Provider outreach manual:
Medicare Advantage Part C STAR Measures
Table of contents
1.. Breast cancer screening (C01).....................................................................................................................................................................1
• Take care of yourself (Brochure)
2.. Colorectal cancer screening (C02)............................................................................................................................................................3
• Screening for Colorectal Cancer: Clinical Summary of U.S. Preventative Services Task Force
Recommendation (Annals of Internal Medicine)
3.. Cholesterol management for patients with cardiovascular conditions (C03)...................................................................8
• ATP III LCL cholesterol cutoffs for lifestyle interventions and drug therapy in different risk
4.. Comprehensive diabetes care (C04, C15, C16, C17, C18)..........................................................................................................10
• Control your diabetes (Flyer)
• Mercy Care Plan diabetes management project
5.. Glaucoma screening (C05).........................................................................................................................................................................13
6.. Consumer Assessment of Healthcare Providers and Systems (CAHPS®) health plan surveys...............................14
• Annual flu vaccine (C06)
• Medicare Satisfaction Survey
7.. Health Outcomes Surveys (HOS).............................................................................................................................................................27
• HOS questionnaire
8.. Improving or maintaining physical health (C07)............................................................................................................................40
9.. Improving or maintaining mental health (C08)..............................................................................................................................41
10.. Physical activity in older adults (C09)...................................................................................................................................................42
11.. Adult body mass index (BMI) assessment (C10).............................................................................................................................43
• BMI charts
• Screening for Obesity in Adults: Recommendations and Rationale (Annals of Internal Medicine)
12.. Care of older adults (C11, C12, C13).....................................................................................................................................................49
13.. Osteoporosis management in women who had a fracture (C14)..........................................................................................50
• Osteoporosis Management for Postmenopausal Women (Flyer)
• Fall assessment charting tool
14.. Controlling high blood pressure (C19).................................................................................................................................................54
• The Importance of Accurate Blood Pressure Measurement (The Permanente Journal)
15.. Rheumatoid arthritis: Use of disease modifying antirheumatic drugs (DMARDs) (C20)..........................................59
• DMARDs on Mercy Care Advantage formulary
• Rheumatoid arthritis: Key priorities for implementation
16.. Improving bladder control (C21).............................................................................................................................................................62
17.. Reducing the risk of falling (C22)............................................................................................................................................................63
18.. Plan all cause readmissions (C23)..........................................................................................................................................................64
Member name
Missed
appointment date
and time
Late and
not seen
No show
Cancelled
<24 hrs.
Reason for appointment
This message is intended only for the use of the individual or entity to which it is addressed and may contain confidential and/or proprietary information. If you are not the intended
recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this
communication is prohibited. If you received this communication in error, please notify the sender at the phone number above.
Member ID #
Provider name:___________________________________________________________________ Date faxed:_____________________ # of pages___
In an effort to improve our member’s health and assist your office with missed and “No Show” appointments, please fill in the requested information for Mercy Care Advantage
members only. With this information, our outreach staff can call each member to offer assistance with issues that may be hindering the member from keeping their appointments,
such as transportation. Please notify Mercy Care Advantage within one week of the appointment by faxing this form to 1-860-907-3430. If you have any questions, please
call 602-361-9194.
Missed appointment log
Breast cancer screening
Goal: the percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.
Billing codes for breast cancer screening per the HEDIS technical specifications:
1
CPT
HCPCS
ICD-9-CM Procedure
77055-77057
G0202, G0204, G0206
87.36, 87.37
www.MercyCareAdvantage.com
2
www.MercyCareAdvantage.com
MammogramBrochure2014.indd 1
AZ-14-05-14
Mercy Care Advantage (HMO SNP) es un plan
de atención coordinada que tiene contrato
con Medicare y con el programa Medicaid
de Arizona. La inscripción en Mercy Care
Advantage depende de la renovación del
contrato. Esta es información general de
salud y no debe reemplazar la atención que
usted recibe de su médico. Tampoco tiene
como objetivo reemplazar el asesoramiento
que recibe del profesional. Siempre solicite
a este o a otro proveedor de atención de
salud información sobre sus necesidades de
atención médica. Beneficios, formulario, red de
farmacias, red de proveedores, y/o copagos/
coseguros pueden cambiar en Enero 1, de cada
año. Limitaciones, copagos, y restricciones
podrían aplicar. La información de beneficios
previstos aquí es un breve resumen, no una
descripción completa de beneficios. Para
más información, comuníquese con el plan.
Como miembro de Mercy Care Advantage,
se le puede hacer un examen físico anual
cubierto por Medicare sin costo alguno.
Hable con su doctor sobre hacerse una
mamografía.
Sobre su visita anual de bienestar:
Mercy Care Advantage (HMO SNP) is a
Coordinated Care plan with a Medicare
contract and a contract with the Arizona
Medicaid Program. Enrollment in Mercy Care
Advantage depends on contract renewal.
This is general health information and should
not replace care you get from your doctor.
It is not meant to replace advice you get
from your doctor. Always ask your doctor or
other health care provider for information
about your own health care needs. Benefits,
formulary, pharmacy network, provider
network, and/or copayments/coinsurance
may change on January 1, of each year.
Limitations, copayments, and restrictions
may apply. The benefit information
provided herein is a brief summary, not
a complete description of benefits. For
more information, contact the plan.
As a Mercy Care Advantage enrollee,
you can get a Medicare‑covered annual
physical exam at no cost. Talk to your
doctor about getting a mammogram.
About your annual wellness visit :
H5580_E_14_035
Pídale a su doctor una orden (referencia)
durante su visita anual de bienestar.
Mercy Care Advantage (HMO SNP) cubre una
mamografía cubierta por Medicare sin cargo
alguno para usted.
Sus probabilidades de sufrir cáncer del seno
aumentan mientras envejece. Si usted tiene
de 50 a 74 años de edad, necesita hacerse
una mamografía cada 2 años. Si tiene de 40
a 49 años de edad, hable con su doctor para
determinar cuándo debe comenzar a hacerse
mamografías y qué tan frecuentemente.
Una mamografía puede ayudar a su
doctor a determinar si usted tiene
cualquier anomalía en sus senos
Ask your PCP for an order (referral) during
your annual wellness visit.
Mercy Care Advantage (HMO SNP) covers
one Medicare-covered mammogram with $0
copay.
Your chance for getting breast cancer increases
as you get older. If you are 50-74 years old,
you need to get a mammogram every 2
years. If you are 40-49 years old, talk to your
doctor about when you should start getting a
mammogram screening and how often.
A mammogram can help your
doctor see if you have any
abnormalities in your breasts
Health or wellness or prevention information
Información de salud o bienestar o prevención
4350 E. Cotton Center Blvd.
Building D
Phoenix, AZ 85040
www.MercyCareAdvantage.com
6/19/14 2:22 PM
Cuídese a sí misma –
hágase una mamografía.
Take care of yourself –
get a mammogram
Colorectal cancer screening
Goal: To increase the percentage of members 50-75 years of age who had appropriate screening for colorectal
cancer. Appropriate screenings are defined as:
• Fecal occult blood test (FOBT) during the measurement year
• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year
• Colonoscopy during the measurement year or the nine years prior to the measurement year
Codes to identify colorectal cancer screening:
3
Description
CPT
HCPCS
ICD-9-CM Procedure
FOBT
82270, 82274
G0328
Flexible sigmoidoscopy
45330-45335, 4533745342, 45345
G0104
45.24
Colonoscopy
44388-44394, 44397,
45355, 45378-45387,
45391, 45392
G0105, G0121
45.22, 45.23, 45.25,
45.42, 45.43
www.MercyCareAdvantage.com
Focus on strategies that maximize the number of individuals who get screened.
Practice shared decision making; discussions with patients should incorporate information on test quality and availability.
Individuals with a personal history of cancer or adenomatous polyps are followed by a
surveillance regimen, and screening guidelines are not applicable.
The USPSTF recommends against the use of aspirin or nonsteroidal anti-inflammatory
drugs for the primary prevention of colorectal cancer.
This recommendation is available at www.preventiveservices.ahrq.gov.
For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to www.preventiveservices.ahrq.gov. FOBT fecal occult blood testing.
* These recommendations do not apply to individuals with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) or
those with inflammatory bowel disease.
Relevant USPSTF
Recommendations
Figure. Screening for colorectal cancer: clinical summary of a U.S. Preventive Services Task Force (USPSTF) recommendation.*
Implementation
Balance of Harms
and Benefits
The benefits of screening outweigh the
potential harms for 50- to 75-year-olds.
The likelihood that detection and early intervention will yield a mortality benefit
declines after age 75 because of the long average time between
adenoma development and cancer diagnosis.
High-sensitivity FOBT, sigmoidoscopy with FOBT, and colonoscopy are effective in decreasing colorectal cancer mortality.
The risks and benefits of these screening methods vary.
Colonoscopy and flexible sigmoidoscopy (to a lesser degree) entail possible serious complications.
Intervals for recommended screening strategies:
• Annual screening with high-sensitivity FOBT
• Sigmoidoscopy every 5 years, with high-sensitivity FOBT every 3 years
• Screening colonoscopy every 10 years
Do not screen
Screening Tests
Recommendation
Population
For all populations, evidence is insufficient to assess the benefits and harms of screening with
computed tomographic colonography and fecal DNA testing.
Do not screen
Do not screen routinely
Grade: C
Screen with high-sensitivity
FOBT, sigmoidoscopy,
or colonoscopy
Grade: A
Grade: D
Adults Older Than 85 Years*
Adults Age 76 to 85 Years*
Intervals for recommended screening strategies:
• Annual screening with high-sensitivity FOBT
• Sigmoidoscopy every 5 years, with high-sensitivity FOBT every 3 years
• Screening colonoscopy every 10 years
Adults Age 50 to 75 Years*
The likelihood that detection and early intervention will yield a mortality benefit
declines after age 75 because of the long average time between
adenoma development and cancer diagnosis.
Screening for Colorectal Cancer
SCREENING FOR COLORECTAL CANCER
CLINICAL SUMMARY OF U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATION
The benefits of screening outweigh the
potential harms for 50- to 75-year-olds.
Focus on strategies that maximize the number of individuals who get screened.
Practice shared decision making; discussions with patients should incorporate information on test quality and availability.
Individuals with a personal history of cancer or adenomatous polyps are followed by a
surveillance regimen, and screening guidelines are not applicable.
The USPSTF recommends against the use of aspirin or nonsteroidal anti-inflammatory
drugs for the primary prevention of colorectal cancer.
This recommendation is available at www.preventiveservices.ahrq.gov.
Figure. Screening for colorectal cancer: clinical summary of a U.S. Preventive Services Task Force (USPSTF) recommendation.*
www.annals.org
High-sensitivity FOBT, sigmoidoscopy with FOBT, and colonoscopy are effective in decreasing colorectal cancer mortality.
The risks and benefits of these screening methods vary.
Colonoscopy and flexible sigmoidoscopy (to a lesser degree) entail possible serious complications.
Grade: I (insufficient evidence)
Grade: I (insufficient evidence)
For all populations, evidence is insufficient to assess the benefits and harms of screening with
computed tomographic colonography and fecal DNA testing.
Screening Test
Intervals
Do not screen routinely
Grade: D
Adults Older Than 85 Years*
Screen with high-sensitivity
FOBT, sigmoidoscopy,
or colonoscopy
Grade: C
Adults Age 50 to 75 Years*
Grade: A
Adults Age 76 to 85 Years*
SCREENING FOR COLORECTAL CANCER
CLINICAL SUMMARY OF U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATION
Population
Recommendation
Screening Tests
Screening Test
Intervals
Balance of Harms
and Benefits
Implementation
Relevant USPSTF
Recommendations
For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to www.preventiveservices.ahrq.gov. FOBT fecal occult blood testing.
* These recommendations do not apply to individuals with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) or
those with inflammatory bowel disease.
www.MercyCareAdvantage.com
4 November 2008 Annals of Internal Medicine Volume 149 • Number 9 635
www.annals.org
4
Clinical Guidelines
Screening for Colorectal Cancer
4 November 2008 Annals of Internal Medicine Volume 149 • Number 9 635
Clinical Guidelines
Clinical Guidelines
Screening for Colorectal Cancer
Table 1. What the U.S. Preventive Services Task Force Grades Mean and Suggestions for Practice*
Grade
Definition
Suggestions for Practice
A
The USPSTF recommends the service. There is high certainty that the
net benefit is substantial.
The USPSTF recommends the service. There is high certainty that the
net benefit is moderate or there is moderate certainty that the net
benefit is moderate to substantial.
The USPSTF recommends against routinely providing the service. There
may be considerations that support providing the service in an
individual patient. There is moderate or high certainty that the net
benefit is small.
The USPSTF recommends against the service. There is moderate or
high certainty that the service has no net benefit or that the harms
outweigh the benefits.
