wisconsin medicaid nursing home drug quality indicator report … · 2005-06-02 ·...

Wisconsin Medicaid Nursing Home

Drug Quality Indicator Report

User Guide December 2004

Center for Health Systems Research and Analysis

University of Wisconsin – Madison

Contents 1. Introduction 2. Drug Quality Indicator Report 3. Significance of Each Quality Indicator 4. Drug Quality Indicator Definition Matrix 5. Drug Quality Indicator Report Tabulation Notes 6. Sample Report Output

Introduction Wisconsin Medicaid contracted with the Center for Health Systems Research and Analysis at the University of Wisconsin-Madison to develop and distribute a nursing home drug summary report that combines information from the MDS and Medicaid claims data. The first round of reports was distributed in January 2002 covering the six month period from April through September of 2001. Several revisions have occurred to the report logic and layout over the subsequent rounds. This user guide describes the methods and definitions used to produce the most recent version of reports, covering the period from April 2004 through September 2004.

Drug Quality Indicator Report The report for each facility is presented in two sections, the Facility Characteristics Report (FCR) and the Facility Summary Report (FSR). Sample report pages, for ABC Nursing Home from October 1, 2003 through March 31, 2004, are attached to the end of this User Guide.

CHSRA, UW – Madison 1 December 2004

Facility Characteristics Report The first page of the FCR shows Medicaid resident characteristics for the current and prior two reporting periods, including resident count, sex, age groups, diagnostic groups, MDS assessment type and Medicaid drug claim payments per patient day. Values are shown for both the facility resident population and for all Wisconsin Medicaid residents. All resident values, except the drug claim amounts, are based upon the resident’s most recent MDS assessment dated within the reporting period. Each Medicaid resident with at least one MDS assessment in the reporting period is included in the tabulation. (This is the same approach used in the MDS-based nursing home quality indicator reports provided by the state.) The “Average Medicaid Drug Claims” values at the bottom of the first page of the FCR represent total Medicaid drug claim payments during the six month reporting period for the facility divided by total Medicaid patient days for the same period. The percentile ranking indicates the percentage of facilities with a lower drug cost per patient day. Corresponding values are shown for all Wisconsin Medicaid residents. Aside: Note that the statewide drug cost per Medicaid patient day is not the 50%-tile. In this case, roughly 60% of facilities (by count) exhibit costs per patient day below the statewide average for each of the three periods shown. This implies that there are some large facilities with above-average costs per patient day. The average drug cost per patient day provides an indication of where the facility falls relative to other Wisconsin facilities with respect to expenditures on drugs for its Medicaid residents. If a facility is above the 50%-tile, it is not necessarily the case that drug costs are inappropriately high. Likewise, falling below the 50%-tile is not always an indication that the facility is out-performing the majority of other facilities. The appropriate drug expenditure level per patient day depends, of course, upon the needs of the residents, which vary from facility to facility. The average cost per patient day shown here simply provides an unadjusted indication of the expenditure level versus other facilities and over time. Other drug-related values shown in the remainder of the report attempt to adjust for the facility’s mix of resident characteristics before comparing results to other facilities. The second page of the FCR has been modified in Round 7. The revised purpose is to concentrate solely on the most recent reporting period (not the last three periods) to break down Medicaid prescriptions between “Brand Name” and “Generic” categories within five key drug classifications (ACE Inhibitors, statins, Proton Pump Inhibitors, non-sedating antihistamines, antidepressants). “Generic” represents drugs in the class available generically or over-the-counter at a much lower cost. For each class, the drugs considered to fall into the generic category for the reporting period are listed at the bottom of the page. “Brand Name” represents the balance of drugs in the class. For example, lovastatin, a statin drug commonly used to treat elevated cholesterol, is available as a generic for about $1.03 per prescription day while other drugs in this category that are not available as a generic sell for about $2.90 per prescription day. For most people, lovastatin works as well as the other drugs in the class and has similar side effects. For each drug class and category, the report shows the number of Medicaid prescriptions, the amount paid, the amount paid per prescription, and the amount paid per prescription day. (Prescription days are not shown. You can calculate the average number of prescription days per prescription by dividing the amount paid per prescription by the amount paid per prescription day. In most cases, the average prescription period is about 30


