eMeasure Title Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
eMeasure Identifier
(Measure Authoring Tool)
69 eMeasure Version number 1
NQF Number 0421 GUID 9a031bb8-3d9b-11e1-8634-00237d5bf174
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Centers for Medicare & Medicaid Services
Measure Developer Quality Insights of Pennsylvania
Endorsed By National Quality Forum
Description
Percentage of patients aged 18 years and older with an encounter during the reporting period with a documented calculated BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters.

Normal Parameters:       Age 65 years and older BMI => 23 and < 30 
                                    Age 18 – 64 years BMI => 18.5 and < 25
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
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
BMI Above Upper Parameter 
In 2009, no state met the healthy people 2012 obesity target of 15 percent, and the self reported overall prevalence of obesity among U.S. adults had increased 1.1 percentage points from 2007. Overall self-reported obesity prevalence in the U.S. was 26.7 percent (CDC, 2010).  

Obesity continues to be a public health concern in the United States and throughout the world. In the United States, obesity prevalence doubled among adults between 1980 and 2004 (Flegal et al., 2002; Ogden et al., 2006). Obesity is associated with increased risk of a number of conditions, including diabetes mellitus, cardiovascular disease, hypertension, and certain cancers, and with increased risk of disability and a modestly elevated risk of all-cause mortality. “Obesity is associated with an increased risk of death, particularly in adults younger than age 65 years. Obesity has been shown to reduce life expectancy by 6 to 20 years depending on age and race. Ischemic heart disease, diabetes, cancer (especially liver, kidney, breast, endometrial, prostate and colon), and respiratory diseases are the leading causes of death in persons who are obese” (AHRQ, 2011).

Results from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) indicate that an estimated 35.7 percent of adults are obese (CDC, 2012). Although the prevalence of adults in the U.S. who are obese is still high with about one-third of adults obese in 2007-2008, data suggest that the rate of increase for obesity in the U.S. in recent decades may be slowing (Flegal et al., 2010). 

Finkelstein et al. (2009) found that across all payers, per capita medical spending for the obese is $1,429 higher per year, or roughly 42 percent higher than for someone of normal weight. In aggregate, the annual medical burden of obesity has increased from 6.5 percent to 9.1 percent of annual medical spending and could be as high as $147 billion per year (in 2008 dollars).  A study by Tsai et al. (2010) estimated cost for obesity to be even higher. A recent study by Cawley et al. (2012) reported findings that indicate that the effect of obesity of medical care cost is much greater than previously appreciated.  

Ma et al. (2009) performed a retrospective, cross-sectional analysis of ambulatory visits in the National Ambulatory Medical Care Survey from 2005 and 2006. The study findings on obesity and office-based quality of care concluded the evidence is compelling that obesity is underappreciated in office-based physician practices across the United States. Many opportunities are missed for obesity screening and diagnosis, as well as for the prevention and treatment of obesity and related health risks, regardless of patient and provider characteristics. 

BMI Below Normal Parameters 
Poor nutrition or underlying health conditions can result in underweight. Results from the 2007-2008 National Health and Nutrition Examination Survey (CDC, 2010), using measured heights and weights, indicate an estimated 1.6% of U.S. adults are underweight with women more likely to be underweight than men. 

Huffman (2002) states elderly patients with unintentional weight loss are at higher risk for infection, depression and death. The leading causes of involuntary weight loss are depression (especially in residents of long-term care facilities), cancer (lung and gastrointestinal malignancies), cardiac disorders and benign gastrointestinal diseases. Medications that may cause nausea and vomiting, dysphagia, dysgeusia and anorexia have been implicated. Polypharmacy can cause unintended weight loss, as can psychotropic medication reduction (e.g., by unmasking problems such as anxiety). In an observational study, Ranhoff et al. (2005) recommended  using BMI< 23 for the elderly to identify positive, results with malnutrition screens and poor nutritional status.
Clinical Recommendation Statement
Although multiple clinical recommendations addressing obesity have been developed by professional organizations, societies and associations, two recommendations have been identified which exemplify the intent of the measure and address the numerator and denominator.

The US Preventive Health Services Task Force (USPSTF) The Guide to Clinical Preventive Services, 2010-2011 recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults (Level Evidence B). 

Institute for Clinical Systems Improvement (ICSI, 2011) Prevention and Management of Obesity (Mature Adolescents and Adults) provides the following guidance: 

•  Calculate the body mass index; classify the individual based on the body mass index categories. Educate patients about their body mass index and their associated risks. 

•  Weight management requires a team approach. Be aware of clinical and community resources. The patient needs to have an ongoing therapeutic relationship and follow-up with a health care team. 

