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Clinical Quality Performance Measures
Set (152 KB)
A Commitment
to Quality Improvement in the Safety Net
The Health Resources and Services Administration
(HRSA) has begun implementation of a Clinical
Quality Core Measure Set of 12 performance
measures as part of a larger clinical
quality measurement and improvement initiative.
This initiative underscores HRSA’s commitment
to quality improvement and begins to measure
and demonstrate the quality of care across
the Agency as a whole—a capstone to the
program are specific quality measures
now in use by many HRSA programs. The
new initiative not only aligns clinical
performance measures across HRSA’s clinical
service delivery programs, but also makes
them consistent with national quality
measures endorsed by the National Quality
Forum (NQF), AQA, and other national quality
organizations. The Core Measures are also
consistent with OMB Circular A-119 and
relies on a metric and definitions also
used by Medicare, Medicaid, HEDIS, and
other organizations involved in health
care related quality performance measurement
in both the public and the private sectors.
The Core Clinical Measures Set was approved
by HRSA senior leadership in December
of 2006 and is available for use by HRSA
programs. Four of the measures have already
been incorporated into program grant guidance
including those for health information
systems, rural quality improvement grants,
and the Consolidated Community Health
Centers program UDS reporting tool. Performance
data from the Consolidated Community Health
Centers will be reported in January of
2010. To help HRSA plan for technical
assistance support, data analysis, and
quality performance reporting, the measures
were tested during performance review
site visits and through feasibility study
testing during the summer and fall of
2007.
The core measures address priority health
conditions of HRSA safety-net populations,
cover all life cycles, are amenable for
quality improvement, and were selected
for their relevance to HRSA programs.
To reflect HRSAs’ important role in population
and community health, the core measure
set includes screening for colon, breast
and cervical cancer screening; cancers
which disproportionately affect HRSA populations
and for which early detection and care
can significantly decrease mortality and
improve 5 year survival.
In addition, the HRSA set includes measures
for prenatal HIV screening, access to
prenatal care, and appropriate immunizations
by life cycle. Chronic disease management
performance measures are included for
diabetes and hypertension. Additional
Core Clinical measures are planned in
the areas of mental health, oral health,
asthma, obesity, and smoking. Quality
measures for patient safety, patient satisfaction,
and health literacy/communication are
also being considered.
The list of measures below is supported
by a more extensive document of measure
specifications. Questions about the measures
can be directed to Dr. Deborah Willis-
Fillinger in HRSAs’ Center for Quality
at DWillis-Fillinger@HRSA.Gov
or 301-443-6614.
Medical Condition:
Prenatal Care
Source: NCQA
Description: Percentage of
pregnant women beginning prenatal care in the
first trimester of pregnancy.
Rational/Purpose
Measuring enrollment of pregnant patients in
first trimester is accepted as a way to assess
access to care for pregnant women. Enrollment
in care during the first trimester (first three
months) of pregnancy is a reflection of timely
initiation of prenatal care. Early prenatal
care is associated with positive pregnancy outcomes.
The goal for this measure is to increase the
positive outcomes of healthy mothers and babies
and to minimize maternal and infant morbidity
and mortality.
Numerator/Denominator:
Numerator: Number of pregnant
women from the denominator who began prenatal
care during the first trimester.*
Denominator: Total number
of pregnant women who entered prenatal care
during the measurement year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusion: None
Denominator Inclusion: Any
woman who receives pregnancy related services,
including delivery, during the measurement year.
Women who had 2 different pregnancies during
the measurement year should be counted twice.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: Patients
that had not reached 13 weeks of pregnancy by
Dec. 31 of the measurement year and patients
that did not enter into the care of the clinic
until after 13 weeks into their pregnancy.