The USPSTF concludes that the current evidence is insufficient to assess
the balance of benefits and harms of the service. Evidence is lacking,
of poor quality, or conflicting, and the balance of benefits and harms
cannot be determined.
Offer/provide this service.
B
C
D
I statement
Offer/provide this service.
Offer/provide this service only if other considerations support offering or
providing the service in an individual patient.
Discourage the use of this service.
Read clinical considerations section of USPSTF Recommendation Statement.
If the service is offered, patients should understand the uncertainty about
the balance of benefits and harms.
* USPSTF U.S. Preventive Services Task Force.
Table 2. U.S. Preventive Services Task Force Levels of Certainty Regarding Net Benefit
Level of Certainty*
Description
High
The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care
populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to
be strongly affected by the results of future studies.
The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate
is constrained by such factors as:
the number, size, or quality of individual studies
inconsistency of findings across individual studies
limited generalizability of findings to routine primary care practice
lack of coherence in the chain of evidence.
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large
enough to alter the conclusion.
The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
the limited number or size of studies
important flaws in study design or methods
inconsistency of findings across individual studies
gaps in the chain of evidence
findings that are not generalizable to routine primary care practice
a lack of information on important health outcomes.
More information may allow an estimation of effects on health outcomes.
Moderate
Low
* The U.S. Preventive Services Task Force (USPSTF) defines certainty as “likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.” The
net benefit is defined as benefit minus harm of the preventive service as implemented in a general primary care population. The USPSTF assigns a certainty level based on
the nature of the overall evidence available to assess the net benefit of a preventive service.
5
636 4 November 2008 Annals of Internal Medicine Volume 149 • Number 9
www.annals.org
www.MercyCareAdvantage.com
Screening for Colorectal Cancer
tematic review focusing on performance characteristics and practicalness. Int J
Cancer. 2005;117:169-76. [PMID: 15880368]
16. Itoh M, Takahashi K, Nishida H, Sakagami K, Okubo T. Estimation of the
optimal cut off point in a new immunological faecal occult blood test in a corporate colorectal cancer screening programme. J Med Screen. 1996;3:66-71.
[PMID: 8849762]
17. Colorectal Cancer Study Group. Fecal DNA versus fecal occult blood for
colorectal-cancer screening in an average-risk population. N Engl J Med. 2004;
351:2704-14. [PMID: 15616205]
18. Pickhardt PJ, Choi JR, Hwang I, Butler JA, Puckett ML, Hildebrandt HA,
et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:2191-200. [PMID:
14657426]
19. Kim SH, Lee JM, Eun HW, Lee MW, Han JK, Lee JY, et al. Two- versus
three-dimensional colon evaluation with recently developed virtual dissection
software for CT colonography. Radiology. 2007;244:852-64. [PMID:
17709833]
20. Johnson CD, Fletcher JG, MacCarty RL, Mandrekar JN, Harmsen WS,
Limburg PJ, et al. Effect of slice thickness and primary 2D versus 3D virtual
dissection on colorectal lesion detection at CT colonography in 452 asymptomatic adults. AJR Am J Roentgenol. 2007;189:672-80. [PMID: 17715116]
21. Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for
colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev. 2007:CD001216. [PMID: 17253456]
22. Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of
colorectal cancer screening: a systematic review for the U.S. Preventive Services
Task Force. Ann Intern Med. 2002;137:96-104. [PMID: 12118964]
Clinical Guidelines
23. Burch JA, Soares-Weiser K, St John DJ, Duffy S, Smith S, Kleijnen J, et al.
Diagnostic accuracy of faecal occult blood tests used in screening for colorectal
cancer: a systematic review. J Med Screen. 2007;14:132-7. [PMID: 17925085]
24. Young GP, Cole S. New stool screening tests for colorectal cancer. Digestion.
2007;76:26-33. [PMID: 17947816]
25. Petrone TJ, Steidley KD, Appleby A, Christman E, Haughey F. X-ray beam
energy, scatter, and radiation risk in chest radiography. Health Phys. 1996;70:
488-97. [PMID: 8617588]
26. Winawer SJ. Natural history of colorectal cancer. Am J Med. 1999;106:3S6S; discussion 50S-51S. [PMID: 10089106]
27. Regueiro CR. Will screening colonoscopy disappear and transform gastroenterology practice? Threats to clinical practice and recommendations to reduce
their impact: report of a consensus conference conducted by the AGA Institute
Future Trends Committee. Gastroenterology. 2006;131:1287-312. [PMID:
17030197]
28. Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J,
et al. American Cancer Society Colorectal Cancer Advisory Group. Screening
and surveillance for the early detection of colorectal cancer and adenomatous
polyps, 2008: a joint guideline from the American Cancer Society, the US MultiSociety Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008;134:1570-95. [PMID: 18384785]
29. American College of Obstetricians and Gynecologists. ACOG Committee
Opinion No. 384 November 2007: colonoscopy and colorectal cancer screening
and prevention. Obstet Gynecol. 2007;110:1199-202. [PMID: 17978144]
30. Canadian Task Force on Preventive Health Care. Colorectal cancer screening. Recommendation statement from the Canadian Task Force on Preventive
Health Care. CMAJ. 2001;165:206-8. [PMID: 11501466]
CME CREDIT
Readers can get CME credit for the following: 1) questions from the
ACP’s Medical Knowledge Self-Assessment Program (MKSAP) related to
In the Clinic articles that are published in the first issue of every month,
and 2) designated articles in each issue. To access CME questions, click
on the CME option under an article’s title on the table of contents at
www.annals.org. Subscribers may take the tests free of charge. For a
nominal fee, nonsubscribers can purchase tokens electronically that enable them to take the CME quizzes.
Reviewers who provide timely, high-quality reviews also may get CME
credit.
6
www.annals.org
4 November 2008 Annals of Internal Medicine Volume 149 • Number 9 637
www.MercyCareAdvantage.com
Annals of Internal Medicine
APPENDIX: U.S. PREVENTIVE SERVICES TASK FORCE
Members of the U.S. Preventive Services Task Force† are
Ned Calonge, MD, MPH, Chair (Colorado Department of Public Health and Environment, Denver, Colorado); Diana B.
Petitti, MD, MPH , Vice-Chair (Keck School of Medicine, University of Southern California, Sierra Madre, California);
Thomas G. DeWitt, MD (Children’s Hospital Medical Center,
Cincinnati, Ohio); Allen J. Dietrich, MD (Dartmouth Medical
School, Hanover, New Hampshire); Kimberly D. Gregory, MD,
MPH (Cedars-Sinai Medical Center, Los Angeles, California);
Russell Harris, MD, MPH (University of North Carolina School
of Medicine, Chapel Hill, North Carolina); George Isham, MD,
MS (HealthPartners Inc., Minneapolis, Minnesota); Michael L.
LeFevre, MD, MSPH (University of Missouri School of Medicine, Columbia, Missouri); Roseanne M. Leipzig, MD, PhD
7
W-116 4 November 2008 Annals of Internal Medicine Volume 149 • Number 9
(Mount Sinai School of Medicine, New York, New York): Carol
Loveland-Cherry, PhD, RN (University of Michigan School of
Nursing, Ann Arbor, Michigan); Lucy N. Marion, PhD, RN
(School of Nursing, Medical College of Georgia, Augusta, Georgia); Bernadette Melnyk, PhD, RN (Arizona State University
College of Nursing & Healthcare Innovation, Phoenix, Arizona);
Virginia A. Moyer, MD, MPH (University of Texas Health Science Center, Houston, Texas); Judith K. Ockene, PhD (University of Massachusetts Medical School, Worcester, Massachusetts);
George F. Sawaya, MD (University of California, San Francisco,
California); and Barbara P. Yawn, MD, MSPH, MSc (Olmsted
Medical Center, Rochester, Minnesota).
†Members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go
to www.ahrq.gov/clinic/uspstfab.htm.
www.annals.org
www.MercyCareAdvantage.com
Cholesterol management for patients with
cardiovascular conditions
Goal: To increase the percentage of members 18–75 years of age who were discharged status post AMI,
coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI), or who had a diagnosis of
ischemic vascular disease (IVD) who have an LDL-C less than 100 mg/dl.
Codes to identify LDL-C:
CPT
80061, 83700, 83701, 83704, 83721
8
www.MercyCareAdvantage.com
ATP III LDL cholesterol cutoffs for lifestyle
interventions and drug therapy in different risk
categories
Initiate therapeutic
lifestyle changes
Risk category
LDL cholesterol goal
Consider drug therapy
High risk: CHD or CHD
risk equivalents (10-year
risk >20%)
<100 mg/dL (with an
optional goal of <70 mg/
dL)
>100 mg/dL
>100 mg/dL (consider
drug options if LDL-C
<100 mg/dL)
Moderately high risk:
two or more risk factors
(10-year risk 10%-20%)
<130 mg/dL (with an
optional goal of <100
mg/dL)
>130 mg/dL
>130 mg/dL (consider
drug options if LDL-C
100-129 mg/dL)
Moderate risk: two or
more risk factors (10year risk <10%)
<130 mg/dL
>130 mg/dL
>160 mg/dL
Low risk: <1 risk factor
<160 mg/dL
>160 mg/dL
>190 mg/dL (consider
drug options if LDL-C
160-189 mg/dL)
Grundy SM et al. Circulation; available at http://circ.ahajournals.org
9
www.MercyCareAdvantage.com
Comprehensive diabetes care
Goal: To increase the percentage of diabetic members ages 18-75 who receive: at least annual HbA1c testing
with good control (less than 7%), annual lipid profiles with good control (less than 100 mg/dl), and biennial
retinal examinations (or annual if there is evidence of diabetic retinopathy), and nephropathy screening test
annually.
10
www.MercyCareAdvantage.com
Control your diabetes!
Take action now:
• Blood glucose A-1-C
• Blood pressure
• Cholesterol
Useful Websites:
Organization
Website
American Diabetes Association
www.diabetes.org
National Diabetes Education Program
www.ndep.nih.gov
American Association of Diabetes Educators
www.diabetesedcator.org
American Dietetic Association
www.eatright.org
National Institute of Diabetes and Digestive and
Kidney Diseases
www.diabetes.niddk.nih.gov
Centers for Disease Control and Prevention
www.cdc.gov/diabetes
11
www.MercyCareAdvantage.com
Mercy Care Advantage diabetes
management project
Recommendations for diabetic screening from American Diabetes Association:
HbA1C test
Lipid screening
Retinal eye exam
• HbA1C <7%
Every 6 months if well controlled (<7%)
Every 3 months if poorly controlled (>7%)
• LDL <100
Once a year
Annually by ophthalmologist or optometrist
Checklist for physician office staff
Front office
❏❏ Review chart - identify patient with diabetes
Back office
❏❏ Add diabetic care checklist
❏❏ Update diabetic care checklist
❏❏ Review recent lab - HbA1C, lipid panel in chart
❏❏ Request a copy of lab if it was ordered recently by physician or other specialists
❏❏ Request a copy of recent office notes by endocrinologist if any
Medical assistant/nurse
❏❏ Check body weight / height
❏❏ Check blood pressure (130/80mmhg)
❏❏ Check fasting blood glucose by glucometer if indicated
❏❏ Review & document the medications with patient vs in record (name, dosage & frequency)
❏❏ Instruct patient to take off shoes for sensory foot exam by physician
Referral
❏❏ Lab order - HbA1C & lipid panel
❏❏ Retinal eye exam referral to ophthalmologist or optometrist
❏❏ Diabetic class referral
Check out
❏❏ Provide diabetic education materials as indicated by physician
❏❏ Schedule next office visit - in 3 months
12
www.MercyCareAdvantage.com
Glaucoma screening in older adults
Goal: To increase the percentage of Medicare members 65 years and older (with no previous history of
glaucoma) who received a glaucoma eye exam by an eye care professional for early identification of
glaucomatous conditions in the current year or year prior.
Table GSO-A: Codes to identify glaucoma screening eye exams:
CPT
HCPCS
92002, 92004, 92012, 92014, 92081-92083,
92100, 92120, 92130, 92140, 99202-99205,
99213-99215, 99242-99245
G0117, G0118, S0620, S0621
13
www.MercyCareAdvantage.com
Consumer Assessment of Healthcare
Providers and Systems (CAHPS®)
health plan surveys
Goal: Flu vaccine (C06): To increase the percentage of Medicare members 65 years of age and older as of
January 1 of the measurement year who receive an annual influenza vaccination (as self reported by the
member).
14 www.MercyCareAdvantage.com
MEDICARE SATISFACTION SURVEY
2014 Medicare Advantage Prescription Drug Survey
MEDICARE SURVEY INSTRUCTIONS
This survey asks about you and the health care you received in the last six months. Answer each
question thinking about yourself. Please take the time to complete this survey. Your answers are very
important to us. Please return the survey with your answers in the enclosed postage-paid envelope to
the Center for the Study of Services.
