITHM Implemented for Blue Cross Blue Shield of Illinois DIABETIC RETINAL EXAM Diabetes, Retinopathy A Indicator Classification1 Disease Management
Measure Title Disease State Strength of Recommendation2 Clinical Intent
To ensure that all members with diabetes receive a diabetic retinopathy screening test at a clinically appropriate frequency Family Practice, General Practice, Internal Medicine, Mixed Specialty Disease Burden Diabetes is a chronic, serious disease that affects approximately 147 million Americans This disease is the leading cause of new cases of blindness among adults aged 20-74[1] After living with diabetes for 20 years, almost all patients with type 1 diabetes and 50 to 80 percent of those with type 2 diabetes will manifest signs of retinopathy[2] Retinopathy is a major cause of morbidity in patients with diabetes The incidence of blindness, for example, is 25 times higher in patients with diabetes than in the general population Furthermore, diabetic retinopathy is the most common cause of blindness in middle-aged subjects, accounting for at least 12 percent of all new
cases in the United States each year[3] Reason for Indicated Intervention or Treatment Evidence supports that screening and early treatment for diabetic retinopathy is associated with a decreased rate of visual loss[4-6] Evidence supporting Intervention or Treatment In their cost-effectiveness analyses, Javitt and colleagues have reported that in patients with type 1 diabetes, annual screening ophthalmoscopy with dilated pupils for those without retinopathy and screening every six months for those with retinopathy followed by guideline concordant treatment would result in a saving of 70,000 to 80,000 person-years of sight and 60 to 80 million dollars annually in the United States[7] In patients with type 2 diabetes, the same screening program and treatment would result in saving over 94,000 person-years of sight and over 250 million dollars per year[8] Appropriate screening and early detection of retinopathy preserves vision[5, 9-11] At least three randomized controlled trials have reported that photocoagulation for diabetic retinopathy preserves vision[12-14] Clinical Recommendations The American Diabetes Association, the American Academy of Ophthalmology, and the American
College of Physicians guidelines recommend[15-17] :
Physician Specialties Clinical Rationale
1999-2007 Health Benchmarks Confidential and Proprietary All Rights Reserved
250retinal HSC_250retinal_v60_abstract Measure: retina250
Patients with type 1 diabetes defined operationally as diabetes onset before age 30 years and requiring therapy with insulin should have a complete examination by an ophthalmologist within three to five years after the onset of diabetes Subsequent examinations should be determined by the presence and severity of retinopathy at the initial examination, but the minimum recommendation is annual examination One exception is that screening is not indicated before puberty[19] Patients with type 2 diabetes should have a complete examination by an ophthalmologist beginning at the time of diagnosis Subsequent examinations or referral for treatment should be determined by the presence and severity of retinopathy at the initial examination, but the minimum recommendation is annual examination[20]
Source
Adapted from Health Plan Employer Data and Information Set HEDIS 2007 Technical Specification unable to include evidence of negative retinal exam in year
prior to measurement year as this is ascertained with result data that are not generally available via administrative claims HBIs standard algorithm contains an additional exclusion for members with Type I diabetics The numerator deviates from HEDIS in that the ophthalmology/optometry specific E M codes for dilated eye exams do not require specialty codes Continuously enrolled members ages 18 - 75 years by the end of the measurement year who were identified as having diabetes during the measurement year or year prior Members in the denominator with a diagnosis of polycystic ovaries at any time in the members history who did who did NOT receive a diagnosis of diabetes during the measurement year or year prior, or members diagnosed with gestational diabetes, or steroid-induced diabetes during the measurement year or year prior
Denominator
Denominator Exclusion
Numerator
Members who received at least one screening exam for diabetic retinal disease by an eye-care professional or had at least one office visit with an eye care professional during the measurement year Eye exams provided by eye care professionals are a proxy for dilated eye examinations because there is no
administrative way to determine that a dilated exam was performed Source: HEDIS 2007
Interpretation of Score Physician Attribution
High score implies better performance
Score all physicians in the selected specialties who saw the member during the measurement year
References
1
2 3 4
1999-2007 Health Benchmarks Confidential and Proprietary All Rights Reserved
CDC National Diabetes Surveillance System 2004 [cited 2004 November 17th]; Available from: http://wwwcdcgov/diabetes/statistics/prev/national/figpersonshtm Frank, RN, Diabetic retinopathy N Engl J Med, 2004 3501: p 48-58 Klein, R, et al, Association of ocular disease and mortality in a diabetic population Arch Ophthalmol, 1999 11711: p 1487-95 Javitt, JC and LP Aie 
llo, Cost-effectiveness of detecting and treating