Numerator Inclusions: Patients
in the numerator must have received care in
the first trimester* from an advanced clinical
OB practitioner designated by the organization
to provide prenatal examinations (e.g. Obstetrician
Gynecologist, Certified Nurse Midwife, Family
Practitioner, Advanced Practice Nurse with competence
in prenatal care) NOTE: Documentation of a
dated prenatal examination or office visit with
associated obstetric screening tests** (See
below for details)
* First Trimester is defined by a visit before
the 13th week of pregnancy and should be determined
by one of the four following methods:
- The first prenatal visit occurs before the
13th week as counted from the first day of
last menstrual period (LMP) noted in the chart;
- The first prenatal visit occurs before
the 13th week as counted from the documented
Estimated Date of Delivery (EDD);
- Note by provider indicating week of pregnancy
(e.g., “8 week exam”);
- An ultrasound is performed before 20 weeks
EGA (estimated gestational age) with documentation
of the age of fetus. Look for concordance
of the size versus the date. If the dates
are correct and the sonogram is early enough
to indicate 13 weeks or smaller this is evidence
that a prenatal visit occurred before the
13th week of pregnancy.
** Prenatal Visit is defined as: Documentation
in the medical record that includes a note indicating
the date on which the prenatal care visits occurred
and evidence of one of the following.
- A basic physical obstetrical examination
that includes auscultation for fetal heart
tone, or pelvic exam with obstetric observations,
or measurement of fetus height (a standardized
prenatal flow sheet may be used)
- Evidence that a prenatal care procedure
was performed, such as: – Screening test in
the form of an obstetric panel (e.g., hematocrit,
differential WBC count, platelet count, hepatitis
B surface antigen, rubella antibody, syphilis
test, RBC antibody screen, Rh[D] and ABO blood
typing), or -TORCH Antibody panel alone or
a rubella antibody test/titer with an Rh incompatibility(ABO/Rh)
blood typing or Echography of a pregnant uterus
- Documentation of LMP or EDD in conjunction
with either of the following: - prenatal risk
assessment and counseling/education, or -
complete obstetrical history
Note: Count any documentation of a visit to
an OB practitioner, a certified Nurse-midwife,
family practitioner, or advanced practice nurse,
with experience, training and demonstrated competence
in prenatal care with a principal diagnosis
of pregnancy.
Note:
- The use of an EDD date is optional and requires
medical record review.
- Services that occur over multiple visits
count toward this measure as long as all services
are within the time frame established in the
measure.
Medical Condition:
HIV Perinatal Prevention
Source: AMA/PCPI
Description: Percentage of
pregnant women who were screened for HIV infection
during the first or second prenatal care visit.
Rationale/Purpose
The goal for improvement for Prenatal HIV Screening
is to minimize perinatal transmission of HIV
infection through early diagnosis and treatment
of HIV-infected pregnant women. Measuring Prenatal
HIV Screening is important because:
- HIV and AIDS are leading causes of illness
and death in the US and only 40% of the U.S.
population has been tested.
- Perinatal transmission of HIV can be reduced
by 70% with antiretroviral therapy. The CDC
recommends that HIV screening be included
in the routine panel of prenatal screening
tests for all pregnant women.
Numerator/Denominator:
Numerator: Number of women
from the denominator who were screened for HIV
infection during the first or second prenatal
care visit.
Denominator: All pregnant
women seen for two prenatal visits during the
measurement year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusion: Patients
previously documented as HIV positive.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
- There is no exclusion for patient refusal.
Numerator Inclusions: All
patients with documentation of screening for
HIV infection including: Enzyme immunoassay
(EIA), Enzyme linked immunosorbent assay (ELISA),
Western blot (WB), Indirect immunofluorescence
assay (IFA), rapid test, during the first or
second prenatal visit. If a patient transfers
into care during pregnancy, documentation of
prenatal HIV screening done elsewhere for the
same pregnancy, must be dated within the first
or 2nd visit.
Medical Condition:
Cancer Screening
Source: NQF/NCQA
Description: Percentage of
women 40-69 years of age who had a mammogram.
Rationale/Purpose: Breast
cancer continues to be a leading cause of morbidity
and mortality in the US female adult population.
The goal is to further reduce the morbidity
and mortality associated with breast cancer.
