Edward Westrick, MD PhD 

Stephen Kogut, PhD, MBA 

MagnaCare 

Health Services 

Improvement, Inc. 

Karen Milgate, MPP 

MedPAC Project Officer 

MedPAC 

601 New Jersey Avenue, 

NW 

Suite 9000 

Washington, DC 20001 

(202) 220-3700 

Fax: (202) 220-3759 

www.medpac.gov

The views expressed in this report 

are those of the authors. 

No endorsement by MedPAC 

is intended or should be inferred. 

MEDICARE AMBULATORY CARE 

INDICATORS FOR THE ELDERLY: 

REFINEMENT OF THE ACCESS TO CARE 

FOR THE ELDERLY PROJECT 

INDICATORS 

FINAL REPORT 

January, 2006 

T13605748
TABLE OF CONTENTS 

page 

Executive Summary 2 

Project Background 6 

Methods 10 

 Overview, Selection of Conditions / Topics 

 Clinical Logic 

 Expert Panel 

Recommendations for Testing 19 

 Diabetes Mellitus 22 

 Coronary Artery Disease 39 

 Stroke / Transient Ischemia / Hypertension 48 

 Chronic Heart Failure 58 

 Cancer 69 

 Anemia / GI Bleed 81 

 Miscellaneous: COPD; Depression; Infectious Disease 87 

 Measurement Issues and Recommendations 95 

Measures Recommended for Inclusion in Medicare Ambulatory 

Care Indicators for the Elderly Set 99 

References 100 

Appendices 101 

 1. Summary Matrix of Conditions / Topics Considered 

 2. Preparatory Materials for Expert Panel Meeting 

 3. Summary of Expert Panel Recommendations 

 4. Revised ACE-PRO Indicator Set: Measure Short Descriptions 

 5. Revised ACE-PRO Measures General Analytic Rules 

 6. Bibliography 

1
Executive Summary 

The Medicare Payment Advisory Commission contracted with MagnaCare Health 

Services Improvement, Inc. (MagnaCare-HSI) to coordinate an effort to refine the 

Access to Care for the Elderly Project (ACE-PRO) indicators, for the purposes of 

measuring and tracking the quality of ambulatory care and the access to 

ambulatory care for Medicare beneficiaries. 

The ACE-PRO indicators were developed for MedPAC (known then as the 

Physician Payment Review Commission) by RAND, which received guidance 

from a panel of leading clinicians using a structured rating process. MedPAC 

has used these indicators to study the access to and quality of care associated 

with various geographic and socioeconomic factors, and has used the results of 

these analyses in their reports to Congress. 

The delivery of health care has changed since these indicators were originally 

developed. Medical science has advanced as newer technologies and 

therapeutic interventions have been introduced. The science of performance 

measurement has also advanced, and indicators of appropriate care are now 

commonly used for evaluation and in quality improvement efforts across health 

care settings. MedPAC required a refined set of indicators for use in evaluating 

the quality of ambulatory care to Medicare beneficiaries. It is essential that the 

Medicare Ambulatory Care Indicator for the Elderly (MACIE) set reflects 

important aspects of routine care for health conditions that are common to the 

Medicare population, while also maintaining consistency with contemporary 

methods for performance measurement. 

In their role as coordinators of this refinement effort, staff from MagnaCare 

Health Service Improvement, Inc. conducted a comprehensive evaluation of the 

ACE-PRO measure set which included: 1.) The identification and consideration 

of health conditions and clinical topics; 2.) A review of the evidence; 3.) The 

identification of existing measures from other sources; 4.) The contrasting of 

ACE-PRO indicators with similar performance measures used by others; 5.) The 

consideration of the appropriateness of indicators given existing limitations (e.g. 

data availability) and the intended purpose of the measures (e.g. must be 

sensitive to ambulatory care); 6.) Convening a meeting of technical experts in 

performance measurement; 7.) Facilitating a meeting of these technical experts 

to receive guidance pertaining to clinical and measurement issues; 8.) Reviewing 

the results of initial analyses; and 9) Incorporating the recommendations of the 

technical experts and results of initial analyses into recommendations for a 

revised set of indicators that can be used to evaluate access and quality of 

ambulatory care provided to Medicare beneficiaries. 

