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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act
E Tables of HIV/AIDS Quality Measures from Selected Sources
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Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act
TABLE E-1 Commonly Used Quality Measures by Measure Type
Measure Type
Measure
Source
STRUCTURAL MEASURES
The committee found no explicit structural measures in use; however, certain process measures such as visits with HIV specialists imply the availability of appropriate health care resources.
PROCESS MEASURES
Prevention
Counseling and testing
HIVQUAL
Counseling on high-risk behaviors
RAND
Tobacco use assessment
HIVQUAL
Screening & Monitoring
CD4+ cell count
HCSUS
CD4+ cell count
IHI
CD4+ cell count
UHC
CD4+ cell count and HIV viral load
FACCT
CD4+ cell count and HIV viral load
IDSA
CD4+ cell count and HIV viral load
QUERI
CD4+ cell count and HIV viral load
RAND
CD4+ cell count and HIV viral load
RAND
CD4+ cell count and HIV viral load
UHC
Cervical cancer
EQHIV
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Eligible Population
Measure Criterion/Definition
Pregnant women
The number of pregnant women with counseling offered and testing performed during the prenatal period
All
Counseled regarding high risk behavior at time of HIV diagnosis and within one month of presentation with an initial infection of STD
All
Number of patients with whom tobacco use was discussed during the past year
All
At least one CD4+ cell count determination per studied 6 month interval, by chart review or interview
All
Percent with CD4+ cell count taken in the past 6 months
All
Semi-annual CD4+ cell count attainment (most recent 6 months)
1) If CD4+ cell count > 300 cells/µL; 2) If CD4+ cell count <300 cells/µL
1) CD4+ cell count and HIV viral load every 6 months; 2) CD4+ cell count and HIV viral load every 3 months
Patients being followed actively (having at least 1 visit in last 6 months)
Percent with CD4+ cell count and HIV viral load; every 3–4 months when CD4+ cell count is <350/µL or every 6–7 months when CD4+ cell count is >350/µL
1) Patients on HAART; 2) All
1) CD4+ cell count or HIV viral load test every 3 months; 2) CD4+ cell count or HIV viral load test every 6 months
CD4+ cell count > 300 cells/µL
Offer of CD4+ test (count or percent) and HIV viral load every 6 months
patients with detectable HIV viral loads
Offer HIV viral load every 4 months
All
1 each (CD4+ cell count and HIV viral load) in 2 consecutive 6-month periods
All females
Documentation of Pap smear or colposcopy
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Measure Type
Measure
Source
Cervical cancer
EQHIV
Cervical cancer
FACCT
Cervical cancer
HCSUS
Cervical cancer
IDSA
Cervical cancer
IHI
Cervical cancer
UHC
Cervical cancer and other pelvic disease
HIVQUAL
Complete blood count
FACCT
Complete blood count, CD4+ cell count, HIV viral load
RAND
Complete blood count, CD4+ cell count, HIV viral load
RAND
Cytomegalovirus disease
FACCT
Cytomegalovirus disease
HCSUS
Cytomegalovirus disease
RAND
Hepatitis A
QUERI
Hepatitis B
FACCT
Hepatitis B
QUERI
Hepatitis B
UHC
Hepatitis B and C
IHI
Hepatitis C
EQHIV
Hepatitis C
EQHIV
Hepatitis C
FACCT
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Eligible Population
Measure Criterion/Definition
Females with abnormal Pap smear
Repeat of Pap smear
All females
Annual Pap smear
All females
All Pap smears according to guidelines (currently baseline, 6 months, and every 12 months thereafter if normal)
HIV-infected adult and adolescent women being followed
Percent who had at least one Pap smear done in the past year
All females
Percent with Pap smear in last 6 months
All females
Percent with Pap smear (between 9/2000 and 9/2001)
All females 18 years or older AND sexually active female patients 13 to 18 years of age
Number of patients with a pelvic exam recorded in the last year (pelvic exam includes Pap smear; chlamydia screen; gonorrhea test)
All
Complete blood count at first visit
All
Offer baseline laboratories (complete blood count, HIV viral load, CD4+ cell count) within one month of initial diagnosis