Regular mammograms for women ages 50 to 69 can
reduce breast cancer mortality by up to 35 percent
through early detection and a mammogram can
detect breast cancer 1 to 4 years before a woman
can feel the lump. Mammography can also detect
80 to 90 percent of breast cancers in women
without symptoms.
Numerator/Denominator:
Numerator: Women in the denominator
who received one or more mammograms during the
measurement year or the year prior to the measurement
year.
Denominator: All women patients
aged 42 to 69 years of age during the measurement
year or year prior to the measurement year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusion: Women
who had a bilateral mastectomy and for whom
administrative data does not indicate that a
mammogram was performed. The bilateral mastectomy
must have occurred by Dec. 31 of the measurement
year.
Numerator/Exclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Documentation
in the medical record must include: a note indicating
the date the test was performed and the result
of the finding, or a copy of a mammogram result,
or if a note documents the date, and results
from a test ordered by another provider.
Source: NQF/NCQA
Description: Percentage of
women 21-64 years of age who received one or
more Pap test.
Rationale/Purpose:
Most cervical cancer can be prevented, and
when found and treated early, most cervical
cancer can be cured. Despite effective screening
techniques, it is estimated that 3,870 women
will die from cervical cancer during 2008. The
goal for this measure is to ensure adequate
screening of women for cervical cancer using
the Papanicolaou or Pap smear.
Numerator/Denominator:
Numerator: Women in the denominator
with one or more Pap test during the measurement
year or the 2 years prior to the measurement
year.
Denominator: All women patients
24-64 years of age during the measurement year
or 2 years prior to the measurement year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions: Women
who had a hysterectomy and with no residual
cervix and for whom the administrative data
do not indicate that a Pap test was performed.
Denominator Inclusion: Patients
ages 24-64 who have had at least one office
visit in the prior 12 months.
Note: Given the measurement look back period,
women ages 21-64 will be captured in this measurement.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Documentation
in the medical record must include: a note or
billing code indicating the date the test was
performed and the result of the finding, or
a copy of a lab test performed by another provider
is in the chart, or if a note documents the
name, date, and results from a test performed
by another provider.
Source: NQF/NCQA
Description: Percentage of
adults 50-80 years of age who had an appropriate
screening for colorectal cancer.
Rationale/Purpose:
Colorectal cancer is the third most common
cancer diagnosed in both men and women in the
United States and is the third leading cause
of cancer-related deaths in the United States.
Screening allows more colorectal cancers to
be found earlier when the disease is easier
to cure. The goal for this measure is to further
reduce the morbidity and mortality associated
with colorectal cancer.
Numerator/Denominator:
Numerator: Patients in the
denominator who received one or more screenings
for colorectal cancer.
Denominator: All patients
51-80 years of age during the measurement year
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusion: Patients
with a diagnosis of colorectal cancer or total
colectomy.
Note: Given the measurement look back period,
adults 50-80 will be captured in this measure.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Inclusions: Appropriate
screenings are defined by any one of the four
criteria below:
- fecal occult blood test (FOBT) during the
measurement year.
- flexible sigmoidoscopy during the measurement
year or the 4 years prior to the measurement
year.
- double contrast barium enema (DCBE) during
the measurement year or the 4 years prior
to the measurement year. Air contrast enema
is a clinical synonym.
- colonoscopy during the measurement year
or the 9 years prior to the measurement year.
Medical Condition:
Immunizations
Source: NQF/NCQA
Description: Percentage of
children 2 years of age with appropriate immunizations.
Rationale/Purpose:
Despite the demonstrated importance of immunization
of young children, there remains a gap between
ideal immunization coverage and current rates.
In 2005, the NIS revealed
an overall vaccine coverage rate for 4xDTaP/DT,
3xIPV, 1xMMR, 3xHiB, 3xHepB, and 1xVZV of about
76% with considerable variation among coverage
rates in different states and urban areas.
The goal for this measure is to increase the
vaccine coverage rate for all recommended immunobiologics
for children by the age of 2 years.
