![](media/image1.png){width="5.972916666666666in"
height="0.4791666666666667in"}

Top of Form

## Complete Summary

#### TITLE

Bipolar disorder: the percentage of patients diagnosed with bipolar
disorder and treated with an antipsychotic agent who were assessed for
the presence of extrapyramidal symptoms twice within the first 24 weeks
of treatment.

#### SOURCE(S)

STABLE (STAndards for BipoLar Excellence) performance measures. Boston
(MA): Center for Quality Assessment and Improvement in Mental Health;
2007. various p.

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Process

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the percentage of patients diagnosed with
bipolar disorder and treated with an antipsychotic agent who were
assessed for the presence of extrapyramidal symptoms (EPS) twice within
the first 24 weeks of treatment.

#### RATIONALE

**Extrapyramidal Symptoms**

-   Extrapyramidal symptoms refer to movement disorders that occur when
    there is a disruption of the brain\'s extrapyramidal system.
    Extrapyramidal Symptoms are referred to as EPS.

-   EPS neurological side effects include akathisia, a motor
    restlessness, and muscle rigidity and tremor, which are sometimes
    referred to as drug-induced Parkinsonian symptoms.

-   EPS also includes tardive dyskinesia and acute dystonia, rare but
    severe side effects that also relate to disruption of the
    extrapyramidal system. Sometimes these symptoms are referred to as
    distinct side effects due to their severity.

**Extrapyramidal Symptoms and Antipsychotic Agents**

-   Typical antipsychotics are associated with significant acute
    neurologic side effects.

-   Tardive dyskinesia (TD) is the principal adverse effect of long-term
    typical (first generation) antipsychotic treatment; however, studies
    indicate that TD still occurs with atypical (second generation)
    antipsychotic agents.

-   Atypical (second generation) antipsychotics have been reported to
    have a lower rate of EPS, particularly acute dystonia and
    drug-induced Parkinsonism.

**Monitoring for Extrapyramidal Symptoms**

-   Patients with bipolar disorder should be regularly monitored for
    iatrogenic adverse effects of antipsychotic medication including
    extrapyramidal symptoms.

-   Regular examination for early signs of tardive dyskinesia is an
    appropriate monitoring plan.

#### PRIMARY CLINICAL COMPONENT

Bipolar disorder; assessment for extrapyramidal symptoms (EPS)

#### DENOMINATOR DESCRIPTION

Patients diagnosed and treated for bipolar disorder with an
antipsychotic agent (see the related \"Denominator
Inclusions/Exclusions\" field in the Complete Summary)

#### NUMERATOR DESCRIPTION

Patients assessed for extrapyramidal symptoms (EPS) twice during initial
24 weeks of treatment (see the related \"Numerator
Inclusions/Exclusions\" field in the Complete Summary)

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

-   One or more research studies published in a National Library of
    Medicine (NLM) indexed, peer-reviewed journal

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Unspecified

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Ambulatory Care\
Behavioral Health Care\
Physician Group Practices/Clinics

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Individual Clinicians

#### TARGET POPULATION AGE

Age greater than or equal to 18 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Unspecified

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

See the \"Rationale\" field.

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

Patients with a diagnosis involving bipolar disorder: International
Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) or Diagnostic and Statistical Manual of Mental Disorders,
Fourth Revision, Text Revision (DSM-IV-TR): 296.0x; 296.1x; 296.4x;
296.5x; 296.6x; 296.7; 296.80-82; 296.89; or 301.13

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Patients 18 years of age or older with an initial or new episode of
bipolar disorder

AND

Documentation of a diagnosis involving bipolar disorder; to include at
least one of the following:

-   Codes 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.81;
    296.82; 296.89; 301.13 documented in body of chart, such as, a
    pre-printed form completed by a clinician and/or codes documented in
    chart notes/forms

-   Diagnosis or impression documented in chart indicating bipolar
    disorder

-   Use of a screening/assessment tool for bipolar disorder with a score
    or conclusion that patient has bipolar disorder and indication that
    this information is used to establish or substantiate the diagnosis

AND

Documentation of treatment with an antipsychotic agent (Refer to the
\"Data Dictionary Reference\" in the original measure documentation for
specified medications.)

**Exclusions**\
Unspecified

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition\
Encounter\
Therapeutic Intervention

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Assessment of extrapyramidal symptoms (EPS) to include a documented
reference of at least one of the following (Refer to the \"Data
Dictionary Reference\" in the original measure documentation for EPS
definitions):

-   Clinician narrative information concerning patient\'s EPS symptoms
    documented in chart

-   Clinician scored EPS tool is present in chart

-   Patient\'s self-reported symptoms (may be included on an assessment
    tool or preprinted form) are documented in chart

AND

Timeframe:\
Documentation must include at least two recordings within the first 24
weeks of treatment.