Patients on antiretroviral therapy
Offer CD4+ cell count or percent, HIV viral load and complete blood count within past 4 months
1) All; 2) CD4+ cell count less than 200 cells/µL
1) Cytomegalovirum IgG determination; 2) Annual fundoscopic exam
All, as indicated
Fundoscopic exam by eye care provider
Lowest recorded CD4+ cell count of less than 100 cells/µL
Receipt of yearly fundoscopic exam
All
Receipt of hepatitis A test (ever)
All
Hepatitis B antibody determination
All
Receipt of hepatitis B test (ever)
All
Hepatitis B serology attainment (ever)
All
Percent with hepatitis B & C screening
All
Hepatitis C status was known (whether positive or negative)
All
Appropriate hepatitis C screening
All
Hepatitis C antibody determination
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Measure Type
Measure
Source
Hepatitis C
HIVQUAL
Hepatitis C
HIVQUAL
Hepatitis C
HIVQUAL
Hepatitis C
QUERI
Hepatitis C
UHC
HIV Specialist Visits
HIVQUAL
Lipid screening (for disease and drug related metabolic abnormalities)
HIVQUAL (optional measure)
Lipid screening (for disease and drug related metabolic abnormalities)
QUERI
Oral Health / Dental exam
HIVQUAL (optional measure)
Outpatient visits
IHI*
Outpatient visits
EQHIV
Syphilis
FACCT
Syphilis
HCSUS
Syphilis
HIVQUAL
Syphilis
HIVQUAL
Syphilis
HIVQUAL
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Eligible Population
Measure Criterion/Definition
All
The number of patients for whom hepatitis C was document in the medical record
HCV+ patients
The number for whom alcohol counseling and HCV education was provided
All
The number of patients for whom hepatitis A status was documented.
All
Receipt of hepatitis C test (ever)
All
Hepatitis C serology attainment (ever)
All; with exception of those either incarcerated or hospitalized and with no ambulatory clinic visits during 4-month review period
Number of patients who are seen by an HIV specialist at least once every 4 months
Patients receiving antiretroviral therapy
The number of patients for whom lipid screen was performed during the past year
Patients on protease inhibitors (PI) or nonnucleoside reverse transcriptase inhibitors (NNRTI) for consecutive months
Receipt of lipid panel testing
All
The number of patients with a dental exam documented during the past year
All
Percent with visit(s) in last 3 months
All
Have outpatient visits in 3 or 4 quarter during review period.
All
Serologic test for syphilis measured at least once
All
Any serologic test for syphilis performed
All patients 18 years or older AND sexually active patients 13 to 18 years of age
The number of patients for whom syphilis screening was performed in the last year
Patients with reactive RPR/VDRL
Number with RPR/VDRL titer result verified (FTA-ABS)
Patients with positive serology
Number of patients that have been addressed in the chart
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Measure Type
Measure
Source
Syphilis
QUERI
Syphilis
RAND
Toxoplasmosis
FACCT
Toxoplasmosis
HCSUS
Toxoplasmosis
QUERI
Toxoplasmosis
RAND
Toxoplasmosis
UHC
Tuberculosis
EQHIV
Tuberculosis
EQHIV
Tuberculosis
FACCT
Tuberculosis
HCSUS
Tuberculosis
HIVQUAL
Tuberculosis
IDSA
Tuberculosis
IHI
HIV viral load
HCSUS
HIV viral load
HIVQUAL
HIV viral load
IHI
HIV viral load
RAND
HIV viral load
UHC
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Eligible Population
Measure Criterion/Definition
All
Receipt of VDRL test ever
All
Documented serologic test for syphilis (VDRL or RPR)
All
Toxoplasma IgG antibody measured at least once
All
Toxoplasma IgG antibody determination noted in chart
All
Receipt of toxoplasmosis test (ever)
All
Toxoplasmosis serology should be documented
All
Toxoplasmosis serology attainment ever
All
Documentation of PPD (skin test for TB) during the review period
All
Documentation of PPD (skin test for TB) during the review period and that it was actually read
All
PPD (skin test for TB) if no prior positive test
All
1) PPD (skin test for TB) ever documented in chart or by interview. 2) periodic PPD tests (skin test for TB) documented in chart or by interview
All
The number of patients whose PPD (skin test for TB) was placed and results read during the past year