Numerator/Denominator:
Numerator: Number of children
from the denominator who have received 4xDTaP/DT,
3xIPV, 1xMMR, 3xHiB, 3xHepB, 1xVZV, and 4x PCV
vaccines by their second birthday.
Denominator: All children
who turn 2 years of age during the measurement
year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions: Children
who had a contraindication for a specific vaccine
may be excluded from the denominator. The exclusion
must have occurred by the child's 2nd birthday.
Exclusions should be looked for as far back
as possible in the child's history.
Denominator Inclusions: Patients
who turned 2 years of age during the measurement
year, and who have had at least one office visit
in the prior 12 months.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Evidence
of having received: 4xDTaP/DT, 3xIPV, 1xMMR,
3xHiB, 3xHepB, 1xVZV(chicken pox vaccine), and
4x PCV (pneumococcal conjugate) vaccines by
their second birthday. Also include patients
in the numerator who have evidence of antigen,
documented history of illness, or seropositive
test result, or certificates of immunization
from authorized provider.
See immunization details below**
**Appropriate Childhood Immunizations: For
DTaP, IPV, HiB and pneumococcal conjugate, evidence
of the antigen or vaccine must be found. For
MMR, hepatitis B and VZV, any of the following
may be counted : Evidence of the antigen or
combination vaccine, or documented history of
the illness or a seropositive test result.
For combination vaccinations that require more
than one antigen (i.e., DTaP and MMR), evidence
of all the antigens must be found. The appropriate
Immunizations are the following: DTaP / DT:
Four DTaP vaccinations with different dates
of service on or before the child’s second birthday.
Do not count any vaccination administered prior
to 42 days after birth. IPV: At least three
polio vaccinations (IPV) with different dates
of service on or before the child’s second birthday.
IPV administered prior to 42 days after birth
cannot be counted. MMR: At least one measles,
mumps and rubella (MMR) vaccination, with a
date of service falling on or before the child’s
second birthday. HiB: H Three H influenza
type B (HiB) vaccinations, with different dates
of service on or before the child’s second birthday.
HiB administered prior to 42 days after birth
cannot be counted. Note: Because one particular
type of HiB vaccine requires only three doses,
the measure requires meeting the minimum possible
standard of three doses, rather than the recommended
four doses. Hepatitis B: Three hepatitis B
vaccinations, with different dates of service
on or before the child’s second birthday. VZV:
At least one chicken pox vaccination (VZV),
with a date of service falling on or before
the child’s second birthday. Pneumococcal
conjugate: At least four pneumococcal conjugate
vaccinations with different dates of service
on or before the child’s second birthday. Combination
2 (DTaP, IPV, MMR, HiB, hepatitis B, VZV): Children
who received four DTaP/DT vaccinations; three
IPV vaccinations; one MMR vaccination; three
HiB vaccinations; three hepatitis B; and one
VZV vaccination on or before the child's second
birthday. Combination 3 (DTaP, IPV, MMR, HiB,
hepatitis B, VZV, pneumococcal conjugate): Children
who received all of the antigens listed in Combination
2 and four pneumococcal conjugate vaccinations
on or before the child's second birthday.
Source: NQF/NCQA
Description: Percentage of
patients 50-64 years of age who have received
an influenza vaccine during flu season.
Rationale/Purpose:
The goal for this measure is to reduce the
morbidity and mortality associated with influenza
for adults ≥50 years of age. Annual influenza
epidemics continue to be a leading cause of
morbidity and mortality in the US adult population.
Annual influenza vaccination is the most effective
method for preventing influenza virus infection
and its complications.
Numerator/Denominator:
Numerator: Number of patients
from the denominator who received influenza
vaccination from September 1st through February
29th.
Denominator: All patients
50-64 years of age during the measurement
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions:
- Patients with egg allergy.
- Patients with previous adverse reaction
to influenza vaccine.
- Patients with other medical reasons documented
by the practitioner for not receiving influenza
vaccination.
- Patients with documented refusal.
Denominator Inclusions: All
patients between 50 - 64 years and older with
a visit in the measurement year, even if seen
just once.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Documented
evidence of having received influenza vaccination
including certificate of immunization from authorized
provider.
