Hypertension: Improvement in Blood Pressure

Last updated: May 18, 2016

CMS Measure ID: CMS65v4
Version: 4
NQF Number: None
Measure Description:

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

Initial Patient Population:

All patients aged 18-85 years of age, who had at least one outpatient visit in the first six months of the measurement year, who have a diagnosis of essential hypertension documented during that outpatient visit, and who have uncontrolled baseline blood pressure at the time of that visit

Denominator Statement:

Equals Initial Patient Population

Denominator Exclusions:
  • Exclude from the denominator all patients with evidence of end-stage renal disease (ESRD) on or prior to December 31 of the measurement year. Documentation of dialysis or kidney transplant also meets the criteria for evidence of ESRD.
  • Exclude from the denominator all patients with a diagnosis of pregnancy during the measurement year.
Numerator Statement:

Patients whose follow-up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled.

If a follow-up blood pressure reading is not recorded during the measurement year, the patient’s blood pressure is assumed “not improved.”

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare & Medicaid Services
National Quality Strategy Domain: Effective Clinical Care
Next Version: Hypertension: Improvement in Blood Pressure
Measure Score: Proportion
Score Type: Outcome
Improvement Notation:

A higher score indicates better quality

Guidance:

Blood pressure readings must be taken while the patient is sitting. If multiple measurements occur on the same date, the last systolic and diastolic readings should be used.

Occurrence A of Physical Exam, Finding: Systolic Blood Pressure (result) represents the baseline blood pressure, which must occur prior to Occurrence B of Physical Exam, Finding: Systolic Blood Pressure (result), which represents the follow-up blood pressure.

To calculate the Physical Exam, Finding: Delta systolic blood pressure (result) data element, subtract the value of Occurrence B of Physical Exam, Finding: Systolic Blood Pressure (result) from the value of Occurrence A of Physical Exam, Finding: Systolic Blood Pressure (result).

The data element Physical Exam, Finding: Delta systolic blood pressure (result) is intended to represent the result of the mathematic comparison between systolic blood pressures taken during two separate visits. This is a calculation artifact, and there’s no requirement to document the delta data element in the medical record.

Specifications

External Resources