HIV-infected persons being followed
Percent who had a documented tuberculin skin test at any time
All
Percent with PPD (skin test for TB)
All
At least one HIV viral load determination per measured 6 month interval, by chart review or interview
All; with exception of those either incarcerated or hospitalized and with no ambulatory clinic visits during 4-month review period
The number of patients for whom HIV viral load test was performed every 4 months
All
Percent with HIV viral load tests taken in past 3 months
Patients on antiretroviral therapy
Offer HIV viral load measurement within 2 months of initiation or change in antiretroviral treatment
All
Semi-annual HIV viral load attainment (most recent 6 months)
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Measure Type
Measure
Source
Treatment (Antiretroviral)
Appropriate management of patients on antiretroviral therapy (ART)
HIVQUAL
Appropriate management of patients on ART
HIVQUAL
Appropriate management of patients on ART
HIVQUAL
Provision of adherence counseling and/or monitoring
IHI*
Provision of adherence counseling and/or monitoring
HIVQUAL
Provision of adherence counseling and/or monitoring
IHI
Provision of adherence counseling and/or monitoring
RAND
Provision of adherence counseling and/or monitoring
UHC
Provision of indicated ART
IHI*
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Eligible Population
Measure Criterion/Definition
Patients who are receiving ART therapy, received ART therapy in the past, or are eligible for ART therapy based on New York State ART therapy guidelines; virologically stable
The number of stable patients for whom HIV viral load is monitored every 4 months
Patients who are receiving ART therapy, received ART therapy in the past, or are eligible for ART therapy based on New York State ART therapy guidelines; virologically unstable
One of the following four management options is documented in the medical record in every 4-month period that the patient is considered unstable: (1) regimen was changed and HIV viral load assay performed within 8 weeks of decision; (2) justification provided not to change therapy and HIV viral load assay performed within 8 weeks of decision; (3) documentation that patient decides not to take medication and HIV viral load assay performed within 4 months; (4) decision made to discontinue therapy and planned clinical follow-up plan noted in record within 4 months
Patients who are receiving ART therapy, received ART therapy in the past, or are eligible for ART therapy based on New York State ART therapy guidelines; end stage or patients with no other therapeutic options
The number of patients for whom a follow-up clinic visit is recorded every 4 months
Patients on HAART
Percent with adherence counseling/intervention at their last visit
Patients prescribed antiretroviral therapy
Adherence is measured and described quantitatively at least once every 4 months
Patients on HAART
Percent who self-report adherence to prescribed regimen according to some standard method (3 months)
Patients started on protease inhibitors
Documented counseling regarding compliance with therapy within 1 month of the start of therapy.
Patients on antiretroviral therapy
Documentation of adherence to ART at most recent visit
All
Percent on HAART
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Measure Type
Measure
Source
Pneumocystis carinii pneumonia (PCP)
UHC
Toxoplasmosis
FACCT
Toxoplasmosis
RAND
Tuberculosis
FACCT
Tuberculosis
RAND
Social and Support Services
Benefits advocacy
HCSUS
Emotional counseling
HCSUS
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Eligible Population
Measure Criterion/Definition
Most recent CD4-cell count <200/µL
Receipt of PCP prophylaxis
Positive antibody (IgG) to toxoplasma present and CD4+ <50 cells/µL
Receipt of trimethoprim-sulfamethoxazole, or Dapsone plus pyrimethamine, in recommended doses for recommended duration
Patients who do not have active toxoplasmosis and who meet either of the following conditions: Toxo IgG positive; or completion of therapy for active toxoplasmosis
Offered toxoplasmosis prophylaxis within 1 month of meeting all these conditions