Source: NQF/NCQA
Description: Percentage of
patients 65 years and older who have received
influenza vaccine during flu season.
Rationale/Purpose:
The goal for this measure is to reduce the
morbidity and mortality associated with influenza
for adults ≥65 years of age. Annual influenza
epidemics continue to be a leading cause of
morbidity and mortality in the US adult population.
Annual influenza vaccination is the most effective
method for preventing influenza virus infection
and its complications.
Numerator/Denominator:
Numerator: Number of patients
from the denominator who received an influenza
vaccination from September 1st through February
29th.
Denominator: All patients
65 years of age and older during the measurement
year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions:
- Patients with egg allergy.
- Patients with previous adverse reaction
to influenza vaccine.
- Patients with other medical reasons documented
by the practitioner for not receiving influenza
vaccination.
- Patients with documented refusal.
Denominator Inclusions: All
patients 65 years and older with a visit in
the measurement year, even if seen just once.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Documented
record of having received Pneumonia vaccination
including certificate of immunization from authorized
provider.
Source: NQF/CMS/NCQA
Description: Percentage
of patients > 65 years of age who
have ever received a pneumococcal
vaccine.
Rationale/Purpose: Pneumococcal
pneumonia is a preventable disease that continues
to cause substantial morbidity and mortality
among seniors. There are approximately 100,000
hospitalizations and 7,000 deaths per year from
pneumococcal pneumonia, with a disproportionate
representation by older adults 65 years and
older.
Numerator/Denominator:
Numerator: Number of patients
from the denominator who have ever received
pneumococcal vaccine.
Denominator: All patients
65 years and older in the measurement year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions:
- Previous anaphylactic reaction to the vaccine
or any of its components
- Other medical reason(s) documented by the
practitioner for not receiving a pneumococcal
vaccination.
- Documented patient reason(s) (e.g. economic,
social, religious).
Denominator Inclusions: All
patients 65 years and older with a visit in
the measurement year, even if seen just once.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Documented
record of having received Pneumonia vaccination
including certificate of immunization from authorized
provider.
Source: HRSA HAB August 2008
and Adapted from AMA/NCQA/PCPI May 2008
Description: Percentage of
patients with HIV infection who completed the
vaccination series for Hepatitis B.
Rationale/Purpose:
Risk factors for exposure to Hep B are similar
to those for HIV. HIV-1 infection is associated
with an increased risk for the development of
chronic hepatitis B after HBV exposure. Hepatitis
B is the leading cause of chronic liver disease
worldwide. Co-infected HIV + and Hep B patients
have increased risk of liver-related mortality.
Despite the significant impact of Hep B, the
rate of vaccination in the HIV + population
is low. The goal for this measure is to increase
the hepatitis B vaccine coverage rate for those
infected with HIV.
Numerator/Denominator:
Numerator: Number of patients
in the denominator who ever received a complete
vaccination series for Hepatitis B (vaccine
Hep B x3 vaccinations).
Denominator: All patients
with HIV with at least one visit in the measurement
year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions:
- HIV positive patients who already have had
documented diagnosis of Hepatitis B infection,
Chronic Hepatitis B, or have documentation
of positive results to any one or more than
one of the following should be excluded from
the denominator: — Hep B Surface Antigen —
Hep B Surface Antibody — Hep B core Antibody
— Hep B e Antigen — Hep B e Antibody — Hep
B DNA
- The patient is newly enrolled to care for
the first time within the last six months
of the measurement year).
Denominator Inclusions: Include
all patients with a medical visit to a provider
with prescribing privileges, and that are diagnosed
with HIV, and that are known to be completely
Hep B negative OR if Hepatitis B Status is unknown.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Documented
evidence of a completed series of 3 vaccinations
including certificate of immunizations from
authorized provider.
Medical Condition:
Chronic Disease Management
{POOR CONTROL}
Source: NCQA / NQF/ PQRI/
PCPI
Description: Percentage of
patients aged 18 through 75 years with type
1 or type 2 diabetes mellitus who had a most
recent hemoglobin A1c (HbA1c) greater than 9%.