Answer all the questions by putting an “X” in the box to the left of your answer, like this:
X Yes
Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. When this happens you will see
an arrow with a note that tells you what question to answer next, like this: [→If No, Go to Question 3].
See the example below:
EXAMPLE
1.
Do you wear a hearing aid now?
3.
Yes
X No → If No, Go to Question 3
2.
In the last 6 months, did you have any
headaches?
X Yes
No
How long have you been wearing a
hearing aid?
Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing aid
1.
Our records show that in 2013 your health
services were covered by the plan named on
the back page. Is that right?
Yes → If Yes, Go to Question 3
No
2.
Please write below the name of the health plan
you had in 2013 and complete the rest of the
survey based on the experiences you had with
that plan. (Please print)
______________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0732. The time required to complete this information collection is estimated to
average 20 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.
OMB 0938-0732
15
M14GEN2E01
www.MercyCareAdvantage.com
Your Health Care in the Last 6 Months
3.
7.
In the last 6 months, did you have an illness,
injury, or condition that needed care right away
in a clinic, emergency room, or doctor’s office?
None → If None, Go to Question 9
1
2
3
4
5 to 9
10 or more
Yes
No → If No, Go to Question 5
4.
In the last 6 months, when you needed care
right away, how often did you get care as soon
as you thought you needed?
Never
Sometimes
Usually
Always
5.
6.
8.
In the last 6 months, not counting the times
you needed care right away, how often did you
get an appointment for your health care at a
doctor’s office or clinic as soon as you thought
you needed?
Never
Sometimes
Usually
Always
Wait time includes time spent in the waiting
room and exam room. In the last 6 months, how
often did you see the person you came to see
within 15 minutes of your appointment time?
Never
Sometimes
Usually
Always
In the last 6 months, not counting the times
you needed care right away, did you make any
appointments for your health care at a doctor’s
office or clinic?
Yes
No → If No, Go to Question 7
In the last 6 months, not counting the times
you went to an emergency room, how many
times did you go to a doctor’s office or clinic to
get health care for yourself?
9.
In the last 6 months, did you phone a doctor’s
office or clinic with a medical question after
regular office hours?
Yes
No → If No, Go to Question 12
10. In the last 6 months, when you phoned a
doctor’s office or clinic after regular office
hours, how often did you get an answer to your
medical question as soon as you needed?
Never
Sometimes
Usually
Always
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11. In the last 6 months, when you phoned a
doctor’s office or clinic after regular office
hours, how long did it take for someone to
call you back?
Less than 1 hour
1 to 3 hours
More than 3 hours but less than 6 hours
More than 6 hours
I did not ask for a return call
I did not get a return call
I was told to go to the Emergency Room
12. Using any number from 0 to 10, where 0 is
the worst health care possible and 10 is the
best health care possible, what number would
you use to rate all your health care in the last
6 months?
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible
Your Personal Doctor
13. A personal doctor is the one you would see
if you need a check-up, want advice about a
health problem, or get sick or hurt. Do you
have a personal doctor?
Yes
No → If No, Go to Question 33
14. In the last 6 months, how many times did
you visit your personal doctor to get care
for yourself?
None → If None, Go to Question 33
1
2
3
4
5 to 9
10 or more
15. In the last 6 months, how often did your
personal doctor explain things in a way that
was easy to understand?
Never
Sometimes
Usually
Always
16. In the last 6 months, how often did your
personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
17. In the last 6 months, how often did your
personal doctor show respect for what you
had to say?
Never
Sometimes
Usually
Always
18. In the last 6 months, how often did your
personal doctor spend enough time with you?
Never
Sometimes
Usually
Always
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19. Using any number from 0 to 10, where 0 is the
worst personal doctor possible and 10 is the
best personal doctor possible, what number
would you use to rate your personal doctor?
0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor possible
20. In the last 6 months, when you visited your
personal doctor for a scheduled appointment,
how often did he or she have your medical
records or other information about your care?
Never
Sometimes
Usually
Always
21. In the last 6 months, did your personal doctor
order a blood test, x-ray or other test for you?
Yes
No → If No, Go to Question 24
22. In the last 6 months, when your personal
doctor ordered a blood test, x-ray or other test
for you, how often did someone from your
personal doctor’s office follow up to give you
those results?
Never → If Never, Go to Question 24
Sometimes
Usually
Always
23. In the last 6 months, when your personal
doctor ordered a blood test, x-ray or other test
for you, how often did you get those results as
soon as you needed them?
Never
Sometimes
Usually
Always
24. In the last 6 months, did you take any
prescription medicine?
Yes
No → If No, Go to Question 26
25. In the last 6 months, how often did you
and your personal doctor talk about all the
prescription medicines you were taking?
Never
Sometimes
Usually
Always
26. Doctors may use computers or handheld
devices during an office visit to do things like
look up your information or order prescription
medicines. In the last 6 months, did your
personal doctor use a computer or handheld
device during any of your visits?
Yes
No → If No, Go to Question 29
27. During your visits in the last 6 months, was
your personal doctor’s use of a computer or
handheld device helpful to you?
Yes, a lot
Yes, a little
No, not at all
28. During your visits in the last 6 months, did
your personal doctor’s use of a computer or
handheld device make it harder or easier for
you to talk to him or her?
Harder
Not harder or easier
Easier
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29. In the last 6 months, did you get care from
more than one kind of health care provider or
use more than one kind of health care service?
Yes
No → If No, Go to Question 32
30. In the last 6 months, did you need help from
anyone in your personal doctor’s office to
manage your care among these different
providers and services?
Yes
No → If No, Go to Question 32
31. In the last 6 months, did you get the help you
needed from your personal doctor’s office
to manage your care among these different
providers and services?
Yes, definitely
Yes, somewhat
No
32. Visit notes sum up what was talked about on
a visit to a doctor’s office. Visit notes may be
available on paper, on a website or by e-mail.
In the last 6 months, did anyone in your
personal doctor’s office offer you visit notes?
Yes
No
Getting Health Care From Specialists
33. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and other
doctors who specialize in one area of health
care. Is your personal doctor a specialist?
Yes → If Yes, Please include your
personal doctor as you answer
these questions about specialists
No
I do not have a personal doctor
34. In the last 6 months, did you try to make any
appointments to see a specialist?
Yes
No → If No, Go to Question 39
Someone else made my specialist
appointments for me
35. In the last 6 months, how often was it easy to
get appointments with specialists?
Never
Sometimes
Usually
Always
Someone else made my specialist
appointments for me
36. How many specialists have you seen in the last
6 months?
None → If None, Go to Question 39
1 specialist
2
3
4
5 or more specialists
37. We want to know your rating of the specialist
you saw most often in the last 6 months. Using
any number from 0 to 10, where 0 is the worst
specialist possible and 10 is the best specialist
possible, what number would you use to rate
that specialist?
0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible
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38. In the last 6 months, how often did your
personal doctor seem informed and up-to-date
about the care you got from specialists?
Never
Sometimes
Usually
Always
I do not have a personal doctor
I did not visit my personal doctor in the
last 6 months
My personal doctor is a specialist
Your Health Plan
39. In the last 6 months, did you try to get any
kind of care, tests or treatment through your
health plan?
Yes
No → If No, Go to Question 41
40. In the last 6 months, how often was it easy to
get the care, tests or treatment you thought
you needed through your health plan?
Never
Sometimes
Usually
Always
41. In the last 6 months, did you try to get
information or help from your health plan’s
customer service?
Yes
No → If No, Go to Question 44
43. In the last 6 months, how often did your health
plan’s customer service staff treat you with
courtesy and respect?
Never
Sometimes
Usually
Always
44. In the last 6 months, did your health plan give
you any forms to fill out?
Yes
No → If No, Go to Question 46
45. In the last 6 months, how often were the forms
from your health plan easy to fill out?
Never
Sometimes
Usually
Always
46. Using any number from 0 to 10, where 0 is the
worst health plan possible and 10 is the best
health plan possible, what number would you
use to rate your health plan?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible
42. In the last 6 months, how often did your
health plan’s customer service give you the
information or help you needed?
Never
Sometimes
Usually
Always
M14GEN2E06
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47. In the last 6 months, did anyone from a
doctor’s office or your health plan contact you:
Yes
No
a. To remind you to
make appointments
for tests or treatment?
b. To remind you to get
a flu shot or other
immunization?
c. To remind you about
screening tests
such as breast cancer
or colorectal cancer
screening?
48. In the last 6 months, did you spend one or
more nights in a hospital?
Yes
No → If No, Go to Question 50
49. In the last 6 months, did anyone from a
doctor’s office or your health plan contact you
to follow up about your hospital stay?
Yes
No
Your Medicare Rights
50. In the last 6 months, was there a time when
you believed you needed care or services that
your health plan decided not to give you?
Yes
No → If No, Go to Question 53
51. In the last 6 months, have you ever asked
anyone at your health plan to reconsider a
decision not to provide or pay for health care
or services?
Yes
No → If No, Go to Question 53
Don’t know → If Don’t know,
Go to Question 53
52. When you spoke to your health plan about
the decision not to provide care or services,
did they…
Please mark one or more.
Tell you that you can file an appeal
Offer to send you forms that you need
in order to file an appeal
Suggest how to resolve your complaint
Listen to your complaint but did not help
to resolve it
Discourage you from taking action
Do none of these things
53. In the last 6 months, have you called or written
your health plan with a complaint or problem?
Yes
No → If No, Go to Question 57
54. Thinking about the complaint process, regardless
of whether you agree or disagree with the final
outcome, how satisfied are you with how your
health plan handled your complaint?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
55. How long did it take for your health plan to
settle your complaint?
Same day
1 week
2 weeks
3 weeks
4 or more weeks
I am still waiting for it to be settled
56. Was your complaint or problem settled to
your satisfaction?
Yes
No
I am still waiting for it to be settled
M14GEN2E07
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Your Prescription Drug Plan
Now we would like to ask you some questions
about the prescription drug coverage you get
through your prescription drug plan.
57. You contact customer service to get information
about what is covered and how to use a drug
plan. In the last 6 months, did you try to get
information or help about prescriptions from
your prescription drug plan’s customer service?
Yes
No → If No, Go to Question 60
58. In the last 6 months, how often did your
prescription drug plan’s customer service give
you the information or help you needed about
prescription drugs?
Never
Sometimes
Usually
Always
I did not try to get information or
help from my prescription drug plan’s
customer service in the last 6 months
→ Go to Question 60
59. In the last 6 months, how often did your
prescription drug plan’s customer service staff
treat you with courtesy and respect when
you tried to get information or help about
prescription drugs?
Never
Sometimes
Usually
Always
I did not try to get information or
help from my prescription drug plan’s
customer service in the last 6 months
60. In the last 6 months, did you try to get
information from your prescription drug
plan about which prescription medicines
were covered?
Yes
No → If No, Go to Question 62
61. In the last 6 months, how often did your
prescription drug plan’s customer service give
you all the information you needed about
which prescription medicines were covered?
Never
Sometimes
Usually
Always
I did not try to get information or
help from my prescription drug plan’s
customer service in the last 6 months
62. In the last 6 months, did you try to get
information from your prescription drug plan
about how much you would have to pay for
your prescription medicines?
Yes
No → If No, Go to Question 64
63. In the last 6 months, how often did your
prescription drug plan’s customer service give
you all the information you needed about
how much you would have to pay for your
prescription medicines?
Never
Sometimes
Usually
Always
I did not try to get information or
help from my prescription drug plan’s
customer service in the last 6 months
M14GEN2E08
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64. In the last 6 months, how many different
prescription medicines did you fill or
have refilled?
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines
65. In the last 6 months, did a doctor prescribe a
medicine for you that your prescription drug
plan did not cover?
Yes
No → If No, Go to Question 68
66. When this happened, did you contact your
prescription drug plan to ask them to cover the
medicine your doctor prescribed?
Yes
No → If No, Go to Question 68
All my prescribed medicines are covered
→ Go to Question 68
67. When you contacted your prescription
drug plan about the decision not to cover a
prescription medicine did they…
Please mark one or more.
Tell you that you can file an appeal
Offer to send you forms that you need in
order to file an appeal
Suggest how to resolve your complaint
Listen to your complaint but did not help
to resolve it
Discourage you from taking action
Do none of the above
All my prescribed medicines were covered
68. In the last 6 months, did anyone from a
doctor’s office, pharmacy or your prescription
drug plan contact you:
Yes
No
a. To make sure you
filled or refilled
a prescription?
b. To make sure you were
taking medications
as directed?
69. In the last 6 months, how often was it easy
to use your prescription drug plan to get the
medicines your doctor prescribed?