This report provides detail describing the methods employed and rationale for 

decision-making that generated the recommendations for inclusion in the 

2
Medicare Ambulatory Care Indicator for the Elderly set. This report details 

various attributes of the candidate indicators including the clinical logic, 

supporting evidence and rationale, existing measure versions, and 

considerations for refinement. 

Overall, the results from the testing of the measure set indicated that relevant 

numerators and denominators were identifiable, and in most instances the 

ranges of scores were consistent with previous analyses. Results for several of 

the measures differed from expectation. However, only one of the tested 

measures is recommended to be excluded from further consideration leaving 39 

measures recommended for inclusion in the Medicare Ambulatory Care 

Indicators for the Elderly set (see table below). The use of subsets of these 

measures for various purposes should be based upon careful consideration of 

validity testing and appropriateness at specific units of analysis. Approaches to 

validity testing are discussed. 

3
Table 1: Measures Recommended for Inclusion in Medicare Ambulatory 

Care Indicators for the Elderly set 

 Indicator Name Additional Description

1. Eye Exam In Diabetes Mellitus Comprehensive Eye Exam Every 2 Years 

2. A1C Testing In Diabetes Mellitus Hemoglobin A1C Test In One Year 

3. Lipid Testing In Diabetes Mellitus Lipid Profile In One Year 

4. Clinical Assessment In Diabetes 

Mellitus 

Two Out-Patient Visits In One Year 

5. Follow-Up After Hospitalization For 

Diabetes Mellitus 

Visit Within 4 Weeks Of Discharge 

6. Serious Short Term Complications 

Of Diabetes Mellitus 

Hospitalizations For Diabetic, Hyperosmolar, Ketotic 

Coma, And Uncontrolled Diabetes Mellitus 

7. Serious Long Term Complications 

Of Diabetes Mellitus 

Hospitalizations For Renal, Ophthalmologic, Neurologic 

And Circulatory Complications Of Diabetes Mellitus And 

Non-Traumatic Lower Extremity Amputation 

8. Lipid Testing In Coronary Artery 

Disease 

Annual Lipid Profile 

9. Follow-Up After Hospitalization For 

Acute MI 

Visit Within 4 Weeks Of Discharge 

10. Clinical Assessment In Coronary 

Artery Disease 

Two Out-Patient Visits In One Year 

11. ER Use For Unstable Angina 3 Or More ER Visits In One Year 

12. Carotid Imaging At Initial Diagnosis 

Of Carotid Artery Stroke 

Within 2 Weeks Of Hospitalization 

13. Carotid Imaging In Carotid Territory 

Event 

Within 2 Months Prior To Carotid Endarterectomy 

14. Follow-Up After Hospitalization For 

Stroke/TIA 

Visit Within 4 Weeks Of Discharge 

15. Clinical Assessment For History Of 

Stroke/TIA 

Two Out-Patient Visits In One Year 

16. LVEF Assessment In Heart Failure: 

At Initial Diagnosis 

Within 3 Months Before Or After Initial Diagnosis 

17. LVEF Assessment In Heart Failure: 

Associated With Hospitalization 

Within 3 Months Before Or After Hospitalization 

18. Laboratory Testing In Heart Failure Electrolytes And Renal Function Within One Year 

19. EKG After Initial Diagnosis Of Heart 

Failure 

Within One Month Before Or 3 Months After Diagnosis 

20. CXR After Initial Diagnosis Of Heart 

Failure 

Within One Month Before Or 3 Months After Diagnosis 

21. Follow-Up After Hospitalization For 

Heart Failure 

Visit Within 4 Weeks Of Discharge 

22. Clinical Assessment In Heart Failure Two Out-Patient Visits In One Year 

23. Hospitalizations For Heart Failure Hospital Admission Within One Year 

4
Table 1: Measures Recommended for Inclusion in Medicare Ambulatory 

Care Indicators for the Elderly set (continued) 

