eMeasure Title Preventive Care and Screening: Cholesterol - Fasting Low Density Lipoprotein (LDL-C) Test Performed
eMeasure Identifier
(Measure Authoring Tool)
61 eMeasure Version number 2
NQF Number Not Applicable GUID 0a7f0278-a05c-40aa-94a4-70ec44f5c568
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Centers for Medicare & Medicaid Services
Measure Developer Quality Insights of Pennsylvania
Endorsed By None
Description
Percentage of patients aged 20 through 79 years whose risk factors have been assessed and a fasting LDL-C test has been performed.
Copyright
Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications.

CPT (R) contained in the Measure specifications is copyright 2007-2011 American Medical Association. 

LOINC (R) copyright 2004-2011 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2011 International Health Terminology Standards Development Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Disclaimer
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
Measure Scoring Proportion
Measure Type Process
Stratification
There are three criteria for this measure based on the patient’s risk category. 
1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Equivalent 
2. Moderate Level of Risk: Multiple (2+) Risk Factors 
3. Lowest Level of Risk: 0 or 1 Risk Factor
Risk Adjustment
None
Rate Aggregation
This measure will be calculated for each of the three strata based on risk category for all patients aged 20 through 79 years who were seen by the eligible professional during the measurement period.
Rationale
The Agency for Healthcare Research and Quality (AHRQ) conducts systematic evidence reviews prior to recommendations issued by the U.S. Preventive Services Task Force (USPSTF). In the systematic evidence review, Screening for Lipid Disorders, (Pignone et al. 2001), “Coronary Heart Disease (CHD) was identified as the leading cause of morbidity and mortality in the United States, causing nearly 500,000 deaths each year and requiring nearly 12 million hospital days of care per year. It is the leading cause of disabled life-years and is second only to injuries as a cause of life-years lost. The age-adjusted annual death rate for CHD is 100 per 100,000 persons overall and 140 per 100,000 persons among African Americans. The lifetime risk of having a CHD event, calculated at age 40, is estimated to be 49% for men and 32% for women in the United States. CHD accounted for $78 billion in health care costs in 1995.

The risk of CHD is independently related to several potentially modifiable risk factors besides abnormal lipids, including smoking, diabetes, hypertension, and physical inactivity. Recent epidemiologic studies and basic science research expanded knowledge about several new potential CHD risk factors. Use of a Framingham risk-based algorithm that directly incorporates age, the presence and magnitude of other risk factors, and measures of total cholesterol and HDL is the most accurate approach. Screening for lipid disorders by measuring cholesterol levels in adult patients is quite feasible for physicians because it involves ordering only a blood test. Providers appear to have achieved high levels of lipid screening based on population-based patient survey data. (AHRQ, 2001) This systematic review recommends using a supplemental table to improve the feasibility of a risk-based strategy. 

The primary recommendation of several advisory bodies state adults should undergo an office-based assessment as the first step to identify patients at a higher CHD risk. The National Cholesterol Education Program Panel III (NCEP-III) has adopted using an adaptation of the risk prediction algorithm originating from the Framingham Heart Study estimating a patient’s 10-year risk for developing CHD and has recommended its use as the primary goal of preventive treatment. Stratifying CHD risk includes determining if CHD is present as well as CHD risk equivalents and major CHD risk factors. A history of CHD includes myocardial infarction, myocardial ischemia, angina (stable, unstable), percutaneous transluminal coronary angioplasty & coronary artery bypass surgery. CHD risk equivalents include peripheral artery disease, abdominal aortic aneurysm, thrombotic stroke, transient ischemic attacks, diabetes & Framingham 10-yr CHD risk > 20%. Major CHD risk factors include age, yr (men > 45; women > 55), cigarette smoking, hypertension (BP >140/90 mm Hg) or anti hypertensive medication, Low HDL-C (<40 mg/dL) & negative risk factor: high HDL-C (>60 mg/dL). The Framingham risk categories include gender, age, systolic blood pressure, smoking status, total cholesterol, and HDL-C levels. 