Never
Sometimes
Usually
Always
I did not use my prescription drug plan to
get any medicines in the last 6 months
70. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription at
your local pharmacy?
Yes
No → If No, Go to Question 72
71. In the last 6 months, how often was it easy
to use your prescription drug plan to fill a
prescription at your local pharmacy?
Never
Sometimes
Usually
Always
I did not use my prescription drug plan
to fill a prescription at my local pharmacy
in the last 6 months
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72. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription
by mail?
Yes
No → If No, Go to Question 74
I am not sure if my drug plan
offers prescriptions by mail
→ Go to Question 74
73. In the last 6 months, how often was it easy
to use your prescription drug plan to fill a
prescription by mail?
Never
Sometimes
Usually
Always
I did not use my prescription drug plan
to fill a prescription by mail in the last
6 months
I am not sure if my drug plan offers
prescriptions by mail
74. Using any number from 0 to 10, where 0 is
the worst prescription drug plan possible and
10 is the best prescription drug plan possible,
what number would you use to rate your
prescription drug plan?
0 Worst prescription drug plan possible
1
2
3
4
5
6
7
8
9
10 Best prescription drug plan possible
75. Would you recommend your prescription drug
plan for coverage of prescription drugs to other
people like yourself?
Definitely yes
Somewhat yes
Somewhat no
Definitely no
About You
76. In general, how would you rate your
overall health?
Excellent
Very good
Good
Fair
Poor
77. In general, how would you rate your overall
mental or emotional health?
Excellent
Very good
Good
Fair
Poor
78. In the past 12 months, have you seen a doctor
or other health provider 3 or more times for
the same condition or problem?
Yes
No → If No, Go to Question 80
79. Is this a condition or problem that has lasted
for at least 3 months?
Yes
No
80. Do you now need or take any medicine
prescribed by a doctor for any condition?
Yes
No → If No, Go to Question 82
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81. Is this to treat a condition that has lasted for
at least 3 months?
Yes
No
82. In the last 6 months, did you delay or not fill
a prescription because you felt you could not
afford it?
Yes
No
My doctor did not prescribe any
medicines for me in the last 6 months
83. In the last 6 months, did you receive any mail
order medicines that you did not request?
Yes
No
Don’t know
84. Has a doctor ever told you that you had any
of the following conditions?
Yes
No
a. A heart attack?
b. Angina or coronary
heart disease?
c. Hypertension or
high blood pressure?
d. Cancer, other than
skin cancer?
e. Emphysema,
asthma or COPD
(chronic obstructive
pulmonary disease)?
f. Any kind of diabetes
or high blood sugar?
85. Have you had a flu shot since July 1, 2013?
Yes
No
Don’t know
86. Have you ever had a pneumonia shot? This shot
is usually given only once or twice in a person’s
lifetime and is different from a flu shot. It is also
called the pneumococcal vaccine.
Yes
No
Don’t know
87. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
Every day
Some days
Not at all → If Not at all,
Go to Question 89
Don’t know → If Don’t know,
Go to Question 89
88. In the last 6 months, how often were you
advised to quit smoking or using tobacco by
a doctor or other health provider?
Never
Sometimes
Usually
Always
I had no visits in the last 6 months
89. What is the highest grade or level of school that
you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
90. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
91. What is your race? Please mark one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
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92. How many people live in your household now,
including yourself?
1 person
2 to 3 people
4 or more people
93. The Medicare Program is trying to learn more
about the health care or services provided to
people with Medicare. May Medicare contact
you again about the health care services that
you received?
Yes
No
94. Did someone help you complete this survey?
Yes
No → Thank you. Please return the
completed survey in the postagepaid envelope.
95. How did that person help you? Please mark one
or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Thank you.
Please return the completed survey in the
postage-paid envelope to:
Center for the Study of Services
PO Box 1930
Manchester, CT 06045-9946
Please do not include any other correspondence.
Contract Name:
M14GEN2E
M14GEN2E12
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Health Outcome Surveys (HOS)
A survey administered to members to measure each member’s physical and mental health status at the
beginning and the end of a two-year period. NCQA, in partnership with the Centers for Medicare and Medicaid
Services, administers the HEDIS® Medicare Health Outcomes Survey.
27
www.MercyCareAdvantage.com
Medicare Health Outcomes Survey Instructions
This survey asks about you and your health. Answer each question, thinking about yourself.
Please take the time to complete this survey. Your answers are very important to us. If you
are unable to complete this survey, a family member or “proxy” can fill out the survey about
you.
Please return the survey with your answers in the enclosed postage-paid envelope.
Sample Questions:
 Answer the questions by putting an ‘X’ in the box next to the appropriate answer like this:
55. Are you male or female?
1
2
Male
Female
 Be sure to read all the answer choices given before marking a box with an ‘X.’
 You are sometimes told to answer some questions in this survey only when you have answered
a previous question. When this happens, you will see an italicized instruction like the one below:
If you answered "yes" to question 34 above (that you have had cancer),
All information that would permit identification of any person who completes
this survey is protected by the Privacy Act and the Health Insurance Portability
and Accountability Act (HIPAA). This information will be used only for purposes
permitted by law and will not be disclosed or released for any other reason. If
you have any questions or want to know more about the study, please call
[vendor name] at [toll-free number].
“According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information that does not display a valid OMB control
number. The valid OMB control number for this information collection is 09380701. The time required to complete this information collection is estimated to
average 20 minutes including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, C1-25-05, Baltimore, Maryland 21244-1850.”
OMB 0938-0701 Version 02-1
© 2014 by the National Committee for Quality Assurance (NCQA). This survey instrument may not be reproduced or
transmitted in any form, electronic or mechanical, without the express written permission of NCQA. All rights reserved.
Items 1–9: The VR-12 Health Survey item content was developed and modified from a 36-item health survey.
28
OMB 0938-0701
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Medicare Health Outcomes Survey
1.
In general, would you say your health is:
Excellent
1
2.
Very good
Good
2
Fair
3
4
Yes,
limited
a lot
2
3
b. Climbing several flights of stairs .................................
1
2
3
During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health?
Yes,
a little
of the
time
Yes,
some
of the
time
Yes,
all of
the
time
Yes,
most
of the
time
a. Accomplished less than you would like ....
1
2
3
4
5
b. Were limited in the kind of work or other
activities .....................................................
1
2
3
4
5
During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)?
Yes,
a little
of the
time
Yes,
some
of the
time
Yes,
all of
the
time
Yes,
most
of the
time
a. Accomplished less than you would like ....
1
2
3
4
5
b. Didn't do work or other activities as
carefully as usual ......................................
1
2
3
4
5
During the past 4 weeks, how much did pain interfere with your normal work (including both
work outside the home and housework)?
Not at all
29
No, not
limited
at all
1
No,
none
of the
time
5.
Yes,
limited
a little
a. Moderate activities, such as moving a table, pushing
a vacuum cleaner, bowling, or playing golf ..................
No,
none
of the
time
4.
5
The following items are about activities you might do during a typical day. Does your health
now limit you in these activities? If so, how much?
ACTIVITIES
3.
Poor
1
A little bit
2
Moderately
3
Quite a bit
4
Extremely
5
www.MercyCareAdvantage.com
These questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give the one answer that comes closest to the way you have
been feeling.
6.
How much of the time during the past 4 weeks:
All
of the
time
7.
Most
of the
time
A good
bit of
the time
Some
of the
time
A little
of the
time
None
of the
time
a. Have you felt calm and
peaceful? ..................................
1
2
3
4
5
6
b. Did you have a lot of energy? ...
1
2
3
4
5
6
c. Have you felt downhearted
and blue? ..................................
1
2
3
4
5
6
During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
All of
the time
1
Most of
the time
2
Some of
the time
3
A little of
the time
4
None of
the time
5
Now, we’d like to ask you some questions about how your health may have changed.
8.
Compared to one year ago, how would you rate your physical health in general now?
Much better
1
9.
2
About the
same
3
Slightly worse
4
Much worse
5
Compared to one year ago, how would you rate your emotional problems (such as feeling
anxious, depressed or irritable) in general now?
Much better
1
30
Slightly better
Slightly better
2
About the
same
3
Slightly worse
4
Much worse
5
www.MercyCareAdvantage.com
Earlier in the survey you were asked to indicate whether you have any limitations in your activities.
We are now going to ask a few additional questions in this area.
10. Because of a health or physical problem, do you have any difficulty doing the following
activities without special equipment or help from another person?
No, I do not
have difficulty
Yes, I have
difficulty
I am unable to
do this activity
a. Bathing ..............................................
1
2
3
b. Dressing ............................................
1
2
3
c. Eating ................................................
1
2
3
d. Getting in or out of chairs ..................
1
2
3
e. Walking .............................................
1
2
3
f. Using the toilet...................................
1
2
3
11. Because of a health or physical problem, do you have any difficulty doing the following activities?
No, I do not
have difficulty
a. Preparing meals ................................
b. Managing money ...............................
c. Taking medication as prescribed .......
Yes, I have
difficulty
I don’t do this
activity
1
2
3
1
2
3
1
2
3
These next questions ask about your physical and mental health during the past 30 days.
12. Now, thinking about your physical health, which includes physical illness and injury, for how
many days during the past 30 days was your physical health not good?
Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best
estimate is fine.
days
13. Now, thinking about your mental health, which includes stress, depression, and problems with
emotions, for how many days during the past 30 days was your mental health not good?
Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best
estimate is fine.
days
31
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14. During the past 30 days, for about how many days did poor physical or mental health keep
you from doing your usual activities, such as self-care, work, or recreation?
Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best
estimate is fine.
days
Now we are going to ask some questions about specific medical conditions.
Yes
No
15. Are you blind or do you have serious difficulty seeing, even when
wearing glasses? ......................................................................................
1
2
16. Are you deaf or do you have serious difficulty hearing, even with a
hearing aid?..............................................................................................
1
2
17. Because of a physical, mental, or emotional condition, do you have
serious difficulty concentrating, remembering or making decisions? ........
1
2
18. Because of a physical, mental, or emotional condition, do you have
difficulty doing errands alone such as visiting a doctor’s office or
shopping?.................................................................................................
1
2
19. In the past month, how often did memory problems interfere with your daily activities?
Every day
(7 days a week)
1
Most days
(5-6 days a
week)
2
Some days
(2-4 days a
week)
3
Rarely
(once a week or
less)
4
Never
5
Has a doctor ever told you that you had:
Yes
20. Hypertension or high blood pressure ........................................................
1
2
21. Angina pectoris or coronary artery disease ...............................................
1
2
22. Congestive heart failure ............................................................................
1
2
23. A myocardial infarction or heart attack ......................................................
1
2
24. Other heart conditions, such as problems with heart valves or the rhythm
of your heartbeat ......................................................................................
1
2
25. A stroke ....................................................................................................
1
2
26. Emphysema, or asthma, or COPD (chronic obstructive pulmonary
disease)....................................................................................................
1
2
32
OMB 0938-0701
No
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Has a doctor ever told you that you had:
Yes
No
27. Crohn’s disease, ulcerative colitis, or inflammatory bowel
disease.....................................................................................................
1
2
28. Arthritis of the hip or knee.........................................................................
1
2
29. Arthritis of the hand or wrist ......................................................................
1
2
30. Osteoporosis, sometimes called thin or brittle bones ................................
1
2
31. Sciatica (pain or numbness that travels down your leg to below your
knee) ........................................................................................................
1
2
32. Diabetes, high blood sugar, or sugar in the urine......................................
1
2
33. Depression ...............................................................................................
1
2
34. Any cancer (other than skin cancer) .........................................................
1
2
If you answered "yes" to question 34 above (that you have had cancer),
Yes
35. Are you currently under treatment for:
No
a. Colon or rectal cancer ..........................................................................
1
2
b. Lung cancer .........................................................................................
1
2
c. Breast cancer .......................................................................................
1
2
d. Prostate cancer ....................................................................................
1
2
e. Other cancer (other than skin cancer) ..................................................
1
2
36. In the past 7 days, how much did pain interfere with your day to day activities?
Not at all
A little bit
1
Somewhat
2
Quite a bit
3
4
Very much
5
37. In the past 7 days, how often did pain keep you from socializing with others?
Rarely
Never
1
Sometimes
2
Often
3
4
38. In the past 7 days, how would you rate your pain on average?
No
pain
1
2
3
4
5
6
7
8
9
01
02
03
04
05
06
07
08
09
Always
5
Worst imaginable
pain
10
10
OMB 0938-0701
33
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39. Over the past 2 weeks, how often have you been bothered by any of the following problems?
a. Little interest or pleasure in
doing things .........................
b. Feeling down, depressed or
hopeless ..............................