days.) The same values are shown for the statewide Medicaid nursing home population, except for amount paid. (Again, you can calculate the statewide amount paid by multiplying the prescription count by the amount paid per prescription.) Comparing the facility payments per prescription day to the corresponding statewide values may identify situations worth investigating, especially if the generic costs differ significantly. More variation in the brand name costs per day might be expected, since this category encompasses a wider variety of specific drugs. In some cases, there may be no drug prescriptions within a given class/category. For example, on the sample report the facility shows no generic Proton Pump Inhibitor prescriptions (i.e., Prilosec OTC). In such a case, zeroes are shown for the prescription count and the amount paid, and no values are shown for the amount paid per prescription and the amount paid per prescription day. Within each class, the percent of prescriptions considered generic is shown for the facility and for the statewide Medicaid nursing home population. As with the costs per prescription day, comparing the facility generic percentage to the statewide percentage may highlight situations worth investigating. With each new reporting period, the drugs assigned to each classification and generic/brand-name category will be revisited. Additional drug classifications may be introduced as well. These changes may complicate comparisons of results from period to period, but are necessary due to the evolving mix of available and appropriate drugs.

Facility Summary Report The Facility Summary Report (FSR) summarizes the Drug Quality Indicator (QI) values for the most recent three reporting periods. All of the QI’s are computed as ratios of specific resident counts based upon information from the most recent MDS assessment in the period linked to Medicaid drug claim records. For each resident, drug claim records with prescription periods overlapping the seven-day assessment period were summarized and attached to the MDS assessment record. The resident counts comprising the QI ratios are obtained by counting assessment records with specific resident characteristics (e.g., diagnoses) and drug use/non-use. All of the QI’s generate values from zero to 100% and are constructed so that large values serve as indicators of potential problems. For example, the denominator of QI 5.5 is the number of residents with horrible/excruciating pain indicated on the MDS assessment (i.e., MDS item J2b=3). The numerator is the number of such resident with no overlapping drug claim record for opioids (i.e., therapeutic classes H3AD through H3AT). The QI ratio indicates the percentage of residents with horrible/excruciating pain for which opioids are not prescribed. For comparison, the report shows the average QI value for all Wisconsin Medicaid facilities, as well as the percentile ranking among Wisconsin facilities. In the sample report, the numerators and denominators of QI 5.5 are consistently zero for all three reporting periods. Consequently, no QI ratio can be computed. Even though no QI value is available, the consistent indication of no residents with horrible/excruciating pain may deserve some attention. It may be that the facility’s pain assessment/monitoring program is not adequately identifying severe pain. Of course, it may also


be the case that the facility has no residents with severe pain or the facility is doing a good job moderating resident pain. Some investigation may be needed to determine which is the case. QI ratios at or above the 90%-tile of the statewide distribution of values are flagged on the report. Such values occur in no more than 10% of Wisconsin nursing homes. While “flagging” on a QI indicates a potential problem, further investigation is needed to explain the unusual value. There may be resident characteristics, not reflected in the QI ratio calculation, that justify an atypically large QI ratio. Before coming to any preliminary conclusions, the following aspects of flagging QI ratios should be considered. QI’s with small denominators are not as reliable as those with larger denominators since they are more sensitive to chance fluctuations in resident characteristics and drug claims unrelated to the quality of care. Small denominators may be due to the small number of Medicaid residents in the facility, in which case all of the QI ratios for the reporting period may be suspect. Small denominators can also occur in larger facilities for those QI’s whose denominator is defined to be a very restricted subset of the total Medicaid population. For example, QI 2.1, QI 2.3 and QI 5.5 restrict the denominator to Medicaid residents with myocardial infarction, atrial fibrillation, and horrible/excruciating pain, respectively. In the sample report, you can see that the denominators for these three QI’s are much smaller than for the other QI’s. A similar caution is appropriate for QI’s whose statewide average value is small, i.e., where the QI numerator is expected to be much smaller than the denominator. Even if the denominator is not small, a single 1-resident change in the numerator can result in a dramatic change in the facility’s percentile ranking. QI’s falling into this category in QI 1.2, QI 1.3, QI 1.6, QI 3.2, QI 4.3, QI 4.4, QI 5.1 and QI 5.4, all having statewide average values less than 5%. Two of the indicators (QI’s 5.3 and 6.2) were deleted from the report because their average values were very low. You should also consider the pattern of a flagging QI’s values over time. QI’s that consistently flag over time provide a more reliable indication that the difference from the statewide average is significant and deserving of further investigation. (See QI 1.6 in the sample report.) Even if each period’s QI value is suspect due to small denominators or numerators, a sequence of QI flaggings over time is unlikely due to chance variation in unrelated factors. Finally, any trend in the reported QI values over time may be helpful in assessing the need for follow-up. Even when no single period’s QI value flags, an increasing trend in QI percentile ranking over time may indicate a problem on the rise. Likewise. a downward trend in flagged QI rankings may indicate that past corrective action is working and the problem is subsiding. Note that a change in percentile ranking over time may also be due to changes in the statewide distribution of QI values over time. It is important to consider trends in both the QI ratio and the percentile ranking. No aggregate drug QI is provided on the current report. There are a variety of approaches that might be considered in forming a single overall QI value for each facility. WI Medicaid is currently studying these approaches to producing an aggregate QI value for possible use in future reports. Since the primary purpose of the current report is to provide useful information to the facility’s quality assurance process in identifying and