A potential limitation of the NCEP-III guidelines is the underestimation of risk in young individuals and women, as highlighted in previous reports. While the NCEP Panel III guidelines are generally valuable in predicting CVD, etc., they may under-predict the risk for relatively young persons (men under age 55 and women under age 65) and women in general. This is further supported by Akosah et al. (2003) that "75% of 222 asymptomatic young adults presenting with their first and unheralded myocardial infarction would not have been considered candidates for statin therapy in the days preceding the event, and the finding by Hecht et al. (2001) "that only 59% of 304 asymptomatic women submitted to EBT screening were correctly identified by NCEP guidelines as either high or low risk." 

In multiple clinical trials, greater LDL-C reduction in both primary and secondary prevention populations can achieve greater reductions in relative risk of CHD. The Adult Treatment Panel (ATP)-II and ATP-III goals were adjusted downward to the current recommendations (Grundy, 2008).
Clinical Recommendation Statement
Routine cholesterol testing should begin in young adulthood (>= 20 years of age). When LDL cholesterol concentrations range from 100-129 mg/dL, young adults should be encouraged to modify life habits to minimize long-term risk. In those with borderline high LDL cholesterol (130-159 mg/dL), clinical attention through therapeutic lifestyle changes is needed both to lower LDL cholesterol and to minimize other risk factors. If LDL cholesterol is high (160-189 mg/dL), more intensive clinical intervention should be initiated, with emphasis on therapeutic lifestyle changes. 

However, if LDL cholesterol remains elevated despite therapeutic lifestyle changes, particularly when LDL cholesterol is >= 190 mg/dL, consideration should be given to long-term management with LDL-lowering drugs. 

ATP III recognizes that detection of cholesterol disorders and other coronary heart disease (CHD) risk factors occurs primarily through clinical case finding. Risk factors can be detected and evaluated as part of a person’s work-up for any medical problem. Alternatively, public screening programs can identify risk factors, provided that affected individuals are appropriately referred for physician attention. The identification of cholesterol disorders in the setting of a medical examination has the advantage that other cardiovascular risk factors including prior CHD, PVD, stroke, age, gender, family history, cigarette smoking, high blood pressure, diabetes mellitus, obesity, physical inactivity co-morbidities, and other factors can be assessed and considered prior to treatment. 
National Cholesterol Education Program 
National Heart, Lung, and Blood Institute 
National Institutes of Health 
NIH Publication No. 02-5215 
September 2002 

The U.S. Preventive Services Task Force (USPSTF), 2008 strongly recommends screening men aged 35 and older for lipid disorders. 

The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. 

The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. 

The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. 

The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease. 

The National Strategy for Quality Improvement in Health Care for 2011 has identified the promotion of the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease as one of its’ national priorities. These priorities are based on the most recent research as well as stakeholder input. Opportunities for success include increase blood pressure control in adults, reduced high cholesterol levels in adults, and decrease smoking among adults and adolescents. Illustrative measures include: 

• Percentage of patients ages 18 years and older with ischemic vascular disease whose most recent blood pressure during the measurement year is <140/90 mm Hg 
• Percentage of patients with ischemic vascular disease whose most recent low-density cholesterol is <100 
• Percentage of patients who received evidence-based smoking cessation services (e.g., medications) 