Not at all
Several
days
More than
half the
days
Nearly
every day
1
2
3
4
1
2
3
4
40. In general, compared to other people your age, would you say that your health is:
1
2
3
4
5
Excellent
Very good
Good
Fair
Poor
41. Do you now smoke every day, some days, or not at all?
1
2
3
4
Every day
Some days
Not at all
Don’t know
42. Many people experience problems with urinary incontinence, the leakage of urine. In the past 6
months, have you accidentally leaked urine?
1
2
Yes
Go to Question 43
No
Go to Question 46
43. How much of a problem, if any, was the urine leakage for you?
1
2
3
A big problem
Go to Question 44
A small problem
Go to Question 44
Not a problem
Go to Question 46
44. Have you talked with your current doctor or other health provider about your urine leakage
problem?
1
2
Yes
No
OMB 0938-0701
34
www.MercyCareAdvantage.com
45. There are many ways to treat urinary incontinence including bladder training, exercises,
medication and surgery. Have you received these or any other treatments for your current urine
leakage problem?
1
2
Yes
No
46. In the past 12 months, did you talk with a doctor or other health provider about your level of
exercise or physical activity? For example, a doctor or other health provider may ask if you
exercise regularly or take part in physical exercise.
1
2
3
Yes
Go to Question 47
No
Go to Question 47
I had no visits in the past 12 months
Go to Question 48
47. In the past 12 months, did a doctor or other health provider advise you to start, increase or
maintain your level of exercise or physical activity? For example, in order to improve your
health, your doctor or other health provider may advise you to start taking the stairs, increase
walking from 10 to 20 minutes every day or to maintain your current exercise program.
1
2
Yes
No
48. A fall is when your body goes to the ground without being pushed. In the past 12 months, did
you talk with your doctor or other health provider about falling or problems with balance or
walking?
1
2
3
Yes
No
I had no visits in the past 12 months
49. Did you fall in the past 12 months?
1
2
Yes
No
50. In the past 12 months, have you had a problem with balance or walking?
1
2
35
Yes
No
www.MercyCareAdvantage.com
51. Has your doctor or other health provider done anything to help prevent falls or treat problems
with balance or walking? Some things they might do include:




1
2
3
Suggest that you use a cane or walker.
Check your blood pressure lying or standing.
Suggest that you do an exercise or physical therapy program.
Suggest a vision or hearing testing.
Yes
No
I had no visits in the past 12 months
52. Have you ever had a bone density test to check for osteoporosis, sometimes thought of as
“brittle bones”? This test may have been done to your back, hip, wrist, heel or finger.
1
2
Yes
No
53. How much do you weigh in pounds (lbs.)?
lbs.
54. How tall are you without shoes on in feet (ft.) and inches (in.)? Please remember to fill in both
feet and inches (for example, 5 ft. 00 in.) If 1/2 in., please round up.
ft.
in.
55. Are you male or female?
1
2
Male
Female
56. Are you Hispanic, Latino/a or Spanish Origin? (One or more categories may be selected)
1
2
3
4
5
36
No, not of Hispanic, Latino/a or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a or Spanish origin
www.MercyCareAdvantage.com
57. What is your race? (One or more categories may be selected)
01
02
03
04
05
06
07
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
08
09
10
11
12
13
14
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
58. How well do you speak English?
1
2
3
4
Very well
Well
Not well
Not at all
59. What is your current marital status?
1
2
3
4
5
Married
Divorced
Separated
Widowed
Never married
60. What is the highest grade or level of school that you have completed?
1
2
3
4
5
6
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2 year degree
4 year college graduate
More than a 4 year college degree
61. Do you live alone or with others? (One or more categories may be selected)
1
2
3
4
5
37
Alone
With spouse/significant other
With children/other relatives
With non-relatives
With paid caregiver
OMB 0938-0701
www.MercyCareAdvantage.com
62. Where do you live?
1
2
3
4
House, apartment, condominium or mobile home Go to Question 63
Assisted living or board and care home
Nursing home
Go to Question 64
Other
Go to Question 64
Go to Question 63
63. Is the house or apartment you currently live in:
1
2
3
4
5
Owned or being bought by you
Owned or being bought by someone in your family other than you
Rented for money
Not owned and one in which you live without payment of rent
None of the above
64. Who completed this survey form?
1
2
3
4
Person to whom survey was addressed
Go to Question 66
Family member or relative of person to whom the survey was addressed
Friend of person to whom the survey was addressed
Professional caregiver of person to whom the survey was addressed
65. If you completed the survey for someone else, please fill in your name. DO NOT complete this
question if you completed the survey for yourself. Please print clearly.
First Name
Last Name
66. Which of the following categories best represents the combined income for all family
members in your household for the past 12 months?
Less than $5,000
01
02
03
04
05
06
07
08
09
10
38
$5,000–$9,999
$10,000–$19,999
$20,000–$29,999
$30,000–$39,999
$40,000–$49,999
$50,000–$79,999
$80,000–$99,999
$100,000 or more
Don’t know
OMB 0938-0701
www.MercyCareAdvantage.com
YOU HAVE COMPLETED THE SURVEY. THANK YOU.
Insert Vendor Contact Information Here
OMB 0938-0701
39
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Improving or maintaining physical activity
Goal: To increase the percentage of all plan members whose physical health was the same or better than
expected after two years.
40
www.MercyCareAdvantage.com
Improving or maintaining mental health
Goal: To increase the percentage of all plan members whose mental health was the same or better than
expected after two years.
41
www.MercyCareAdvantage.com
Physical activity in older adults
Goals:
• Discussing physical activity: To increase the percentage of Medicare members 65 years of age and older
who had a doctor’s visit in the past 12 months and who spoke with a doctor or other health provider about
their level of exercise or physical activity.
• Advising physical activity: To increase the percentage of Medicare members 65 years of age and older who
had a doctor’s visit in the past 12 months and who received advice to start, increase or maintain their level
exercise or physical activity.
42
www.MercyCareAdvantage.com
Adult body mass index (BMI) assessment
Goal: To increase the percentage of members 18–74 years of age who had an outpatient visit and who had
their BMI documented during the measurement year or the year prior the measurement year.
Codes to Identify BMI:
ICD-9-M Diagnosis
V85.0-V85.5
43
www.MercyCareAdvantage.com
Body Mass Index (BMI) Charts
http://www.vertex42.com/ExcelTemplates/bmi-chart.html
© 2009 Vertex42 LLC
Body Mass Index (BMI) Table for Adults
Obese (>30)
WEIGHT
lbs
260
255
250
245
240
235
230
225
220
215
210
205
200
195
190
185
180
175
170
165
160
155
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
(kg)
Overweight (25-30)
Normal (18.5-25)
Underweight (<18.5)
[42]
HEIGHT in feet/inches and centimeters
4'8"
4'9"
142cm
4'10" 4'11" 5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10" 5'11" 6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
147
155
157
160
163
165
168
170
173
175
178
185
188
191
193
196
150
152
180
183
(117.9)
58
56
54
53
51
49
48
46
45
43
42
41
40
38
37
36
35
34
33
32
32
(115.7)
57
55
53
51
50
48
47
45
44
42
41
40
39
38
37
36
35
34
33
32
31
31
30
(113.4)
56
54
52
50
49
47
46
44
43
42
40
39
38
37
36
35
34
33
32
31
30
30
(111.1)
55
53
51
49
48
46
45
43
42
41
40
38
37
36
35
34
33
32
31
31
30
29
(108.9)
54
52
50
48
47
45
44
43
41
40
39
38
36
35
34
33
33
32
31
30
29
28
(106.6)
53
51
49
47
46
44
43
42
40
39
38
37
36
35
34
33
32
31
30
29
29
28
(104.3)
52
50
48
46
45
43
42
41
39
38
37
36
35
34
33
32
31
30
30
29
28
27
(102.1)
50
49
47
45
44
43
41
40
39
37
36
35
34
33
32
31
31
30
29
28
27
27
(99.8)
49
48
46
44
43
42
40
39
38
37
36
34
33
32
32
31
30
29
28
27
27
26
(97.5)
48
47
45
43
42
41
39
38
37
36
35
34
33
32
31
30
29
28
28
27
26
25
(95.3)
47
45
44
42
41
40
38
37
36
35
34
33
32
31
30
29
28
28
27
26
26
25
(93.0)
46
44
43
41
40
39
37
36
35
34
33
32
31
30
29
29
28
27
26
26
25
24
(90.7)
45
43
42
40
39
38
37
35
34
33
32
31
30
30
29
28
27
26
26
25
24
24
(88.5)
44
42
41
39
38
37
36
35
33
32
31
31
30
29
28
27
26
26
25
24
24
23
(86.2)
43
41
40
38
37
36
35
34
33
32
31
30
29
28
27
26
26
25
24
24
23
23
(83.9)
41
40
39
37
36
35
34
33
32
31
30
29
28
27
27
26
25
24
24
23
23
22
(81.6)
40
39
38
36
35
34
33
32
31
30
29
28
27
27
26
25
24
24
23
22
22
21
(79.4)
39
38
37
35
34
33
32
31
30
29
28
27
27
26
25
24
24
23
22
22
21
21
(77.1)
38
37
36
34
33
32
31
30
29
28
27
27
26
25
24
24
23
22
22
21
21
20
(74.8)
37
36
34
33
32
31
30
29
28
27
27
26
25
24
24
23
22
22
21
21
20
20
(72.6)
36
35
33
32
31
30
29
28
27
27
26
25
24
24
23
22
22
21
21
20
19
19
(70.3)
35
34
32
31
30
29
28
27
27
26
25
24
24
23
22
22
21
20
20
19
19
18
(68.0)
34
32
31
30
29
28
27
27
26
25
24
23
23
22
22
21
20
20
19
19
18
18
(65.8)
33
31
30
29
28
27
27
26
25
24
23
23
22
21
21
20
20
19
19
18
18
17
(63.5)
31
30
29
28
27
26
26
25
24
23
23
22
21
21
20
20
19
18
18
17
17
17
(61.2)
30
29
28
27
26
26
25
24
23
22
22
21
21
20
19
19
18
18
17
17
16
16
(59.0)
29
28
27
26
25
25
24
23
22
22
21
20
20
19
19
18
18
17
17
16
16
15
(56.7)
28
27
26
25
24
24
23
22
21
21
20
20
19
18
18
17
17
16
16
16
15
15
(54.4)
27
26
25
24
23
23
22
21
21
20
19
19
18
18
17
17
16
16
15
15
15
14
(52.2)
26
25
24
23
22
22
21
20
20
19
19
18
17
17
16
16
16
15
15
14
14
14
(49.9)
25
24
23
22
21
21
20
19
19
18
18
17
17
16
16
15
15
15
14
14
13
13
(47.6)
24
23
22
21
21
20
19
19
18
17
17
16
16
16
15
15
14
14
13
13
13
12
(45.4)
22
22
21
20
20
19
18
18
17
17
16
16
15
15
14
14
14
13
13
12
12
12
(43.1)
21
21
20
19
19
18
17
17
16
16
15
15
14
14
14
13
13
13
12
12
12
11
(40.8)
20
19
19
18
18
17
16
16
15
15
15
14
14
13
13
13
12
12
12
11
11
11
(38.6)
19
18
18
17
17
16
16
15
15
14
14
13
13
13
12
12
12
11
11
11
10
10
(36.3)
18
17
17
16
16
15
15
14
14
13
13
13
12
12
11
11
11
11
10
10
10
9
Note: BMI values rounded to the nearest whole number. BMI categories based on CDC (Centers for Disease Control and Prevention) criteria.
www.vertex42.com
BMI = Weight[kg] / ( Height[m] x Height[m] ) = 703 x Weight[lb] / ( Height[in] x Height[in] )
© 2009 Vertex42 LLC
44
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Body Mass Index (BMI) Charts
http://www.vertex42.com/ExcelTemplates/bmi-chart.html
© 2009 Vertex42 LLC
[42]
Body Mass Index (BMI) Chart for Adults
280
40
260
Weight [ lbs ]
240
127.0
35
117.9
108.9
Obese
27
30
BMI 30 & Above
220
99.8
25
Overweight
200
22
90.7
BMI 25-30
180
Normal
81.6
18.5
BMI 18.5-25
160
72.6
Underweight
140
BMI < 18.5
63.5
120
54.4
100
45.4
36.3
80
4'8" 4'10" 5'0"
142cm 147 152
www.vertex42.com
45
136.1
Weight [ kg ]
300
5'2"
157
5'4"
163
5'6"
168
5'8" 5'10" 6'0"
173 178 183
Height (no shoes)
6'2"
188
6'4"
193
6'6"
198
6'8" 6'10" 7'0"
203 208 213cm
© 2009 Vertex42 LLC
www.MercyCareAdvantage.com
Clinical Guidelines
Screening for Obesity in Adults: Recommendations and Rationale
U.S. Preventive Services Task Force*
This statement summarizes the U.S. Preventive Services Task Force
(USPSTF) recommendations on screening for obesity in adults
based on the USPSTF’s examination of evidence specific to obesity
and overweight in adults and updates the 1996 recommendations
on this topic. The complete USPSTF recommendation and rationale
statement on this topic, which includes a brief review of the
supporting evidence, is available through the USPSTF Web site
(www.preventiveservices.gov), the National Guideline Clearinghouse (www.guideline.gov), and in print through the Agency for
Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, [email protected]). The complete
SUMMARY
OF
information on which this statement is based, including evidence
tables and references, is available in the accompanying article in
this issue and in the summary of the evidence and systematic
evidence review on the Web sites already mentioned. The summary of the evidence is also available in print through the Agency
for Healthcare Research and Quality Publications Clearinghouse.