monitoring specific potential problems, it was felt that the current report was valuable even without such an overall QI value. Some of the drug quality indicators are available from other MDS-based reports produced by the Wisconsin Department of Health and Family Services. We added several quality indicators that were developed solely from MDS data (e.g., QI 4.2 and QI 6.1). We included these QI measures in this report to provide a more complete drug report. The quality of the information is only as good as the quality of the MDS and claims data used in the report. When diagnoses are used to define a quality measure (e.g., myocardial infarction, atrial fibrillation), the measures appear to significantly under-report the true prevalence. The MDS coding of ICD-9 codes should be more complete. We have extracted diagnostic information from Medicaid patient day billing records to supplement the MDS diagnoses. However, we urge you to include the ICD-9 codes for Myocardial Infarction (410) and Atrial Fibrillation (427.3) on the MDS assessment when indicated. At this time, we are not able to provide the names of residents who trigger the drug quality indicators. The Medicaid program does not provide CHSRA with resident identifiers in order to protect the confidentiality of resident information. The next section discusses the significance of each QI presented in the FSR. A detailed table of QI definitions is provided in the following section.


Significance of Each Quality Indicator Domain 1: Psychotropic Drug Utilization 1.1 Residents without psychotic or related diagnosis who are receiving antipsychotic drugs.

Use of antipsychotics to treat psychotic or agitated behavior in residents with dementia, should include documentation: 1) on the frequency and type of behaviors (e.g. biting, kicking); 2) that preventable reasons for behaviors were ruled out; 3) that resident behaviors are a risk to self and/or others; and 4) that psychotic symptoms were causing resident distress or impairment of functional capacity.

1.2 Residents receiving hypnotic drugs more than twice in the week of the most recent assessment.

Routine use of hypnotics increases the risks of chronic toxicity, especially cognitive impairment, true physiological dependence, and discontinuance symptoms. These problems are more likely under the following conditions: 1) high dose, 2) daily dosing of more than 4 months duration, and 3) advanced age. Use of short half-life benzodiazepines (e.g. Halcion) increases the risk of clinically significant physiologic dependence. Use of long half-life hypnotics (e.g. Dalmane) increases risk of falls. Further, rebound symptoms after termination of the drug mimic the symptoms being treated (e.g. insomnia, anxiety).

1.3 Residents without a diagnosis of Cerebral Palsy, Multiple Sclerosis or Spinal Cord Injury receiving benzodiazepines with a long half-life. Use of benzodiazepines with long half-life (e.g. Valium, Dalmane, Tranxene) increases the risk for falls. Because of this risk, benzodiazepine medications used for behaviors should be short acting (e.g. Xanax, lorazepam). A benzodiazepine with long half-life may be need for seizures, spasticity due to spinal cord injuries, Multiple Sclerosis or Cerebral Palsy.

1.4 Residents receiving anti-anxiety/hypnotic drugs Use of anti-anxiety drugs should occur only when evidence exists that the reason for the resident's distress cannot be treated with non-drug therapy; periodic attempts to gradually reduce the dose resulted in impairment of resident's functional status.

1.5 Residents with a diagnosis of depression not receiving an antidepressant While depression may be treated with non-drug therapy such as supportive psychotherapies and activity therapy, antidepressant medications are appropriate to treat patients with moderate to severe major depression. Major depressive disorders have been found to increase likelihood of death by 59% over a one-year period for nursing home residents.