 Indicator Name Additional Description

24. Breast Cancer Screening Mammogram Within 2 Years 

25. Biopsy To Therapy Interval In 

Breast Cancer 

Less Than 3 Months 

26. CXR At Initial Diagnosis Of Breast 

Cancer 

Within 3 Months Before Or After Diagnosis 

27. Breast Imaging At Initial Dx Of 

Breast Cancer 

Within 3 Months Before Or After Diagnosis 

28. Mammography Surveillance In 

Breast Cancer 

Within One Year Of Visit For Breast Cancer 

29. Colonoscopic Surveillance After 

Colon Cancer 

Within One Year Of Resection 

30. Follow-Up Visit After Hospitalization 

For GI Bleed 

Visit Within 4 Weeks Of Discharge 

31. Follow-Up Visit After Initial 

Diagnosis Of GI Bleed 

Visit Within 4 Weeks Of Diagnosis 

32. Follow-Up Lab Test After 

Hospitalization For GI Bleed 

Hemoglobin Or Hematocrit Within 4 Weeks Of Discharge 

33. Follow-Up Lab Test After Initial 

Diagnosis Of Anemia 

Hemoglobin Or Hematocrit Within One Month Before To 6 

Months After Diagnosis 

34. GI Tract Work-Up After Initial 

Diagnosis Of Iron Deficiency 

Anemia 

Colonoscopy Or Barium Enema Within One Month Before 

To 3 Months After Diagnosis 

35. Clinical Assessment In 

COPD/Asthma 

Two Out-Patient Visits In One Year 

36. Hospitalization For Respiratory 

Diagnosis In COPD/Asthma 

Hospital Admission Within One Year 

37. Follow-Up After Hospitalization For 

Depression 

Within Two Weeks Of Discharge 

38. Hospitalization For Hypertension Hospital Admission Within One Year 

39. Annual Visit Out-Patient Visit In One Year 

5
Project Background 

The Medicare Payment Advisory Commission (MedPAC) has responsibility for 

advising Congress primarily on matters of payment, quality, and access in the 

Medicare program. MedPAC explicitly recognized the importance of 

measurement many years ago when the Physician Payment Review Commission 

(PPRC) contracted with RAND to develop the Access to Care for the Elderly 

Project (ACE-PRO) measures. The commission has used these measures to 

study the quality of and access to care associated with various geographic and 

socioeconomic factors1

 and has used the results of these analyses in their 

reports to Congress.2 

Approximately ten years ago, under congressional mandate to monitor Medicare 

beneficiaries’ access to care, the PPRC contracted with RAND to develop 

measures of access to care, using administrative data. RAND reviewed the 

literature, selected medical conditions/topics, created a conceptual framework 

(taxonomy) for measure development and produced indicators to be considered 

by an expert panel. The taxonomy assigned measures within clinical conditions 

into the following categories: 

Conditions/Topics initially considered by RAND 

• Acute MI 

• Anemia 

• Angina 

• Appendicitis 

• Breast Cancer 

• Cerebrovascular 

Disease/TIA 

• Cholelithiasis 

• COPD 

• Heart Failure 

• Depression 

• Diabetes Mellitus 

• Dyspepsia/PUD/UGI Bleed 

• Hip Fracture 

• Hypertension 

• Pneumonia 

• Preventive Care 

A group of experts was assembled to assess the feasibility, suitability, outcome 

improvement, and necessity of the services associated with the candidate 

measures. 

Forty seven indicators were selected representing fifteen medical conditions. 

Technical specifications were developed by RAND to be used in subsequent 

analyses (RAND 1995) including a peer reviewed publication.3 The original 

measure set is presented below. 