The U.S. Department of Health and Human Service’s Healthy People 2020 has set a target of 82.1% for HDS-6: Increase the proportion of adults who have had their blood cholesterol checked within the preceding 5 years (a 10% improvement over the next decade).
Improvement Notation
Higher score indicates better quality.
Reference
Grundy, S.M. (2008).  Promise of low-density lipoprotein lowering therapy for primary and secondary prevention circulation, 117(5), 69-573 DOI: 10.1161/CIRCULATIONAHA.107.720300
Reference
Health & Human Services. (2011). The National Strategy for Quality Improvement in Health Care for 2011
Reference
Hecht, H.S., Superko, H.R. (2001) Electron beam tomography and National Cholesterol Education Program guidelines in asymptomatic women. Journal of American College of Cardiology, 37(6), 1506-11. Retrieved from http://www.sciencedirect.com/science/article/pii/S0735109701012116
Reference
Pignone MP, Phillips CJ, Lannon CM, Mulrow CD, Teutsch SM, Lohr KN, Whitener BL. Screening for lipid disorders. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ), 2001. (Systematic evidence review; no. 4) Retrieved from http://guideline.gov/content.aspx?id=12634&search=screening+for+lipid+disorders+in+adults
Reference
U. S. Department of Health and Human Services, (2002). Third Report of the National Cholesterol Educational Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III) Final Report, NIH Publication No. 02-5215
Reference
U.S. Preventive Services Task Force (2008). Screening for lipid disorders in adults: U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Jun. 13 p.
Definition
CHD Risk Equivalent: 
A CHD risk equivalent is a condition that carries an absolute risk for developing new CHD equal to the risk for having recurrent CHD events in persons with established CHD including:  
•  Atherosclerotic disease
  o  Peripheral arterial disease (PAD)
  o  Carotid artery disease
  o  Abdominal aortic aneurysm (AAA)
•  Diabetes
  o  Type 1 
  o  Type 2

CHD Risk Factors:
•  Cigarette smoking
•  Active diagnosis of hypertension or on antihypertensive medication
•  Low HDL cholesterol (HDL-C) (<40 mg/dL)
•  Family history of premature CHD
  o  CHD in male first-degree relative <55 years
      OR
  o  CHD in female first-degree relative <65 years
•  Age (men >= 45 years; women >=55 years)

Most Recent LDL-C Test:  A LDL-C test performed or LDL-C result verified by another provider
Guidance
This is part of a two-part measure which is paired with Preventive Care and Screening: Cholesterol – Risk-Stratified Fasting LDL-C. If the fasting LDL-C test is performed, other measure should also be reported.

To be eligible for performance calculations, patients must have at least one face-to-face visit with the eligible professional during the measurement period and have one LDL-C performed during the same measurement period with the exception of patients with 0 or 1 risk factors who may have an LDL-C performed up to four (4) years prior to the current measurement period
Transmission Format
TBD
Initial Patient Population
All patients 20 through 79 years of age before the beginning of the measurement period
Denominator
Denominator 1: (High Risk) 
All patients aged 20 through 79 years who have CHD or CHD Risk Equivalent

Denominator 2 : (Moderate Risk) 
All patients aged 20 through 79 years who have Multiple Risk Factors (2+) of the following: Cigarette Smoking, Hypertension, Low High Density Lipoprotein (HDL-C)**, Family History of Premature CHD, or Age (men >= 45; women >= 55)

Denominator 3 : (Low Risk) 
All patients aged 20 through 79 years who have risk factors 0 or 1 of the following risk factors: Cigarette Smoking, Hypertension, Low High Density Lipoprotein (HDL-C)**, Family History of Premature CHD, or Age (men >= 45; women >= 55)

** For Denominator 2 and Denominator 3, HDL-C > or equal to 60 mg/dL subtracts 1 risk from the above (This is a negative risk factor.)
Denominator Exclusions
Patients who have an active diagnosis of pregnancy
OR
Patients who are receiving palliative care
Numerator
Numerator 1: (High Risk) 
Patients who had a fasting LDL-C test performed or a calculated LDL-C during the measurement period 
 
Numerator 2 : (Moderate Risk) 
Patients who had a fasting LDL-C test performed or a calculated LDL-C during the measurement period 
 
Numerator 3 : (Low Risk) 
Patients who had a fasting LDL-C test performed or a calculated LDL-C during the measurement period or up to four (4) years prior to the current measurement period
Numerator Exclusions
Not Applicable
Denominator Exceptions
Patient Reason(s):

Patient Request

OR

Patient Refusal
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

Table of Contents


Population criteria

      ------ Population Criteria 1 ------

      ------ Population Criteria 2 ------

      ------ Population Criteria 3 ------

Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
Preventive Care and Screening