Patients with tuberculin skin test >5ml or prior positive without treatment or contact with active case of tuberculosis
Receipt of isoniazid plus pyridoxine or rifampin in recommended doses for recommended duration
Patients who do not have active TB and who have not ever previously received TB prophylaxis with current PPD (skin test for TB) >5 mm; or provider noting that patient has had PPD (skin test for TB) >5 mm administered at anytime since HIV diagnosis
Offer of tuberculosis prophylaxis within one month of these conditions
Patients with a need for help in obtaining income assistance such as SSI, SSDI, AFDC, or health care benefits from Medicaid or the VA in the last 6 months as reported at interview
No unmet need
Patients with need for help in obtaining mental health or emotional care or counseling in the last 6 months as reported at interview
No unmet need
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Measure Type
Measure
Source
Home Health Services
HCSUS
Housing
HCSUS
Mental Health Assessment
HIVQUAL
Self-management goal setting
IHI
Substance abuse services
HCSUS
Substance abuse services
HIVQUAL
Substance abuse services
HIVQUAL
Substance abuse services
HIVQUAL
Support Service
IHI
OUTCOME MEASURES
Health Outcomes
CD4+ cell count
IHI
CD4+ cell count
IHI*
CD4+ cell count
IHI
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Eligible Population
Measure Criterion/Definition
Patients with need for help in obtaining home health care in the last 6 months as reported at interview
No unmet need
Patients with a need for help in finding a place to live in the last 6 months as reported at interview
No unmet need
All
The number of patients for whom a mental health assessment was performed during the past year. Assessment components include: cognitive function; screening for depression and anxiety; psychiatric history; psychiatric medication review; psychosocial assessment; sleeping and appetite assessment
All
Percent with self-management goal setting
Patients with need for help in obtaining drug or alcohol treatment in the last 6 months as reported at interview
No unmet need
All
The number of patients with whom substance use was discussed in the past year
Patients with current use (0–6 months from date of review) and not in treatment
Number for whom referrals are made for substance use treatment
Patients with past use (6–24 months from date of review)
Number with whom relapse prevention or ongoing treatment has been discussed and substance use within the last 12 months assessed.
All
Percent with Support Service Assessment
All patients with CD4+ cell count in last 3 months
Average of the last CD4+ cell count
Patients on HAART
Percent with CD4+ cell count >200/µL
All with at least two CD4+ cell count in last 6 months
Percent with CD4+ cell count rise of >50/µL in the past 6 months
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Measure Type
Measure
Source
CD4+ cell count
EQHIV
CD4+ cell count
EQHIV
Emergency room visits
UHC
Hospitalization
UHC
Hospitalization
IHI
HIV viral load
IHI*
HIV viral load
EQHIV
HIV viral load
EQHIV
HIV viral load
EQHIV
NOTES:
1Treatment regimens were recommended at the time that the studies were done and may be outdated according to current standards. Readers are referred to Department of Health and Human Services and International AIDS Society-USA guidelines for the most current treatment guidelines and recommendations.
2Only indicators for adults and adolescents > 13 were included in this table.
3IHI* denotes a key measure; IHI denotes additional measure.
SOURCES:
EQHIV = Evaluation of Quality Improvement for HIV Care (Cleary, 2003).
FACCT = Foundation for Accountability (Wu and Gifford, 1998; Wu et al., 2000).
HCSUS = HIV Cost and Services Utilization Study (Asch, 2003).
HIVQUAL = HIV Quality of Care Program (NYSDHAI and HRSA/HAB, 2003).
IDSA= Infectious Disease Society of America (Gross et al., 2000).
IHI = Institute for Health Care Improvement HIV/AIDS Collaborative (IHI, 2003).
QUERI= Quality Enhancement Research Initiative (Anaya, 2003).
RAND = The RAND Corporation (Asch et al., 2000).
UHC = University Health Consortium (UHC, 2002).