6
Access to Care for the Elderly Project (ACE-PRO): 

Originally Developed Clinically-based Indicators 

Anemia 

• For patients with iron deficiency anemia: gastrointestinal workup 

• Hematocrit/hemoglobin between one and six months following initial diagnosis of 

anemia 

 

Breast cancer 

• For patients with breast cancer and eventual mastectomy: interval from biopsy to 

definitive therapy (surgery delay time) should be less than three months 

• Visit every six months for breast cancer patients who have undergone 

mastectomy and cytotoxic chemotherapy 

• Mammography every year for patients with a history of breast cancer 

• At initial diagnosis of breast cancer, mammogram 

• At initial diagnosis of breast cancer, chest X-ray 

• Visit every year for breast cancer patients who have undergone mastectomy 

without cytotoxic chemotherapy 

 

Diabetes Mellitus 

• Glycosolated hemoglobin or fructosamine every six months for patients with 

diabetes 

• Eye exam every year for patients with diabetes 

• Visit within four weeks following discharge of patients hospitalized with diabetes 

• Visit every six months for patients with diabetes 

 

Gastrointestinal bleeding 

• Visit within four weeks following discharge of patients hospitalized with 

gastrointestinal bleeding 

• Hematocrit within four weeks following discharge of patients hospitalized with 

gastrointestinal bleeding 

• Follow-up visit within four weeks of initial diagnosis of gastrointestinal bleeding 

 

Heart and circulatory system 

• Visit within four weeks following discharge of patients hospitalized with 

myocardial infarction (MI) or heart attack 

• Cholesterol test every six months for patients hospitalized with MI who have an 

elevated cholesterol level 

• Electrocardiogram (EKG) during emergency department visit for unstable angina 

• Visit within four weeks following discharge of patients hospitalized with unstable 

angina 

• Visit every six months for patients with stable angina 

• Follow-up visit or hospitalization within one week of initial diagnosis of unstable 

angina 

• Chest X-ray within three months of initial diagnosis of congestive heart failure 

(CHF) 

• Visit within four weeks following discharge of patients hospitalized for CHF 

• EKG within three months of initial diagnosis of CHF 

• Visit every six months for patients with CHF 

7
• Visit within four weeks following discharge of patients hospitalized with malignant 

or otherwise severe high blood pressure 

 

Pulmonary system 

• Visit every six months for patients with chronic obstructive pulmonary disease 

(COPD) 

 

Stroke 

• EKG within two days of initial diagnosis of transient ischemic attack (TIA) 

• For TIA patients with eventual carotid endarterectomy: interval between carotid 

imaging and endarterectomy less than two months 

• Visit within four weeks following discharge of patients hospitalized for TIA 

• Visit every year for patients with diagnosis of TIA 

• For patients hospitalized for carotid territory stroke: carotid imaging within two 

weeks of initial diagnosis 

• For cerebral vascular accident (CVA) patients with eventual carotid 

endarterectomy: interval between carotid imaging and endarterectomy less than 

two months 

• Visit within four weeks of discharge of patients hospitalized with CVA 

 

Avoidable outcomes 

• Among patients with angina, three or more emergency department visits for 

heart-related diagnoses in one year 

• Among patients with gall stones, diagnosis of perforated gallbladder 

• Among patients with COPD, subsequent admission for respiratory diagnosis 

• Non-elective admission for CHF 

• Among patients with diabetes, admission for diabetic coma 

• Among patients with pneumonia, diagnosis of lung abscess or empyema 

 

Preventive care 

• Visit every year 

• Assessment of visual impairment every two years 

• Mammography every two years in female patients 

 

Other 

• Cholecystectomy (open or laparoscopic) for patients with gall stones and 

inflammation of the gall bladder, bile duct and/or pancreas 

• Arthroplasty or internal fixation of hip during hospital stay for broken hip 

• Visit within two weeks following discharge of patients hospitalized for depression 

8
Quality measurement in health care has advanced considerably over the last ten 

years. A wide variety of efforts have led to increased use of quality measures for 

health plans, hospitals, physicians, home health agencies, nursing homes and 

other providers of care. The purposes of measurement have also become 

clearer. Modern quality improvement theory acknowledges two primary 

purposes for performance measurement as described by the National Quality 

Forum:5

 Measurement for self-assessment and measurement for accountability. 