Ann Intern Med. 2003;139:930-932.
www.annals.org
See related article on pp 933-949.
* For a list of the members of the U.S. Preventive Services Task Force, see the
Appendix.
RECOMMENDATIONS
The U.S. Preventive Services Task Force (USPSTF)
recommends that clinicians screen all adult patients for
obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.
This is a grade B recommendation. (See Appendix Table
1 for a description of the USPSTF classification of recommendations.)
studies were of fair to good quality but showed mixed results. In addition, studies were limited by small sample
sizes, high dropout rates, potential for selection bias, and
reporting the average weight change instead of the frequency of response to the intervention. As a result, the
USPSTF could not determine the balance of benefits and
potential harms of these types of interventions.
The USPSTF found good evidence that body mass index
(BMI), calculated as weight in kilograms divided by height in
meters squared, is reliable and valid for identifying adults at
increased risk for mortality and morbidity due to overweight
and obesity. (See Appendix Table 2 for a description of the
USPSTF classification of levels of evidence.) There is fair to
good evidence that high-intensity counseling—about diet, exercise, or both—together with behavioral interventions aimed
at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3 to 5 kg for 1
year) in adults who are obese (as defined by BMI 30 kg/
m2). Although the USPSTF did not find direct evidence that
behavioral interventions lower mortality or morbidity from
obesity, the USPSTF concluded that changes in intermediate
outcomes, such as improved glucose metabolism, lipid levels,
and blood pressure, from modest weight loss provide indirect
evidence of health benefits. No evidence was found that addressed the harms of counseling and behavioral interventions.
The USPSTF concluded that the benefits of screening and
behavioral interventions outweigh potential harms.
The USPSTF concludes that the evidence is insufficient to recommend for or against the use of counseling of
any intensity and behavioral interventions to promote sustained weight loss in overweight adults. This is a grade I
recommendation.
The USPSTF concludes that the evidence is insufficient to recommend for or against the use of moderate- or
low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. This
is a grade I recommendation.
The USPSTF found limited evidence to determine
whether moderate- or low-intensity counseling with behavioral interventions produces sustained weight loss in obese
(as defined by BMI 30 kg/m2) adults. The relevant
46930
2 December 2003 Annals of Internal Medicine Volume 139 • Number 11
The USPSTF found limited data that addressed the efficacy of counseling-based interventions in overweight adults (as
defined by BMI from 25 to 29.9 kg/m2). As a result, the
USPSTF could not determine the balance of benefits and potential harms of counseling to promote sustained weight loss in
overweight adults.
CLINICAL CONSIDERATIONS
A number of techniques, such as bioelectrical impedance, dual-energy x-ray absorptiometry, and total body water, can measure body fat, but it is impractical to use them
routinely. Body mass index, which is simply weight adjusted for height, is a more practical and widely used
method to screen for obesity. Increased BMI is associated
with an increase in adverse health effects. Central adiposity
increases the risk for cardiovascular and other diseases independent of obesity. Clinicians may use the waist circumference as a measure of central adiposity. Men with waist
circumferences greater than 102 cm (40 inches) and
women with waist circumferences greater than 88 cm
(35 inches) are at increased risk for cardiovascular disease. The waist circumference thresholds are not reliable
for patients with a BMI greater than 35 kg/m2.
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Screening for Obesity in Adults: Recommendations and Rationale
Expert committees have issued guidelines defining
overweight and obesity based on BMI. Persons with a BMI
between 25 and 29.9 kg/m2 are overweight, and those with
a BMI of 30 kg/m2 or more are obese. There are 3 classes
of obesity: class I (BMI 30 to 34.9 kg/m2), class II (BMI
35 to 39.9 kg/m2), and class III (BMI 40 kg/m2). Body
mass index is calculated either as weight in pounds divided
by height in inches squared multiplied by 703, or as weight
in kilograms divided by height in meters squared. The
National Institutes of Health (NIH) provides a BMI calculator at www.nhlbisupport.com/bmi/ and a table at www
.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.
The most effective interventions combine nutrition
education and diet and exercise counseling with behavioral
strategies to help patients acquire the skills and supports
needed to change eating patterns and to become physically
active. The 5-A framework (Assess, Advise, Agree, Assist,
and Arrange) has been used in behavioral counseling interventions such as smoking cessation and may be a useful
tool to help clinicians guide interventions for weight loss.
Initial interventions paired with maintenance interventions
help ensure that weight loss will be sustained over time.
It is advisable to refer obese patients to programs that
offer intensive counseling and behavioral interventions for
optimal weight loss. The USPSTF defined intensity of
counseling by the frequency of the intervention. A highintensity intervention is more than 1 person-to-person (individual or group) session per month for at least the first 3
months of the intervention. A medium-intensity intervention is a monthly intervention, and anything less frequent
is a low-intensity intervention. There are limited data on
the best place for these interventions to occur and on the
composition of the multidisciplinary team that should deliver high-intensity interventions.
The USPSTF concluded that the evidence on the effectiveness of interventions with obese people may not be
generalizable to adults who are overweight but not obese.
The evidence for the effectiveness of interventions for
weight loss among overweight adults, compared with obese
adults, is limited.
Orlistat and sibutramine, approved for weight loss by
the U.S. Food and Drug Administration, can produce
modest weight loss (2.6 kg to 4.8 kg) that can be sustained
for at least 2 years if the medication is continued. The
adverse effects of orlistat include fecal urgency, oily spotting, and flatulence; the adverse effects of sibutramine include an increase in blood pressure and heart rate. There
are no data on the long-term (2 years) benefits or adverse
effects of these drugs. Experts recommend that pharmacological treatment of obesity be used only as part of a program that also includes lifestyle modification interventions,
such as intensive diet and/or exercise counseling and behavioral interventions.
47www.annals.org
Clinical Guidelines
There is fair to good evidence to suggest that surgical
interventions such as gastric bypass, vertical banded gastroplasty, and adjustable gastric banding can produce substantial weight loss (28 kg to 40 kg) in patients with class III
obesity. Clinical guidelines developed by the National
Heart, Lung, and Blood Institute Expert Panel on the
identification, evaluation, and treatment of overweight and
obesity in adults recommend that these procedures be reserved for patients with class III obesity and for patients
with class II obesity who have at least 1 other obesityrelated illness. The postoperative mortality rate for these
procedures is 0.2%. Other complications include wound
infection, re-operation, vitamin deficiency, diarrhea, and
hemorrhage. Re-operation may be necessary in up to 25%
of patients. Patients should receive a psychological evaluation prior to undergoing these procedures. The long-term
health effects of surgery for obesity are not well characterized.
The data supporting the effectiveness of interventions
to promote weight loss are derived mostly from women,
especially white women. The effectiveness of the interventions is less well established in other populations, including
the elderly. The USPSTF believes that, although the data
are limited, these interventions may be used with obese
men, physiologically mature older adolescents, and diverse
populations, taking into account cultural and other individual factors.
The brief review of the evidence that is normally included in USPSTF recommendations is available in the
complete recommendation and rationale statement on the
USPSTF Web site (www.preventiveservices.ahrq.gov).
RECOMMENDATIONS
OF
OTHERS
The Canadian Task Force on Preventive Health Care
finds insufficient evidence to recommend for or against
BMI measurement in the periodic health examination of
the general population and found insufficient evidence to
recommend for or against community-based obesity prevention programs (1). The American Academy of Family
Physicians (2) and the American College of Obstetricians
and Gynecologists recommend periodic measurements of
height and weight. The NIH has a 2-step guideline of
assessment and treatment management of overweight and
obese individuals (3). The American College of Preventive
Medicine recommends periodic BMI measurement of all
adults and diet and exercise counseling of all adults (irrespective of BMI) and endorses NIH management guidelines (4). The American Diabetes Association has published a position statement that recommends the use of
intensive lifestyle modification programs along with standard weight loss strategies for long-term weight loss and
maintenance (5).
2 December 2003 Annals of Internal Medicine Volume 139 • Number 11 931
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Clinical Guidelines
Screening for Obesity in Adults: Recommendations and Rationale
Appendix Table 1. U.S. Preventive Services Task Force Grades
and Recommendations*
Grade
Recommendation
A
The USPSTF strongly recommends that clinicians routinely provide
[the service] to eligible patients. The USPSTF found good
evidence that [the service] improves important health outcomes
and concludes that benefits substantially outweigh harms.
The USPSTF recommends that clinicians routinely provide [the
service] to eligible patients. The USPSTF found at least fair
evidence that [the service] improves important health outcomes
and concludes that benefits outweigh harms.
The USPSTF makes no recommendation for or against routine
provision of [the service]. The USPSTF found at least fair
evidence that [the service] can improve health outcomes but
concludes that the balance of benefits and harms is too close to
justify a general recommendation.
The USPSTF recommends against routinely providing [the service]
to asymptomatic patients. The USPSTF found at least fair
evidence that [the service] is ineffective or that harms outweigh
benefits.
The USPSTF concludes that the evidence is insufficient to
recommend for or against routinely providing [the service].
Evidence that the [service] is effective is lacking, of poor
quality, or conflicting, and the balance of benefits and harms
cannot be determined.
B
C
D
I
* The U.S. Preventive Services Task Force (USPSTF) grades its recommendations
according to 1 of 5 classifications (A, B, C, D, I) reflecting the strength of evidence
and magnitude of net benefit (benefits minus harms).
Appendix Table 2. U.S. Preventive Services Task Force Grades
Medical School, Newark, New Jersey); Jonathan D. Klein, MD,
MPH (University of Rochester School of Medicine, Rochester,
New York); Tracy A. Lieu, MD, MPH (Harvard Pilgrim Health
Care and Harvard Medical School, Boston, Massachusetts); Cynthia D. Mulrow, MD, MSc (University of Texas Health Science
Center, San Antonio, Texas); C. Tracy Orleans, PhD (The Robert Wood Johnson Foundation, Princeton, New Jersey); Jeffrey
F. Peipert, MD, MPH (Women and Infants’ Hospital, Providence, Rhode Island); Nola J. Pender, PhD, RN (University of
Michigan, Ann Arbor, Michigan); Albert L. Siu, MD, MSPH
(Mount Sinai School of Medicine, New York, New York); Steven
M. Teutsch, MD, MPH (Merck & Co., Inc., West Point, Pennsylvania); Carolyn Westhoff, MD, MSc (Columbia University,
New York, New York); and Steven H. Woolf, MD, MPH (Virginia Commonwealth University, Fairfax, Virginia). This list includes members of the Task Force at the time these recommendations were finalized. For a list of current Task Force members,
go to www.ahrq.gov/clinic/uspstfab.htm.
From the U.S. Preventive Services Task Force, Agency for Healthcare
Research and Quality, Rockville, Maryland.
Disclaimer: The USPSTF recommendations are independent of the
U.S. government. They do not represent the views of the Agency for
Healthcare Research and Quality, the U.S. Department of Health and
Human Services, or the U.S. Public Health Service.
for Strength of Overall Evidence*
Grade
Definition
Good
Evidence includes consistent results from well-designed, wellconducted studies in representative populations that directly
assess effects on health outcomes
Evidence is sufficient to determine effects on health outcomes,
but the strength of the evidence is limited by the number,
quality, or consistency of the individual studies;
generalizability to routine practice; or indirect nature of the
evidence on health outcomes
Evidence is insufficient to assess the effects on health outcomes
because of limited number or power of studies, important
flaws in their design or conduct, gaps in the chain of
evidence, or lack of information on important health
outcomes
Fair
Poor
* The U.S. Preventive Services Task Force (USPSTF) grades the quality of the
overall evidence for a service on a 3-point scale (good, fair, poor).
APPENDIX
Members of the U.S. Preventive Services Task Force are
Alfred O. Berg, MD, MPH, Chair (University of Washington,
Seattle, Washington); Janet D. Allan, PhD, RN, CS, Vice-Chair
(University of Maryland Baltimore, Baltimore, Maryland); Paul
Frame, MD (Tri-County Family Medicine, Cohocton, and University of Rochester, Rochester, New York); Charles J. Homer,
MD, MPH (National Initiative for Children’s Healthcare Quality, Boston, Massachusetts); Mark S. Johnson, MD, MPH (University of Medicine and Dentistry of New Jersey–New Jersey
48
932 2 December 2003 Annals of Internal Medicine Volume 139 • Number 11
Requests for Single Reprints: Reprints are available from the USPSTF
Web site (www.preventiveservices.ahrq.gov) and in print through the
Agency for Healthcare Research and Quality Publications Clearinghouse
(telephone, 800-358-9295; e-mail, [email protected]).