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Eligible Population
Measure Criterion/Definition
Patients with CD4+ cell count <200/µL
CD4+ cell count increased to >200/µL at the last visit
All
Last CD4+ cell count recorded were <200/µL
All
Non-injury-related emergency room visits per patient per year UHC categorized this measure under Resource Utilization
All
Non-injury-related hospitalizations per patient per year UHC categorized this measure under Resource Utilization
All
Percent with hospitalizations within the last month
Patients on HAART
Percent with undetectable HIV viral load
Patients on HAART (defined as three or more antiretroviral medications)
HIV viral load between 0 and 399 copies
Patients on HAART (defined as three or more antiretroviral medications)
HIV viral load between 400 and 19,999 copies
Patients on HAART (defined as three or more antiretroviral medications)
HIV viral load > 20,000 copies
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TABLE E-2 Frequency of Process and Outcome Measures by Source
EQHIV
FACCT
PREVENTION
Counseling and testing (pregnant women)
Counseling on high-risk behaviors
Tobacco use assessment
SCREENING & MONITORING
CD4+ cell count
√
Cervical cancer and other pelvic disease
√
√
Complete blood count
√
Cytomegalovirus disease
√
Hepatitis A
Hepatitis B and/or C
√
√
HIV specialists visit
Lipid screening
Oral health/dental exam
Outpatient visits
√
Syphilis
√
Toxoplasmosis
√
Tuberculosis
√
√
HIV viral load
√
ANTIRETROVIRAL TREATMENT (ART)
Appropriate management of patients on ART
Provision of adherence counseling and/or monitoring
Provision of indicated ART
√
√
Regimen change
PROPHYLACTIC TREATMENT
Hepatitis B
√
Influenza
√
√
Mycobacterium avium complex
√
Pneumococcal pneumonia
√
Pneumocystis carinii pneumonia
√
Toxoplasmosis
√
Tuberculosis
√
SOCIAL AND SUPPORT SERVICES
Benefits advocacy
Emotional counseling
Home health services
Housing
Mental health assessment
Self-management goal setting
Substance abuse services
Support services
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HIVQUAL
IDSA
IHI
QUERI
RAND
UHC
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EQHIV
FACCT
HEALTH OUTCOMES
CD4+ cell count
√
Emergency room visits
Hospitalization
HIV viral load
√
NOTE: No structural quality of care measures were identified in this review.
SOURCES:
EQHIV = Evaluation of Quality Improvement for HIV Care (Cleary, 2003).
FACCT = Foundation for Accountability (Wu and Gifford, 1998; Wu et al., 2000).
HCSUS = HIV Cost and Services Utilization Study (Asch, 2003).
HIVQUAL = HIV Quality of Care Program (NYSDHAI and HRSA/HAB, 2003).
IDSA = Infectious Disease Society of America (Gross et al., 2000).
IHI = Institute for Health Care Improvement HIV/AIDS Collaborative (IHI, 2003).
QUERI = Quality Enhancement Research Initiative (Anaya, 2003).
RAND = The RAND Corporation (Asch et al., 2000).
UHC = University Health Consortium (UHC, 2002).
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HCSUS
HIVQUAL
IDSA
IHI
QUERI
RAND
UHC
√
√
√
√
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REFERENCES
Anaya H. 2003. QUERI Indicators. (Email communication, Henry Anaya, Department of Veterans Affairs, May 12, 2003).
Asch S. 2003. Table 2: Adherence to Quality Indicators in HIV. (Email communication, Steven Asch, The RAND Corporation).
Asch SM, Kerr EA, Hamilton EG, Reifel JL, McGlynn EA, Editors. 2000. Quality of Care for Oncologic Conditions and HIV: A Review of the Literature and Quality Indicators. Santa Monica, CA: Rand Health.
Cleary P. 2003. EQHIV Chart Review Dependent Variables. (Email communication, Paul Cleary, Harvard Medical School, December 9, 2003).
Gross PA, Asch S, Kitahata M, Freedberg KA, Barr D, Melnick DA, Bozzette S. 2000. Performance measures for guidelines on preventing opportunistic infections in patients infected with human immunodeficiency virus. Clinical Infectious Diseases 30(Suppl 1):S85–S93.
IHI (Institute for Healthcare Improvement). 2003. Improving Care for People Infected with HIV. [Online]. Available: http://www.ihi.org/collaboratives/breakthroughseries/HIV/charter.asp [accessed July 31, 2003].
New York State Department of Health AIDS Institute and Health Resources and Services Administration, HIV/AIDS Bureau (NYSDHAI and HRSA/HAB). 2003. [Online]. Available: http://www.hivguidelines.org/public_html/center/quality-of-care/qoc-ny-indicators.htm.
UHC (University Health System Consortium). 2002. HIV Ambulatory Care Clinical Benchmarking Executive Summary. 12.
Wu A, Gifford A. 1998. Quality of Care Indicators for HIV/AIDS: A Discussion Paper for the Foundation for Accountability . [Online]. Available: http://www.facct.org/facct/doclibFiles/documentFile_302.pdf [accessed July 31, 2003].
Wu AW, Gifford A, Asch S, Cohn SE, Bozzette SA, Yurk R. 2000. Quality-of-care indicators for HIV/AIDS. Disease Management and Health Outcomes 7(6):315–30.
Representative terms from entire chapter:
hiv viral