Measurement for self-assessment is meant to identify opportunities for 

improvement and to test the effectiveness of process changes designed to 

improve performance. Measurement for accountability can be used in selection 

and potentially as the basis for financial incentives. 

The science and practice of medicine have also advanced over the last 10 years. 

Given these advances in science, practice, and performance measurement, the 

MedPAC acknowledged the need to refine the ACE-PRO measure set and 

contracted with MagnaCare Health Services Improvement, Inc. to assist in this 

refinement. The remainder of this report describes the methods, results, and 

recommendations of this effort. 

There were important assumptions underlying this work: 

• Claims data would remain the only data source. 

• Medication use in the out-patient setting would not be available. 

• The measures had to focus on ambulatory care or be sensitive to 

ambulatory care. 

• The measures had to be sensitive to quality or access (without necessarily 

defining the difference). 

• The primary population of focus was to be the community dwelling elderly. 

• Special populations (e.g. end stage renal disease, nursing home 

residents, disabled, dually enrolled, chronic severe mental illness) would 

not be excluded from the measures, but the special needs of these 

populations would not be the primary focus of the refined measure set. 

• Selection from potential measures for the refined set would follow the 

following prioritization scheme: 

(1) Original ACE-PRO measures; 

(2) Modifications of original ACE-PRO measures; 

(3) Elimination of ACE-PRO measures; 

(4) Existing measures from other sources; 

(5) De novo measure development (minimal). 

9
Methods 

 

The methods included the identification of conditions and clinical topics, the 

identification of existing measures, evidence review, the development of a 

conceptual framework, the identification of issues for consideration in making 

recommendations, management of the expert panel, and providing 

recommendations regarding refinement of the ACE-PRO set as the Medicare 

Ambulatory Care Indicators for the Elderly (new list of measures with analytic 

logic and specifications). 

The potential universe of topics and clinical conditions was composed from lists 

of priority conditions and topics identified by the Institute of Medicine, and topics 

and clinical conditions used in existing quality measures (see table of sources of 

conditions, Appendix 1). Inclusions and exclusions from this universe of topics 

and clinical conditions were made based upon the following considerations. 

Topics were included if they were: 1.) on the original ACE-PRO condition/topic 

list; 2.) an ambulatory care sensitive condition; 3.) logically clustered with original 

ACE-PRO topics; and 4.) other conditions/topics that appeared to be feasible and 

potentially useful. Topics were excluded if they were: 1.) primarily associated 

with hospital rather than ambulatory care; 2.) not particularly pertinent to the 

general population of community dwelling elderly; and 3.) data for measuring 

processes of care are unavailable. Clinical conditions and topics that survived 

this selection process included: 

• Coronary Artery Disease 

• Dyslipidemia 

• Heart Failure 

• Cerebrovascular Disease 

• Diabetes Mellitus 

• Cancer 

• Chronic Obstructive Pulmonary Disease 

• Hypertension 

• Depression 

• Pneumonia 

• Dyspepsia / Peptic Ulcer Disease 

• Upper GI Bleed 

• Anemia 

• Preventive Care 

o Immunization 

o Cancer Screening 

o Cardiovascular Disease Risk Factor Detection 

o Vision Testing 

• Dehydration 

• Urinary Tract Infection 

• Lower Extremity Amputation 

• Mental Illness 

• Pain Control

10
Clinical Conditions/Topics Excluded from Further Consideration 

Rationale for excluding the following conditions / topics is provided below. 

Tobacco Dependence

Despite being a priority area for national action and being a condition in multiple 

measure sources, potential process measures will not be accessible via claims 

data alone. 

Obesity

Despite being a priority area for national action, this condition is not included in 

any existing measure sets. Data for measuring processes of care will not be 

accessible from claims data alone. 

Medication Management

Despite being a priority area for national action and being a topic in multiple 

measure sources, it is assumed that pharmacy claims data will not be available 

for the analysis. 

HIV Infection/AIDS

Despite inclusion in the Quality Chasm priority list and in NQMC, this condition is 

not particularly pertinent to the population of elderly Medicare beneficiaries. 