1.6 Residents receiving amitriptyline, doxepin or imipramine Amitriptyline, doxepin and imipramine have significant side effects including postural hypotension, sedation, dry mouth, urinary retention, constipation and delirium. They can also impact cardiac function and alter seizure threshold. Other tricyclic antidepressants (e.g. desipramine, nortriptyline) or selective serotonin reuptake inhibitors (e.g. Prozac, Paxil) have fewer side effect and are equally effective for treatment of depression.

Domain 2: Cardiovascular Drug Therapy

2.1 Residents with a diagnosis of myocardial infarction and without a co-morbidity diagnosis (e.g. Insulin dependent diabetes, asthma, heart block >1, left ventricular dysfunction, COPD) not receiving a beta blocker (e.g. propranolol). Acute myocardial infarction [AMI], commonly referred to as a heart attack, occurs when there is a blockage in the coronary arteries that supply blood to the heart muscle. In an analysis of over 26 trials, beta blocker (e.g. metoprolol) therapy after myocardial infarction reduced mortality by 23%. Treatment is started as soon as possible after the heart attack and should be continue for at least 2 or 3 years.

2.2 Residents with a diagnosis of congestive heart failure not receiving an ACE Inhibitor Congestive heart failure (CHF) characterized by left ventricular dysfunction, reduced exercise tolerance, and shorted life expectancy. Several large-scale have demonstrated that angiotensin-converting enzymes (ACE) inhibitors (e.g. Enalapril) markedly reduce morbidity and mortality in patients with CHF.

2.3 Residents with diagnosis of atrial fibrillation not receiving warfarin 15% of strokes occur in people with atrial fibrillation. Taking warfarin (a blood thinner) reduces by two-thirds the probability of a person with atrial fibrillation will have a stroke and lowers the risk of death by stroke by one-third.

Domain 3: GI Drug Therapy

3.1 Residents receiving histamine-2 antagonists (e.g. Zantac, Pepcid) or Proton Pump Inhibitors (e.g. Prilosec) for at least two consecutive assessments. Long-term use of histamine-2 receptor antagonists (H2RA) and Proton Pump Inhibitors is common with patients with gastroesophageal reflux disease (GERD) and for Zollinger-Ellison syndrome. For patients with gastric ulcers or gastritis, use should be re-evaluated every 60-90 days. Most ulcer disease is now treated with antibiotics and H2RAs or other anti-ulcer agents for up to 30 days


3.2 Residents with a fecal impaction Fecal impaction is a major complication of constipation , which can result in intestinal obstruction, colonic ulceration , overflow incontinence (leakage of stool around obstructing feces), or paradoxical diarrhea. Fecal impaction is most likely in patients with limited mobility or mental capacity who present with an alteration in bowel habit such as reduced frequency, new-onset diarrhea, and incontinence. Urinary retention and urinary tract infections also occur with fecal impaction. Excessive straining may have deleterious effects on the cerebral, coronary, and peripheral arterial circulation, resulting in syncope, cardiac ischemia, and transient ischemic attacks.

Domain 4: Infection Control

Facilities infection control program should have a system to monitor and investigate causes of infection (nosocomial and community acquired) and the manner of spread.

4.1 Residents receiving anti-infectives and/or antibiotics

4.2 Residents with urinary tract infections

4.3 Residents with antibiotic resistant infections

4.4 Residents with clostridium difficile infection

Domain 5: Pain Management

5.1 Residents receiving propoxyphene Other analgesics (e.g. acetaminophen) are safer and equally effective for mild or moderate pain.

5.2 Residents receiving NSAIDS (e.g. ibuprofen, Vioxx) Nonsteroidal anti-inflammatory drugs (NSAIDS) may cause GI upset or bleeding, renal complications and drowsiness. Topical analgesics (e.g. Capsaicin) or acetaminophen may be used if no anti-inflammatory is needed. Many clinicians consider acetaminophen to be first-line therapy for short-term symptomatic relief of osteoarthritis.

5.3 Residents receiving indomethacin or phenylbutazone Of all the nonsteroidal anti-inflammatory drugs, indomethacin and phenylbutazone produce the most central nervous system side effects (e.g. headache, dizziness depression, fatigue) and should be avoided in the elderly.


5.5 Residents with horrible or excruciating pain without opioids. Opioids are indicated for moderate to severe pain. Is pain assessment and monitoring being done? Is a pain scale being used with measurable goals in the care plan?