•  Weight control is a lifelong commitment, and the health care team can assist with setting specific goals with the patient.
Improvement Notation
Higher score indicates better quality
Reference
Centers for Disease Control and Prevention (2010).  Healthy People 2010.  Retrieved from http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf
Reference
Flegal, K.M., Carroll, M.D., Ogden, C.L., Johnson, C.L. (2002).  Prevalence and trends in obesity among US adults, 1999-2000. Journal of the American Medical Association, 288:  1723-7
Reference
Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., Flegal, K.M. (2006). Prevalence of overweight and obesity in the United States, 1999-2004.  Journal of the American Medical Association, 295(13):  1549-1555
Reference
Reference	Agency for Healthcare Research and Quality (2011).  Screening for and Management of Obesity and Overweight in Adults.  Evidence Synthesis Number 89.  Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf11/obeseadult/obesees.pdf
Reference
Centers for Disease Control and Prevention, National Center for Health Statistics (2012).  Prevalence of Obesity in the United States, 2009-2010.  NCHS Data Brief, No. 82.  Retrieved from http://www.cdc.gov/nchs/data/databriefs/db82.pdf
Reference
Flegal, K.M., Graubard, B.L., Williamson, D.F., Mitchell, H. G. (2010).  Excess Deaths Associated With Underweight, Overweight, and Obesity.  Journal of the American Medical Association, Vol 293, No 15. pp.1861-1867
Reference
Finkelstein, E.A., Trogdon, J.G., Cohen, J.W., & Dietz, W. (2009). Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs, 28(5), w822-w831.  doi:  10.1377/hlthaff.28.5.w822
Reference
Tsai, A.G., Williamson, D.F., & Glick, H.A. (2010). Direct medical cost of overweight and obesity in the USA: a quantitative systematic review. Retrieved from http://www3.interscience.wiley.com/journal/123233768/abstract?CRETRY=1&SRETRY=0
Reference
Cawley, J., Meyerhoefer, C. (2012). The medical care costs of obesity:  An instrumental variables approach. Journal of Health Economics, 31:  219-213
Reference
Ma, J., Xiao, L., & Stafford, R.S. (2009). Adult Obesity and Office-Based of Care in the United States.  Obesity, 17(5):  1077-1085
Reference
Centers for Disease Control and Prevention (2010).  Prevalence of Underweight Among Adults Aged 20 Years and Over: United States, 2007-2008.  Retrieved from http://www.cdc.gov/nchs/data/hestat/underweight_adult_07_08/underweight_adult_07_08.pdf
Reference
Huffman, G.B. (2002). Evaluating and Treating Unintentional Weight Loss in the Elderly.  American Family Physician. Volume 65, Issue 4.  Retrieved from http://www.mdconsult.com
Reference
Ranhoff, A.H., Gjoen, A.U., Mowe, M. (2005).  Screening for Malnutrition in Elderly Acute Medical Patients:  The Usefulness of MNA-SF.  The Journal of Nutrition, Health & Aging.  9(4):  221-225
Reference
Agency for Healthcare Research and Quality. The Guide to Clinical Preventive Services 2010-2011:  Recommendations of the U.S. Preventive Services Task Force.  Retrieved from http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf
Reference
Institute for Clinical Systems Improvement (2011). Health Care Guideline: Prevention and Management of Obesity (Mature Adolescents and Adults).  Fifth Edition. Retrieved From http://www.icsi.org/obesity/obesity_3398.html
Definition
Body mass index (BMI) - expressed as weight/height (BMI; kg/m2), and is commonly used to classify weight categories. 

Calculated BMI – Requires and eligible professional or their staff to measure both the height and weight. Self-reported values cannot be used. BMI 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.

Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. Such follow-up may include, but is not limited to: documentation of a future appointment, education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling
Guidance
BMI calculated and documented in the medical record may be reported if done in the provider’s office/facility or if BMI calculation within the past six months is documented in outside medical records obtained by the provider. If the most recent BMI is outside of normal parameters a follow-up plan is documented within the past six months of the calculated BMI. The documented follow up interventions must be related to the BMI outside of normal parameters, example:  “Patient referred to nutrition counseling for BMI above normal parameters”.
Transmission Format
TBD
Initial Patient Population
There are two (2) Initial  Patient Populations for this measure

Initial Patient Population 1:  All patients 65 years of age and older before the beginning of the measurement period with at least one eligible encounter during the measurement period NOT INCLUDING encounters where the patient is receiving palliative care, refuses BMI measurement, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status, or there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate. 

Initial Patient Population 2:  All patients 18 through 64 years before the beginning of the measurement period with at least one eligible encounter during the measurement period NOT INCLUDING encounters where the patient is receiving palliative care, refuses BMI measurement, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status, or there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate.
Denominator
Equals Initial Patient Population
Denominator Exclusions
Patients who are pregnant.
Numerator
Patients with a documented calculated BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
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

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Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
none