Nosocomial Infection

Despite being a priority area for national action, the topic is unrelated to 

ambulatory care. 

Hepatitis C

Despite inclusion in the NQMC, the condition is mostly applicable to a special 

subset (ESRD) of the Medicare beneficiary population but not particularly 

pertinent to the general population of elderly Medicare beneficiaries. 

Renal Disease

Despite inclusion in the NQMC, the measures are specific to ESRD-related 

processes of care, but not pertinent to the general population of elderly Medicare 

beneficiaries. 

Self-management/Health Literacy

Despite being a priority area for national action, this topic is not included in any 

existing measure sets. Processes of care associated with this topic would not be 

accessible through claims data alone. 

Anxiety Disorders

Despite inclusion on the original Quality Chasm priority list, this condition did not 

make the list of priority areas for national action. This condition is not associated 

with any existing measure sets. Processes of care associated with this condition 

11
would not be accessible through claims data alone. It is assumed that pharmacy 

claims data will not be available for analyses. 

Alzheimer’s Disease

Despite inclusion on the original Quality Chasm priority list, this condition did not 

make the list of priority areas for national action. This condition is not associated 

with any commonly used measure sets. Processes of care associated with this 

condition would not be accessible through claims data alone. It is assumed that 

pharmacy claims data will not be available for analyses. 

Incontinence

Despite inclusion in ACOVE and NCQA measure sets, the data necessary for 

measure composition would not be accessible through claims data alone. 

Frailty in Old Age

Despite inclusion in priority areas for national action, the conditions/topics: 

preventing falls and pressure ulcers; maximizing function; and developing 

advanced care plans; are particularly pertinent to Medicare beneficiaries residing 

in long term care facilities, but not pertinent to the general population of elderly 

Medicare beneficiaries. Measures associated with prevention of falls and 

prevention of pressure ulcers are restricted to institutional settings. Data 

elements required for measure composition would not be available from claims 

data alone. 

Severe and Persistent Mental Illness

Despite inclusion in the priority areas for national action the focus is on treatment 

in the public sector. Data elements for measure composition would not be 

available from the public sector. 

Patient Safety

On the list of eight priority areas for hospital care performance measurement 

from NQF’s hospital measures. No measures actually specified. Only potentially 

related to hospital care. Hospital-Level Patient Safety Indicators from AHRQ are 

not sensitive to ambulatory care practices. 

Care Coordination

Despite inclusion in the priority areas for national action and the existence of one 

related measure in the NQMC, the elements required to compose the measure 

are not available from claims data alone. Other potential measures of care 

coordination would suffer from the same limitation. 

Osteoarthritis

Despite inclusion on the Quality Chasm list of prioritized conditions and existence 

of measures within the NQMC and AMA, none of the measures associated with 

ambulatory care can be composed from claims data alone and the AHRQ 

12
measure of hip replacement mortality rate is not an outcome sensitive to 

ambulatory care. 

Chronic Back Problems

Despite inclusion in Quality Chasm list of prioritized conditions this topic did not 

make the priority areas for national action list. The only measure within NQMC, 

the laminectomy or spinal fusion rate, is not sensitive to ambulatory care. 

Processes of care associated with this topic would not be measurable using 

claims data alone. 

Cholelithiasis, Hip Fracture, Appendicitis

Despite inclusion in original ACE-PRO set these measures are primarily 

associated with hospital care and are not sensitive to ambulatory care. 

Falls with Fracture

This topic could be considered an ambulatory care sensitive condition. Data 

elements could be captured from claims data alone. Outcome should be 

sensitive to 2 ambulatory care processes: treatment/prevention of osteoporosis 

and prevention of falls. However, this would involve de novo measure 

development. 