5.6 Residents with pain

Domain 6: Other Drug Issues

6.1 Residents receiving 9 or more medications during most recent assessment Use of large numbers of drugs increases the risk for adverse drug reactions and drug-drug interactions.


Drug Quality Indicator Definition Matrix Title Definition Source

MOST RECENT ASSESSMENT: Antipsychotics (O4a> 1) OR Using Therapeutic Classes H2G, H2L , H2O, H7O, H7P, H7R, H7S, H7T, H7U EXCLUDE: Residents with one or more psychotic disorders (I3=295.00-295.9 ; 297.00 -298.9); OR schizophrenia (I1gg is checked) OR Tourette’s (I3=307.23); OR Huntington's (I3=333.4); OR with hallucinations/delusions (J1i or J1e is checked).

Numerator: Residents receiving anti-psychotics on most recent assessment. Denominator:

1.1 Prevalence of antipsychotic use, in the absence of psychotic and related conditions.

All residents on most recent assessment, except those with psychotic or related conditions (see exclusion).

CHSRA QI

MOST RECENT ASSESSMENT: Hypnotic drug use more than 2 times in the last 7 day (O4d > 2). Hypnotics include flurazepam, triazolam (e.g., Halcion), temazepam (e.g., Restoril), chloral hydrate (e.g., Noctec).

Numerator: Residents who received hypnotics on a scheduled basis, or who received hypnotics on a PRN basis more than 2 times in last week on most recent assessment.

Denominator:

1.2 Prevalence of hypnotic use on a scheduled basis or PRN more than two times in last week.

All residents on most recent assessment.

CHSRA QI


Title Definition Source

MOST RECENT ASSESSMENT: Long-acting benzodiazepine (Drug Code=H2FN[diazepam], H2FJ [chlordiazepoxide], H2FK [clorazepate] This includes diazepam (e.g. Valium), clorazepate (e.g. Tranxene), chlordiazepoxide (e.g. Librium), EXCLUDE: Residents with seizure disorders (I1aa checked) OR Cerebral Palsy (I1s checked) OR Tardive dyskinesia (I3 = ICD 9 CM 333.82) OR spinal cord injury (I3 = ICD 9 CM 806)

Numerator: Residents who received long-acting benzodiazepines on most recent assessment. Denominator:

1.3 Prevalence of use of any long-acting benzodiazepine.


CHSRA QI

MOST RECENT ASSESSMENT: Antianxiety/hypnotic (O4b> 1). EXCLUDE: Residents with one or more psychotic disorders (I3=295.00-295.9; 297.00-298.9); OR Tourette's (I3=307.23); OR Huntington's (I3=333.4); OR with hallucinations/delusions (J1i=checked).

Numerator: Residents who received antianxiety or hypnotics on most recent assessment. Denominator: All residents on most recent assessment, except those with psychotic or related conditions (see exclusion).

1.4 Prevalence of antianxiety /hypnotic use.

CHSRA-QI



MOST RECENT ASSESSMENT: Depression: See Glossary AND No antidepressants (O4c=0) Numerator: Residents with no antidepressant treatment for depression on most recent assessment. Denominator: All residents with depression on most recent assessment

1.5 Prevalence of depression with no antidepressants

CHSRA QI

MOST RECENT ASSESSMENT: Therapeutic Class=H2JA,H2JB, H2JM (missing HICLs) Numerator: Residents with amitriptyline, Doxepin, Imipramine on most recent assessment. Denominator:

1.6 Prevalence of the use of highly anticholinergic antidpressants - amitriptyline, imipramine, doxepin

All residents on most recent assessment

Beers, et al



MOST RECENT ASSESSMENT: Myocardial Infarction Section I(3)= Diagnosis 410.xx No beta blockers= J7Cx Exclude: Residents with Insulin Dependent Diabetes (250.x1, 250.x3) asthma[493.xx or I(1)hh checked]; Hear Block >1 I(3)= 426.0, 426.12,426.13,426.2-426.4,426.54, 426.7; Sinus Bradycardia 427.81, 427.89; 428.0, 402.xx, Left Ventrical Dysfunction 428.1; COPD 496.xx, 494.xx, 491.20, 491.21, 492.0, 492.8, 518.2, 506.4 COPD or I(1)ii checked.