References
1. Douketis JD, Feightner JW, Attia J, Feldman WF. Periodic health examination, 1999 update: 1. Detection, prevention and treatment of obesity. Canadian
Task Force on Preventive Health Care. CMAJ. 1999;160:513-25. [PMID:
10081468] Available at www.cmaj.ca/cgi/reprint/160/4/513.pdf.
2. American Academy of Family Physicians. Periodic Health Examinations.
Recommend: General Population. Revision 5.3, August 2002. Available at www
.aafp.org/x10598.xml.
3. National Heart, Lung, and Blood Institute Obesity Education Initiative. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight
and Obesity in Adults: The Evidence Report. NIH Publication No. 98-4083.
Bethesda, MD: U.S. Department of Health and Human Services, Public Health
Service, National Institutes of Health, National Heart, Lung, and Blood Institute;
1998.
4. Nawaz H, Katz DL. American College of Preventive Medicine Practice Policy
statement. Weight management counseling of overweight adults. Am J Prev Med.
2001;21:73-8. [PMID: 11418263] Available at www.acpm.org/polstmt_weight
.pdf.
5. Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, et al.
Evidence-based nutrition principles and recommendations for the treatment and
prevention of diabetes and related complications. Diabetes Care. 2002;25:14898. [PMID: 11772915] Available at http://care.diabetesjournals.org/cgi/content
/full/25/1/148.
www.annals.org
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Care of older adults
Goal: To increase the percentage of adults 66 years and older who had each of the following during the
measurement year.
• Advanced care planning – a discussion about preferences for resuscitation, life-sustaining treatment and
end of life care. Evidence of advanced care planning must include:
– The presence of an advanced care plan in the medical record, or
– Documentation of an advanced care planning discussion with the provider and the date when it was
discussed. The documentation of discussion must be noted in the measurement year, or
– Notation that the member previously executed an advance care plan.
• Medication review – at least one medication review conducted by a prescribing practitioner or clinical
pharmacist during the measurement year and the presence of a medication list in the medical record.
Documentation must come from the same medical record and must include the following.
– A medication list in the medical record, and evidence of a medication review by a prescribing practitioner
or clinical pharmacist and the date when it was performed
– Notation that the member is not taking any medication and the date when it was noted
• Functional status assessment – at least one functional status assessment during the measurement year.
• Pain screening – At least one pain assessment or pain management plan during the measurement year.
Documentation in the medical record must include evidence of a pain assessment and the date when it was
performed.
49
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Osteoporosis management in women
who have had a fracture
Goal: To increase the percentage of women 67 years of age and older who suffered a fracture and who had
either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six
months after the fracture.
Bone mineral density test codes:
CPT
HCPCS
ICD-9-CM Diagnosis
ICD-9-CM Procedure
76977, 77078-77083,
78350, 78351
G0130
V82.81
88.98
FDA-approved osteoporosis therapies:
Description
Prescription
JCodes
Biphosphonates
• alendronate
• zoledronic acid
Estrogens
• esterified estrogens
• estradiol
J1000
Miscellaneous
hormones
• calcitonin raloxifene
• teriparatide
J0630,
J3110,
J0897
Sex hormone
combinations
• conjugated estrogensmedroxy-progesterone
• estradiolnorethindrone
• estradiol-levonorgestrel
• estradiolnorgestimate
88.98
J1740,
J3488,
J3487
• ethinyl estradiolnorethindrone
50
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Osteoporosis management for
postmenopausal women
Osteoporosis is the most common bone disease in humans and represents a major public health problem
as outlined in the Surgeon General’s Report on Bone Health and Osteoporosis.1 Osteoporosis characteristics
include low bone mass, deterioration of bone tissue and disruption of bone architecture, compromised bone
strength, and an increased risk of fracture.
The National Osteoporosis Foundation has made the following major recommendations for preventing and
treating osteoporosis in postmenopausal women:2
1.. Counsel on the risk of
osteoporosis and related
fractures.
2.. Check for secondary causes.
3.. Advise on adequate amounts
of calcium (at least 1,200
mg/d, including supplements if
necessary) and vitamin D (800 to
1,000 IU per day of vitamin D3 for
individuals at risk of insufficiency).
4.. Recommend regular
weight- bearing and musclestrengthening exercise to reduce
the risk of falls and fractures.
5.. Advise avoidance of tobacco
smoking and excessive alcohol
intake.
6.. Recommend bone mineral
density (BMD) testing in women
age 65 and older.
7.. Recommend BMD testing in
postmenopausal women when
there is concern based on their
risk factor profile.
8.. Recommend BMD testing to
those who have suffered a
fracture, to determine degree of
disease severity.
9.. Initiate treatment in those
with hip or vertebral (clinical or
morphometric) fractures.
10..Initiate treatment in those
13..Follow these testing guidelines:
with BMD T-scores </= -2.5
BMD testing in DXA center is
at the femoral neck, total hip
appropriate for monitoring
or spine by dual-energy X-ray
bone loss (recommendation
absorptiometry (DXA), after
every two years). For patients on
appropriate evaluation.
pharmacotherapy, BMD testing in
DXA center is typically performed
11..Initiate treatment in
every two years after initiating
postmenopausal women with low
therapy.
bone mass at the femoral neck,
total hip or spine with 10-year hip
fracture probability >/= 3%, or a
10-year all major osteoporosisrelated fracture probability of >/=
20% based on the U.S.-adapted
World Health Organization
absolute fracture risk model.
12..Note that current FDAapproved pharmacologic
options for osteoporosis
prevention and/or treatment are
bisphosphonates (alendronate,
alendronate plus vitamin D,
ibandronate, risedronate,
risedronate plus calcium and
zoledronic acid), calcitonin,
estrogens, estrogen agonists
(raloxifene), and/or estrogen with
progesterone hormone therapy
and parathyroid hormone
(teriparatide).
* Testing should be done by the same equipment and using the same technique for comparability to earlier test results.
1
U.S. Department of Health and Human Services, Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville,
MD: U.S. Department of Health and Human Services, Office of the Surgeon General, 2004.
2
National Osteoporosis Foundation, Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, D.C., 2008.
51
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National resource list
National Osteoporosis
Foundation
1232 22nd St. NW
Washington, DC 20037
202-223-2226
1-800-231-4222
www.nof.org
Agency for Healthcare Research
and Quality (AHRQ)
540 Gaither Rd.
Rockville, MD 20850
301-427-1364
www.ahrq.gov
American College of
Rheumatology
1800 Century Pl., Ste. 250
Atlanta, GA 30345
404-633-3777
www.rheumatology.org
Department of Health & Human
Services Office on Women’s
Health
200 Independence Ave. SW
Washington, DC 20201
1-800-994-9662
www.4woman.gov
National Institute of Arthritis
and Musculoskeletal and Skin
Diseases (NIAMS) National
Institutes of Health Department
of HHS
1 AMS Cir.
Bethesda, MD 20892
301-495-4484
1-877-226-4267
www.niams.nih.gov
CME information
National Osteoporosis
Foundation Online Continuing
Education
Bone Quality & Osteoporotic
Fractures www.nof.org/cmexam/
Issue11BoneQuality/bone-quality.
htm
Medscape Online Continuing
Education
Drug Insight: Choosing a Drug
Treatment Strategy for Women
With Osteoporosis An Evidence-Based Clinical
Perspective http://cme.medscape.
com/ viewprogram/9117
Take advantage of free osteoporosis
resources.
Medscape Online Continuing
Education Supplementation
With Calcium and Vitamin D:
Efficacy Against Fracture and
Total Mortality:
A Best Evidence Review
http://cme.medscape.com/
viewprogram/8686
Mercy Care Advantage (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the Arizona Medicaid Program. Enrollment in Mercy Care
Advantage depends on contract renewal.
52
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AZ-12-06-10
Mercy Care Advantage (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the Arizona Medicaid Program.
Enrollment in Mercy

Care Advantage depends on contract renewal.
53
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Controlling high blood pressure
Goal: To increase the percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN)
and whose BP was adequately controlled (<140/90). The most recent BP reading during the measurement year
(as long as it occurred after the diagnosis of hypertension was made) is used for this measure.
Codes to identify hypertension:
Description
CPT® Category II Codes
ICD-9-CM Procedure
Hypertension
3074F, 3075F, 3077F,
3078F, 3079F, 3080F
401
54
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clinical MeDicine
The Importance of Accurate
Blood Pressure Measurement
Joel Handler, MD
Clinical Scenario
A woman, age 72 years, has
blood pressures of 150/70 mm Hg
and 150/80 mm Hg, obtained by a
medical assistant (MA), on consecutive office visits and does not have a
history of hypertension. The blood
pressure cuff is properly sized, the
MA is inquiring about the patient’s
last mammogram while obtaining
the blood pressure, and the patient
is helping to hold her arm up within
the MA’s grasp. The mean of a
dozen blood pressure readings that
the patient has obtained at home is
128/64 mm Hg. Does this patient
have white-coat hypertension?
Discussion
The most important commonly
performed office test is blood pressure measurement, yet it is considerably undervalued. In the Kaiser
Permanente Southern California
(KPSC) Region, more than 2,300,000
blood pressure measurements were
obtained by office staff in March
2009 (Ralph S Vogel, PhD, personal
communication, 2009 April).a MAs
often work in a rushed atmosphere,
and physicians want their patients
to be roomed promptly. However,
populationwide, small inaccuracies
in blood pressure measurement can
have considerable consequences.
Underestimating true blood pressure by 5 mm Hg would mislabel
more than 20 million Americans
with prehypertension when true
hypertension is present. It has been
predicted that the consequences of
an untreated 5 mm Hg of excessive
systolic blood pressure would be a
25% increase over current levels of
fatal strokes and fatal myocardial infarctions for these individuals.1 Conversely, overestimating true blood
pressure by 5 mm Hg would lead
to inappropriate treatment with antihypertension medications in almost
30 million Americans, with attendant
exposure to adverse drug effects, the
psychological effects of misdiagnosis, and unnecessary cost.2
The trap is that in acknowledging
the consequences of small measurement inaccuracies, errors of 5 to 10
mm Hg commonly occur as a result
of improper blood pressure technique. Table 1 lists blood pressure
aberrancies as a result of common errors. For example, active listening by
the patient, when the MA is talking
during blood pressure measurement,
can increase systolic blood pressure
by 10 mm Hg.3 Obtaining a measurement from an unsupported arm can
increase the systolic pressure by 10
mm Hg. Lack of back support and
crossed legs increase blood pressure.
If a patient needs to urinate, a blood
pressure measurement taken before
bladder emptying can increase the
systolic pressure by >10 mm Hg.
Measurements taken over clothing
or with tight clothing pushed up on
the arm, causing a tourniquet effect,
also produce significant artifacts.4
However, although many textbooks
state that the bell of the stethoscope
is more reliable than the diaphragm,
studies show that is not the case.5,6
Figure 1. Proper performance of a
sitting blood pressure measurement.
note a proper-size cuff over a bare
upper arm, which is positioned at
heart level and supported on a table;
the patient’s back is supported and
her feet are on the floor.
The commonplace use of the diaphragm side of the stethoscope is
satisfactory. Figure 1 illustrates the
proper technique for obtaining a
sitting blood pressure.
Terminal Digit
Preference
Terminal digit preference, a common source of error during manual
blood pressure examinations, is
the rounding off of numbers to the
nearest zero. Usually the result is
an inappropriate increase in the
diagnosis of hypertension because
systolic pressures in the upper 130s
are rounded up to 140 mm Hg. In a
KPSC blood pressure survey, 22% of
recorded blood pressure numbers
ended in zero; the expected occurrence would be 10%. Those results
are better, however, than those
from one literature survey, which
reported that 78% of recorded
… overestimating
true blood
pressure by 5 mm
hg would lead
to inappropriate
treatment with
antihypertension
medications in
almost 30 million
americans,
with attendant
exposure to
adverse drug
effects, the
psychological
effects of
misdiagnosis, and
unnecessary cost.2
Joel handler, Md, is an expert Panel Member of the eighth Joint national committee on High
Blood Pressure; Hypertension clinical lead, care Management institute; and Hypertension lead
for Southern california Kaiser Permanente, anaheim, ca. e-mail: [email protected].