Rationale/Purpose:
Diabetes is a leading cause of disability and
death in the US, affecting an estimated 17 million
people – about 6.2% of the population. Identifying
A1c levels greater than 9.0% among adult patients
aged 18-75 years allows organizations the opportunity
to focus on those patients who are in poor control
and thus at highest risk.
Numerator/Denominator:
Numerator: Number of patients
from the denominator whose most recent hemoglobin
A1c level during the measurement year is greater
than 9%.
Denominator: Number of patients
aged 18 through 75 years of age with a diagnosis
of Type 1 or Type 2 diabetes mellitus during
the measurement year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions: Patients
who have less than two face-to-face encounters
with a diagnosis of diabetes on different dates
during the measurement year should be excluded
from the denominator. Also exclude those who
do NOT have a diagnosis of Diabetes but have
a diagnosis of polycystic ovaries, or steroid
induced diabetes, or gestational diabetes from
the denominator.
Denominator Inclusions: Diabetes
type 1 or type 2
Note: A1c lab result is affected by the presence
of hemoglobinopathy. Normal range varies by
methodology and may require special lab attention.
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: None
Numerator Inclusions: Use
the most recent HbA1c test during the measurement
year. The patient is numerator compliant (goes
into the numerator) if the result for the HbA1c
test is >9.0%, or the most recent test result
is missing or if an HbA1c test was not done
during the measurement year.
Source: NQF/NCQA/ PQRI
Description: Percentage of
patients 18-85 years of age with a diagnosis
of hypertension (HTN) and whose blood pressure
(BP) was adequately controlled (<140/90)
during the measurement year.
Rationale/Purpose:
Persistent hypertension is one of the risk
factors for strokes, heart attacks, heart failure
and arterial aneurysm, and is a leading cause
of chronic renal failure. It is estimated that
1 of 3 adults has high blood pressure or hypertension.
The goal is to minimize further cardiovascular
health risks associated with hypertension (HTN)
through monitoring and treatment.
Numerator/Denominator:
Numerator: Patients from the
denominator with last blood pressure measurement
with systolic blood pressure less than 140 mm
Hg and the diastolic blood pressure less than
90 mm Hg.
Denominator: All patients
18-85 years of age with a diagnosis of hypertension
(HTN) during the measurement year.
Denominator Exclusions/Inclusions/Notes/Comments:
Denominator Exclusions: Patients
newly enrolled in care during the last 6 months
should be excluded from the denominator. Patients
with the diagnosis of end stage renal disease
(ESRD ), dialysis or renal transplant , or
pregnancy, are to be excluded from the denominator.
The following statements alone are insufficient
to confirm the diagnosis of Hypertension: “rule
out hypertension,” possible hypertension,” “white-coat
hypertension,” “questionable hypertension” and
“consistent with hypertension”.
Denominator Inclusions: The
notation of hypertension may appear anytime
on or before June 30 of the measurement year,
including prior to the measurement year. It
does not matter if hypertension was treated
or is currently being treated. Billing code
Diagnosis should be confirmed by chart review
with problem listing of: — HTN — high blood
pressure (HBP) — elevated blood pressure (ˆBP)
— borderline HTN — intermittent HTN — history
of HTN — hypertensive vascular disease (HVD).
Numerator Exclusions/Inclusions/Notes/Comments:
Numerator Exclusions: Do not
include BP readings obtained on the same day
as a major diagnostic or surgical procedure.
Do not include BP home-monitoring results or
self-reported BP readings (e.g., home and health
fair BPs).
Note: If no BP is recorded during the measurement
year, assume the patient is “not controlled.”
Numerator Inclusions: Identify
the lowest systolic and lowest diastolic BP
reading from the most recent BP notation in
the medical record. The reading must occur after
the date the diagnosis of hypertension was made.
If multiple readings on the same day, the systolic
and diastolic results do not need to be from
the same reading.
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