Numerator: Residents who didn’t a receive beta blocker on most recent assessment.

Denominator:

2.1 Prevalence of myocardial infarction without a beta blocker and without co-morbidity diagnosis

All residents on most recent assessment with a diagnosis of myocardial infarction without a diagnosis of insulin dependent diabetes, asthma, heart block>1, sinus bradycardia, left ventricular dysfunction, COPD.

NCQA

MOST RECENT ASSESSMENT: Congestive heart failure I(1)f checked or I(3)= Diagnosis 428.0 ACE Inhibitor Therapeutic Classes Not =A4D Numerator: Residents who received did NOT receive an ACE Inhibitor on most recent assessment. Denominator: All residents on most recent assessment with a diagnosis of congestive heart failure

2.2 Prevalence of congestive heart failure without an ACE Inhibitor



MOST RECENT ASSESSMENT: Atrial Fibrillation I(3)= Diagnosis 427.3 Warfarin Therapeutic Class NOT=M9LC Numerator: Residents who did not received warfarin on most recent assessment. Denominator:

2.3 Prevalence of atrial fibrillation without warfarin

All residents on most recent assessment with a diagnosis of Atrial Fibrillation

NCQA

MOST RECENT and PRIOR ASSESSMENT: HICL= H2RA/Proton Pump Inhibitor Therapeutic HICL=D4EC,D4ED, Z2D, D4K, D4J EXCLUDE: Residents with GERD /ZE I(3)=Diagnosis 530.1, 530.81, 251.5 Numerator: Residents who received H2RA/Proton Pump Inhibitor on prior and most recent assessment. Denominator:

3.1 Prevalence of Histamine-2 receptor antagonists and/or proton pump inhibitors for two or more consecutive assessments without GERD

All residents on most recent assessment with no diagnosis of GERD or Zollinger-Ellison

MOST RECENT ASSESSMENT: Fecal Impaction=h2d checked Numerator: Residents with fecal impaction on most recent assessment. Denominator:

3.2. Prevalence of fecal impaction


CHSRA-QI



MOST RECENT ASSESSMENT: Antibiotic/Anti-infective Therapeutic Class=W1AA-W4EA Numerator: Residents with an anti-infective/antibiotic on most recent assessment. Denominator: All residents on most recent assessment.

4.1. Prevalence of anti-infective/antibiotic use.

CHSRA QI

MOST RECENT ASSESSMENT: Urinary tract infection (I2j is checked). Numerator: Residents with urinary tract infections on most recent assessment. Denominator:

4.2 Prevalence of urinary tract infections.


CHSRA QI

MOST RECENT ASSESSMENT: Antibiotic Resistant Infection (I2a is checked). Numerator: Residents with antibiotic resistant infection on most recent assessment.

Denominator:

4.3 Prevalence of antibiotic resistant infection.


MOST RECENT ASSESSMENT: Clostridium difficile (I2b is checked). Numerator: Residents with clostridium difficile on most recent assessment. Denominator:

4.4 Prevalence of Clostridium difficile




MOST RECENT ASSESSMENT: Propoxyphene Therapeutic Class=, H3AU Numerator: Residents with Propoxyphene at recent assessment. Denominator: All residents on most recent assessment.

5.1 Prevalence of propoxyphene

Beers, et al

MOST RECENT ASSESSMENT: NSAID Therapeutic Class=S2Bx, S2Dx, H3Dx, S2L Numerator: Residents with Nonsteroidal Anti-inflammatory Drug (NSAID) at recent assessment. Denominator: All residents on most recent assessment.

5.2 Prevalence of NSAID use.

MOST RECENT ASSESSMENT: Indomethacin/Phenylbutazone Therapeutic Class=S2BA,S2BB Numerator: Residents receiving Indomethacin or Phenylbutazone in recent assessment. Denominator:

5.4 Prevalence of indomethacin/phenylbutazone


Beers ,et al



MOST RECENT ASSESSMENT: Horrible/Excruciating pain (J2b=3) without opioids (therapeutic class H3AD-H3AT) Numerator: No opioids given on a scheduled basis at most recent assessment. Denominator: Residents with daily horrible/excruciating pain at most recent assessment.

5.5 Prevalence of horrible/excruciating pain without opioids

MOST RECENT ASSESSMENT: Moderate pain (J2a=1 and J2b=2 or 3) Horrible/Excruciating pain (J2a=2and J2b=1,2,3) Numerator: Residents with moderate or horrible/excruciating pain less than daily or mild, moderate or excruciating pain daily at most recent assessment.