250retinal HSC_250retinal_v60_abstract Measure: retina250
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8
9 10 11 12
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15 16
17 18 19
20
diabetic retinopathy Ann Intern Med, 1996 1241 Pt 2: p 164-9 Malone, JI, et al, Prevalence and significance of retinopathy in subjects with type 1 diabetes of less than 5 years duration screened for the diabetes control and complications trial Diabetes Care, 2001 243: p 522-6 Chew, EY, et al, The
long-term effects of laser photocoagulation treatment in patients with diabetic retinopathy: the early treatment diabetic retinopathy follow-up study Ophthalmology, 2003 1109: p 1683-9 Javitt, JC, et al, Detecting and treating retinopathy in patients with type I diabetes mellitus A health policy model Ophthalmology, 1990 974: p 483-94; discussion 494-5 Javitt, JC, et al, Preventive eye care in people with diabetes is costsaving to the federal government Implications for health-care reform Diabetes Care, 1994 178: p 909-17 Singer, DE, et al, Screening for diabetic retinopathy Ann Intern Med, 1992 1168: p 660-71 Fong, DS, et al, Retinopathy in diabetes Diabetes Care, 2004 27 Suppl 1: p S84-7 Zoega, GM, et al, Screening compliance and visual outcome in diabetes Acta Ophthalmol Scand, 2005 836: p 687-690 Proliferative diabetic retinopathy: treatment with xenon-arc photocoagulation Interim report of multicentre randomised controlled trial Br Med J, 1977 16063: p 739-41 Photocoagulation for diabetic maculopathy A randomized controlled clinical trial using the xenon arc British Multicentre Study Group Diabetes, 1983 3211: p 1010-6 Photocoagulation for diabetic macular edema Early
Treatment Diabetic Retinopathy Study report number 1 Early Treatment Diabetic Retinopathy Study research group Arch Ophthalmol, 1985 10312: p 1796-806 Aiello, Lea, Retinopathy in Diabetes Diabetes Care, 2004 271 Screening guidelines for diabetic retinopathy American College of Physicians, American Diabetes Association, and American Academy of Ophthalmology Ann Intern Med, 1992 1168: p 683-5 ADA, Standards of Medical Care in Diabetes Diabetes Care, 2005 28 Supplement 1: S4 AAO, Diabetic Retinopathy, in preferred practice pattern 2003, American Academy of Opthalmology Klein, R, et al, The Wisconsin epidemiologic study of diabetic retinopathy II Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years Arch Ophthalmol, 1984 1024: p 520-6 Klein, R, et al, The Wisconsin epidemiologic study of diabetic retinopathy III Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years Arch Ophthalmol, 1984 1024: p 527-32
1999-2007 Health Benchmarks Confidential and Proprietary All Rights Reserved
250retinal HSC_250retinal_v60_abstract Measure: retina250
Indicator Classification Adapted from Health Plan Employer Data Information Set
HEDIS technical specifications Diagnosis Measures applicable to patients receiving diagnostic workups for a symptom or condition that delineate appropriate laboratory or radiological testing to be performed eg evaluation of thyroid nodule; pregnancy test in patients with vaginal bleeding or abdominal pain Measures applicable to asymptomatic individuals that are designed to prevent the onset of the targeted condition eg immunizations Measures applicable to asymptomatic patients who have risk factors or preclinical disease, but in whom the condition has not become clinically apparent eg pap smears; screening for elevated blood pressure Measures applicable to individuals diagnosed with a condition that are part of the treatment or management of the condition eg cholesterol reduction in patients with diabetes; radiation therapy following breast conserving surgery; appropriate follow-up after acute event Measures applicable to patients taking medications with narrow therapeutic windows and / or potential preventable significant side effects or adverse reactions eg thyroid stimulating hormone TSH testing after levothyroxine dose change; hepatic enzyme monitoring for patients using
antimycotic pharmacotherapy Measures applicable to patients taking medications for chronic conditions that are designed to assess patient adherence to medication eg adherence to lipid lowering medication Measures applicable to patients receiving treatment for a symptom or condition that advocate appropriate utilization of laboratory and pharmaceutical resources eg conservative use of imaging for low back pain; inappropriate use of antibiotics for viral upper respiratory infection
1
Effectiveness of Care Prevention Screening
Disease Management
Medication Monitoring
Medication Adherence Utilization
1999-2007 Health Benchmarks Confidential and Proprietary All Rights Reserved
250retinal HSC_250retinal_v60_abstract Measure: retina250
2
Strength of Recommendation
Strength of Recommendation Based on a Body of Evidence
FIGURE 2 Algorithm for determining the strength of a recommendation based on a body of evidence applies to clinical recommendations regarding diagnosis, treatment, prevention, or screening While this algorithm provides a general guideline, authors and editors may adjust the strength of recommendation based on the benefits, harms, and costs of the intervention
being recommended USPSTF US Preventive Services Task Force
1999-2007 Health Benchmarks Confidential and Proprietary All Rights Reserved
250retinal HSC_250retinal_v60_abstract Measure: retina250
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