The Permanente Journal/ Summer 2009/ Volume 13 No. 3
55
51
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clinical MeDicine
The Importance of Accurate Blood Pressure Measurement
Table 1. Factors affecting accuracy of blood pressure measure
Factor
Talking or active listening
Distended bladder
Cuff over clothing
Cuff too small
Smoking within 30 minutes of measurement
Paralyzed arm
Back unsupported
Arm unsupported, sitting
Arm unsupported, standing
“… if the
standing blood
pressure is
consistently
much lower
than the
sitting blood
pressure,
the standing
blood pressure
should be used
to titrate drug
doses during
treatment.”15
52
56
blood pressure numbers terminated
in zero.7,8 Although studies have
been reported showing that an
automated oscillometric device that
provides five serial blood pressure
measurements reduces the whitecoat effect compared with manual
determinations, 9,10 another study
has shown that blood pressure is
underestimated by this device, leading to significant misclassification
of hypertension.11 The use of an
automatic blood pressure monitor
does have the advantage of obviating terminal digit preference,12 but
the plethora of potential patient
preparation errors still remain.
Forearm Blood Pressure
What about taking a forearm blood
pressure on an obese patient? Nurses
often find that it is faster and easier to
take a forearm blood pressure than to
search for a larger cuff. Studies have
shown that forearm blood pressures
generally run 3.6/2.1 mm Hg higher
than upper arm blood pressures.13,14
The experience in KPSC has been that
once clinicians and MAs are taught
how to obtain forearm blood pressures, inappropriate usage of forearm
pressures becomes commonplace.
Therefore, we no longer teach this
technique. Instead, the regional mandate is to have both standard and
large blood pressure cuffs in every
primary care examination room. Using
a standard blood pressure arm cuff on
Magnitude of systolic/
diastolic blood pressure
discrepancy (mm Hg)
10/10
15/10
5–50/
10/2–8
6–20/
2–5/
6–10/
1–7/5–11
6–8/
an obese patient falsely raises systolic
blood pressure by approximately 10
mm Hg. “Miscuffing” should be
strongly discouraged.
Proper Technique
For which patients is a standing blood pressure measurement
most appropriate, and what is the
proper technique for obtaining
one? Particularly in patients who
are ≥70 years old and taking antihypertension medications, obtaining
standing blood pressure measurements should be routine practice.
Although the sitting blood pressure
measurement represents the standard in hypertension treatment trials,
standing systolic pressure decreases
of ≥20 mm Hg, consistent with a
diagnosis of orthostatic hypotension,
Figure 2. Proper measurement of
a standing blood pressure requires
complete arm support with cuff at
heart level. Hold the arm if an adjustable table is unavailable.
commonly occur and raise safety
and quality-of-life issues in geriatric
patients already at risk for dizziness
and falling. Therefore, the National
High Blood Pressure Working Group
report on Hypertension in the Elderly
concluded “… if the standing blood
pressure is consistently much lower
than the sitting blood pressure, the
standing blood pressure should be
used to titrate drug doses during
treatment.”15 An international neurology consensus statement endorsed
waiting “within three minutes” in the
standing position16 and others have
clarified this recommendation as being three minutes,17 but the protocol
used in the landmark HYpertension in
the Very Elderly Trial (HYVET) waited
two minutes.18 Having patients stand
for two to three minutes before their
upright blood pressure measurement
is taken is reasonable for hypertension management. When blood
pressure is properly measured in the
standing position, the arm should be
supported (Figure 2). When measurement is taken on a dangling arm, the
systolic pressure may artifactually be
6 to 10 mm Hg higher than in an arm
that is properly supported.19,20
Doctor or Nurse or
Medical Assistant
Who should be measuring the
blood pressure after all, physician
or nurse? In all of the hypertension
treatment trials, blood pressure has
been measured by trained nonphysicians, usually nurses. White-coat
effect is common and persistent. In
a classic study of nurse and physician blood pressures undertaken in
patients with continuous intra-arterial
blood pressure monitoring, two concurrent measurement phenomena
were observed: observer effect and
alerting reaction (Figure 3). After a
few minutes, a repeat blood pressure measurement obtained by both
a physician and a nurse produced
The Permanente Journal/ Summer 2009/ Volume 13 No. 3
www.MercyCareAdvantage.com
clinical MeDicine
The Importance of Accurate Blood Pressure Measurement
MAs is expanding in our system:
MAs receiving peer-validator training offer critiques and instruction to
their colleagues in a program that
has generated positive feedback
from participants. Additionally, a
new blood pressure measurement
training video is being developed,
with “train-the-trainer”8 Webinars
planned for later in 2009.
DSBP = change in systolic blood pressure, DDBP = change in diastolic blood pressure. reprinted
with permission from Mancia g, Parati g, Pomidossi g, grassi g, casadei r, Zanchetti a. alerting
reaction and rise in blood pressure during measurement by physician and nurse. Hypertension 1987
Feb;9(2):209–15.
results about 10/5 mm Hg lower
than the first determination, owing
to mitigation of the alerting reaction.
Nonetheless, there was a difference of
10/5 mm Hg between the physician
and the nurse with both the first and
second determinations, demonstrating the persistence of the observer, or
white-coat, effect.21 Patients are more
afraid of physicians than of nurses.
If an initial blood pressure reading
obtained by an MA is elevated and
a physician then obtains a follow-up
reading, that second reading may be
lower because the alerting reaction
has subsided, or it may be higher
because of doctor-related white-coat
effect. Physicians taking blood pressure measurements should be knowledgeable regarding proper technique
and the causes of artifacts.
Multiple competent blood pressure measurements by MAs can
obviate the white-coat effect. Two
studies have shown that several measurements obtained by nurses can
approximate mean blood pressure
measurements obtained by 24-hour
ambulatory blood pressure recordings.22,23 The discrepancy between
office blood pressure measurements
and 24-hour ambulatory measurements is at least in part because of
poor office competence in obtaining accurate readings. When there
is concern regarding the possibility of the white-coat effect, having
MAs obtain weekly blood pressure
measurements for two weeks should
be considered. Whenever the first
blood pressure reading is elevated,
a second reading should be obtained
after a one-minute interval.
Patients
Patients are increasingly helpful
as quality-assurance monitors. Educational materials are available to
teach proper home blood pressure
measurement technique, and other
general patient-education materials demonstrating blood pressure
measurement competency have
been distributed. On a few occasions, we have received accurate
criticism of blood pressure measurement technique performed by our
staff from patients in KPSC. Also,
peer-validator competency review
of blood pressure measurement by
The Permanente Journal/ Summer 2009/ Volume 13 No. 3
57
Photograph courtesy of Mid-atlantic States region, Kaiser Permanente.
Figure 3. Demonstration of relative blood pressure alerting reactions and
observer effects, comparing physician and nurse.
Conclusions
The patient whose case was
presented at the beginning of this
article does not have hypertension
despite the elevated office readings,
and she does not need home blood
pressure measurements for a diagnosis of white-coat hypertension to
be made. White-coat hypertension
indicates a dissociation between
competently determined office blood
pressure elevations and normal blood
pressure readings obtained at home.
Therefore, findings for this patient
do not qualify for a diagnosis of
white-coat hypertension, because the
office blood pressure readings are
inaccurate. Terminal digit preference
if an initial blood
pressure reading
obtained by an
Ma is elevated
and a physician
then obtains
a follow-up
reading, that
second reading
may be lower
because the
alerting reaction
has subsided,
or it may be
higher because
of doctor-related
white-coat effect.
Figure 4. What is wrong with the blood pressure
measurement technique in this picture? can you list
all ten errors? (Key to answers on page 54.)
53
www.MercyCareAdvantage.com
clinical MeDicine
The Importance of Accurate Blood Pressure Measurement
is a marker of inaccurate office technique: all four office measurements
for the patient ended in zero. Active
listening by the patient, from whom
medical information was requested
during blood pressure measurement,
and partial patient support of her
outstretched arm could easily have
accounted for a systolic artifact of >10
mm Hg. This patient was exposed to
the possibility of receiving an inaccurate diagnosis of hypertension and
taking inappropriate antihypertension
medications. Her case illustrates potential patient care problems ensuing from poor office blood pressure
measuring technique.
Take a minute to examine Figure 4
and list all ten errors in obtaining the
sitting blood pressure shown. (Key
to answers listed below.) v
a
Practice leader, Data consulting and
report Production, Southern california Permanente Medical group
clinical analysis
disclosure statement
The author(s) have no conflicts of
interest to disclose.
5.
6.
7.
8.
9.
10.
11.
acknowledgment
Katharine O’Moore-Klopf, ELS, of KOK
Edit provided editorial assistance.
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of white coat hypertension. arch intern
Med 1992 apr;152(4):750–6.
Jula a, Puukka P, Karanko H. Multiple
clinic and home blood pressure measurements versus ambulatory blood
pressure monitoring. Hypertension 1999
aug;34(2):261–6.
Figure 4. What is wrong with the blood
pressure measurement technique in
this picture? Key for errors: 1) Patient’s
arm is unsupported; 2) Patient’s back is
unsupported; 3) Patient is talking; 4) Patient
is engaged in active listening; 5) Wrong
size cuff in use (“miscuffing”); 6) Blood
pressure cuff is positioned too low on the
upper arm; appears to be over the elbow;
the artery marker on the cuff is probably
malpositioned as well; 7) Cuff is over clothing; 8) Observer is not at eye level with the
monitor; where is the monitor? 9) Patient’s
legs are crossed; 10) End of stethoscope is
in clinician’s coat pocket.
The Permanente Journal/ Summer 2009/ Volume 13 No. 3
www.MercyCareAdvantage.com
Rheumatoid arthritis:
Use of disease modifying anti-rheumatic drugs (DMARDs)
Goal: To increase the percentage of members who were diagnosed with rheumatoid arthritis and who were
dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). See
attached information sheet for the list of DMARDs on the Mercy Care Advantage formulary.
Codes to identify rheumatoid arthritis:
Description
ICD-9-CM Procedure
Rheumatoid arthritis
714.0, 714.1, 714.2, 714.81
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DMARDs on Mercy Care Advantage formulary
• Methotrexate – requires prior authorization for 25 mg/ml vial only
• Cyclosporine – requires prior authorization
• Sulfasalazine
• Cyclophosphamide – requires prior authorization
• Hydoxychloroquine
• Leflunomide
• Etanercept (Enbrel)
• Adalimumab (Humira) – requires prior authorization
• Infliximab (Remicade) – requires prior authorization
• Azathioprine – requires prior authorization
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Rheumatoid arthritis:
Key priorities for implementation
Referral for specialist treatment
• Refer for specialist opinion any person with suspected persistent synovitis of undetermined cause.
• Refer urgently if any of the following apply:
– The small joints of the hands or feet are affected
– More than one joint is affected
– There has been a delay of 3 months or longer between onset of symptoms and seeking medical advice.
Disease-modifying and biological drugs
• In people with newly diagnosed active RA, offer a combination of disease-modifying antirheumatic drugs
(DMARDs) (including methotrexate and at least one other DMARD, plus shortterm glucocorticoids) as firstline treatment as soon as possible, ideally within 3 months of the onset of persistent symptoms.
• In people with newly diagnosed RA for whom combination DMARD therapy is not appropriate1, start DMARD
monotherapy, placing greater emphasis on fast escalation to a clinically effective dose rather than on the
choice of DMARD.
• In people with recent-onset RA receiving combination DMARD therapy and in whom sustained and
satisfactory levels of disease control have been achieved, cautiously try to reduce drug doses to levels that
still maintain disease control.
Monitoring disease
• In people with recent-onset active RA, measure C-reactive protein (CRP) and key components of disease
activity (using a composite score such as DAS28) monthly until treatment has controlled the disease to a
level previously agreed with the person with RA.
• The multidisciplinary team
• People with RA should have access to a named member of the multidisciplinary team (MDT) (for example,
the specialist nurse) who is responsible for coordinating their care.
For example, because of comorbidities or pregnancy, during which certain drugs would be contraindicated.
1
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Improving bladder control
Goals:
• Discussing urinary incontinence: To increase the percentage of Medicare members 65 years of age and
older who reported having a problem with urine leakage in the past six months and who discussed their
urine leakage problem with their current practitioner.
• Receiving urinary incontinence treatment: To increase the percentage of Medicare members 65 years
of age and older who reported having a urine leakage problem in the past six months and who received
treatment for their current urine leakage problem.
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Reducing the risk of falling
Goals:
• Discussing fall risk: To increase the percentage of Medicare members 75 years of age and older or
65–74 years of age with balance or walking problems or a fall in the past 12 months, who were seen by a
practitioner in the past 12 months and who discussed falls or problems with balance or walking with their
current practitioner.
• Managing fall risk: To increase the percentage of Medicare members 65 years of age and older who had a
fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the
past 12 months and who received fall risk intervention from their current practitioner.
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Plan all cause readmissions
Goal: To decrease the number of members who have an acute inpatient stay followed by an acute readmission
for any diagnosis within 30 days.
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