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Fixed time period

#### DATA SOURCE

Administrative data\
Medical record

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### PRE-EXISTING INSTRUMENT USED

-   Abnormal Involuntary Movement Scale (AIMS): Clinician tool used to
    assess tardive dyskinesia (available at
    [www.cqaimh.org/stable.html](http://www.cqaimh.org/stable.html))

-   Antipsychotic Symptom Checklist (ASC): Captures adverse effects of
    antipsychotic agents (available at
    [www.cqaimh.org/stable.html](http://www.cqaimh.org/stable.html))

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a higher score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

-   The STABLE measures were developed using the RAND Appropriateness
    Method and have been shown to have content validity and face
    validity.

-   Data feasibility testing was performed to determine the availability
    of the data elements required in the measure numerator and
    denominator specifications.

-   Inter-abstractor reliability testing was performed to assess the
    data collection strategy. The data collection strategy included data
    collection forms; data dictionary references and abstractor
    instructions.

-   A field study was conducted to determine measure conformance in an
    appropriate convenience sample.

Refer to the references listed below for further information.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

STABLE performance measures: data feasibility testing & results. Boston
(MA): Center for Quality Assessment and Improvement in Mental Health;
2007. 2 p.

STABLE performance measures: development process & validity ratings.
Boston (MA): Center for Quality Assessment and Improvement in Mental
Health; 2007. 3 p.

STABLE performance measures: field study process & conformance findings.
Boston (MA): Center for Quality Assessment and Improvement in Mental
Health; 2007. 3 p.

STABLE performance measures: inter-abstractor reliability testing &
results. Boston (MA): Center for Quality Assessment and Improvement in
Mental Health; 2007. 2 p.

### Identifying Information

#### ORIGINAL TITLE

Bipolar disorder: monitoring for extrapyramidal symptoms.

#### MEASURE COLLECTION

[Standards for Bipolar Excellence (STABLE) Performance
Measures](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1995&doc=11485)

#### SUBMITTER

Center for Quality Assessment and Improvement in Mental Health

#### DEVELOPER

STABLE Project National Coordinating Council

#### FUNDING SOURCE(S)

AstraZeneca LLP, Wilmington, Delaware, provided financial sponsorship
for the STABLE Project. They did not otherwise participate in the
development of either the measures or toolkit.

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

The STABLE [National Coordinating Council
(NCC)](http://www.cqaimh.org/members.html) was comprised of national
experts in bipolar disorder, psychiatry, primary care, and performance
improvement. The NCC guided and directed the STABLE Project. NCC members
agreed to serve with the understanding that the STABLE Performance
Measures and Resource Toolkit would be fully transparent and available
without cost in the public domain.

[EPI-Q, Inc.](http://www.epi-q.com/index.html), is a consulting company
providing practice-based outcomes research, pharmacoeconomic studies,
and quality improvement services. EPI-Q managed the STABLE Project.

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

Unspecified

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2007 Jan

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

STABLE (STAndards for BipoLar Excellence) performance measures. Boston
(MA): Center for Quality Assessment and Improvement in Mental Health;
2007. various p.

#### MEASURE AVAILABILITY

The individual measure, \"Bipolar Disorder: Monitoring for
Extrapyramidal Symptoms,\" is published in \"STABLE (STAndards for
BipoLar Excellence) Performance Measures.\" This document is available
in Portable Document Format (PDF) from the [Center for Quality
Assessment and Improvement in Mental Health (CQAIMH) Web
site](http://www.cqaimh.org/stable.html).

#### COMPANION DOCUMENTS

The following is available:

-   STABLE National Coordinating Council Resource Toolkit Workgroup.
    STABLE resource toolkit. Boston (MA): Center for Quality Assessment
    and Improvement in Mental Health; 2007 Mar. 67 p. This document is
    available in Portable Document Format (PDF) from the [Center for
    Quality Assessment and Improvement in Mental Health (CQAIMH) Web
    site](http://www.cqaimh.org/stable.html).

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on January 10, 2008.
The information was verified by the measure developer on April 14, 2008.

#### COPYRIGHT STATEMENT

The STABLE materials published on this Web site are copyrighted by
CQAIMH. They may be used for research, teaching, and quality
measurement/improvement activities -- provided the following:

-   The materials are not sold, distributed or licensed for commercial
    purposes.

-   CQAIMH\'s copyright is acknowledged in reproductions of these
    materials.

-   Modifications to the materials are not made without CQAIMH\'s
    permission.

### Disclaimer

#### NQMC DISCLAIMER

The National Quality Measures Clearinghouse™ (NQMC) does not develop,
produce, approve, or endorse the measures represented on this site.

All measures summarized by NQMC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public and private organizations, other government
agencies, health care organizations or plans, individuals, and similar
entities.

Measures represented on the NQMC Web site are submitted by measure
developers, and are screened solely to determine that they meet the NQMC
Inclusion Criteria which may be found at
<http://www.qualitymeasures.ahrq.gov/about/inclusion.aspx>.

NQMC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or its reliability and/or validity of the quality
measures and related materials represented on this site. The inclusion
or hosting of measures in NQMC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding measure content are directed to contact
the measure developer.

Bottom of Form

© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008