Denominator: All residents on most recent assessment.

5.6 Prevalence of pain

CHSRA QI

MOST RECENT ASSESSMENT: Section O O1equal to 9 or greater Numerator: Residents who received 9 or more scheduled medications on most recent assessment. Denominator:

6.1 Use of 9 or more medications.



QI GLOSSARY Behavior problems. Defined as one or more of the following less than daily or daily: verbally abusive (E4b-Box A > 0), physically abusive (E4c-Box A > 0), or socially inappropriate/disruptive behavior (E4d-Box A > 0).

Cognitive impairment. Any impairment in daily decision making ability (B4 > 0) AND any impairment in recall ability (at least one of B3a-d = 0), AND has short term memory problems (B2a = 1). Note: RUGs pseudocode tests for items B3a-B3d being not equal to 1, this may include missing values. We use the more conservative approach of requiring that the value equals 0.

Severe Cognitive Impairment. Decision making ability is severely impaired (B4=3) AND severe impairment in recall (none of items B3a-d are checked or B3e is checked) AND has short term memory problems (B2a=1)

Depression.

Sad mood (E2 = 1 or 2) and at least 2 symptoms of functional depression; OR Depression or manic depression diagnosis (I1ee or I1ff is checked) and at least 1 symptom of functional depression; OR Depression or manic depression diagnosis (I1ee or I1ff is checked) and sad mood (E2 = 1or 2) Symptoms of functional depression include:

Symptom 1 distress (E1a = 1 or 2 - resident made negative statements);

Symptom 2 agitation or withdrawal (E1n = 1or 2 - repetitive physical movements), or (E4e-Box A = 1, 2, or 3-resists care), or (E1o = 1or2 - withdrawal from activity), or (E1p = 1or 2 - reduced social activity);

Symptom 3 wake with unpleasant mood (E1j = 1 or 2), or not awake most of the day (N1d is checked), or awake 1 period of the day or less and not comatose (N1a + N1b + N1c < 1 and B1 = 0);

Symptom 4 suicidal or has recurrent thoughts of death (E1g = 1 or 2); Symptom 5 weight loss (K3a = 1).


Drug Quality Indicator Report Tabulation Notes The following outline summarizes notable aspects of the tabulation process used to produce the semi-annual drug QI reports from the DHFS MDS and Medicaid claim extract files provided to CHSRA.

• Tabulations are based upon each resident’s most recent MDS assessment dated within the reporting period. Subject to the exclusions listed below, each Medicaid resident with at least one MDS assessment in the reporting period is included in the tabulations. This is the same approach used in the MDS-based nursing home quality indicator reports provided by the state.

• Unlike the conventional MDS nursing home QI reports available from DHFS, the drug QI reports

include residents whose most recent MDS assessment is an admission assessment. The number of admission assessments included in the tabulations can be determined by multiplying the resident counts at the top of the Facility Characteristics report by the Admission assessment percentage shown in the “Types of Assessment” section further down the same page. Note that the denominators for QI’s with no exclusions (e.g., QI 1.2) match the total resident count, which includes residents with admission assessments.

• Residents are excluded from the drug QI report if there is no matching Medicaid patient day billing

record, i.e., they are not Medicaid residents at the time of the most recent MDS assessment during the reporting period.

• Residents are excluded from the drug QI report if there is no available comprehensive MDS assessment

on or prior to the date of the most recent assessment. The prior comprehensive assessment need not fall within the 6-month reporting period.

• The Wisconsin Veterans Home at King and its residents are excluded from the drug QI report.

• Residents with no Medicaid claim records overlapping the seven-day assessment period for the most

recent MDS assessment are excluded if MDS item O1 indicates more than three medications used in the assessment period. This is an indication of inconsistent data.

• Reports are not generated for facilities with fewer than 10 Medicaid residents (the number of unique

Medicaid residents with an assessment dated in the 6-month reporting period). Note, however, that the facility values are used in computing statewide averages and in determining percentile rankings of other facilities.

• The first two report runs were performed with a combination of SPSS code, Visual Basic for

Applications (VBA) code, and Excel spreadsheet logic. A production version of the reporting process written in SAS and Crystal Reports has been in subsequent rounds of the report.


Sample Report Output

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