13
Identification of Existing Measures 

The identification of existing measures involved the examination of nationally 

recognized lists of health care quality measures. The sources of these lists were: 

• Access to Care for the Elderly 

Project (ACE-PRO) 

• Agency for Healthcare Research 

and Quality: Prevention Quality 

Indicators (AHRQ-PQI) 

• National Diabetes Quality 

Improvement Alliance (Alliance) 

• Physician Consortium for 

Performance Improvement 

(Consortium) 

• American Medical Association 

(AMA) 

• American Heart Association 

(AHA) 

• American College of Cardiology 

(ACC) 

• National Committee for Quality 

Assurance (NCQA) 

• Centers for Medicare and 

Medicaid Services (CMS) 

• National Health Quality Report 

(NHQR) 

• Diabetes Quality Improvement 

Project (DQIP) 

• Veterans Administration (VA) 

• Assessing Care of Vulnerable 

Elders (ACOVE) 

• Study of Clinically Relevant 

Indicators of Pharmacologic 

Therapy (SCRIPT) 

• Institute for Clinical Systems 

Improvement (ICSI) 

• National Quality Measures 

Clearinghouse (NQMC) 

The evidence review involved inspection of existing guidelines pertaining to the 

management of the selected clinical conditions and topics, with supplementation 

from subsequently published literature where necessary. Evidence grading 

schemes were studied and considered for use in this evaluation.6-8 For the 

purpose of this evaluation however, there was no clearly superior grading 

method. The predominant level of evidence substantiating the measures was 

expert opinion. Therefore the evidence grading scheme for each guideline was 

used to categorize evidence level for each proposed measure. These guidelines 

were obtained from the following sources: 

14
• American College of 

Cardiology (ACC) 

• American Heart Association 

(AHA) 

• American Diabetes 

Association (ADA) 

• Institute for Clinical Systems 

Improvement (ICSI) 

• Infectious Disease Society of 

America (IDSA) 

• United States Preventive 

Services Task Force 

(USPSTF) 

• Veterans Administration (VA) 

• American College of Surgeons 

(ACS) 

• Agency for Healthcare 

Research and Quality (AHRQ) 

• National Guidelines 

Clearinghouse 

• American College of Physician 

(ACP) 

• Physicians’ Consortium for 

Performance Improvement (PCPI) 

• National Cholesterol Education 

Program (NCEP) 

• Joint National Commission on 

Hypertension (JNC VII) 

• American Gastroenterological 

Association 

• American Geriatric Society (AGS)

• The Global Initiative for Chronic 

Obstructive Lung Disease (GOLD) 

• Society for Surgery of the 

Alimentary Tract (SSAT) 

• American Academy of Neurology 

(AAN) 

• Centers for Disease Control and 

Prevention (CDC) 

• American Psychiatric Association 

(APA) 

Clinical Logic 

The conceptual framework for our approach was influenced by the clinical logic 

paradigm attributed to David Eddy, MD. The conceptual framework captured the 

natural history of disease, the processes of care and outcomes associated with 

disease progression. The natural history starts with the pre-disease state, 

progresses to a pre-symptomatic state, and to a diagnosed disease state, usually 

prior to the development of serious clinical manifestations of disease. 

During the pre-disease state, health care processes of care are designed for 

prevention. Immunizations are the primary example. 

There is commonly a pre-symptomatic state early in the disease. Early detection 

is a common goal in this pre-symptomatic state. Common examples include 

dilated funduscopic examination in patients with diabetes mellitus without visual 

loss and cholesterol measurement in patients with risk factors for but not overt 

coronary artery disease. Therapeutic interventions are also common in this presymptomatic state. Lipid lowering therapy for dyslipidemia is an example. 

Follow-up, monitoring and continuing care are also important processes of care 

in this pre-symptomatic state. Blood pressure measurement during hypertension 

management is an example of monitoring to assess response to therapy. 

15
The diagnosed disease state is characterized by the known presence of disease 

either by symptom-prompted diagnosis or via early detection. In this state there 

are typically initial diagnostic work-ups, therapeutic interventions, and follow-up, 

monitoring, continuing care. 

Eventually the disease progresses such that there might be serious clinical 

manifestations such as death, disability, hospitalizations, or emergency care. 

Therapeutic interventions and follow-up, monitoring, continuing care occur in 

both pre-symptomatic and diagnosed disease states. Therefore, these states do 

not provide much value in categorization. The conceptual framework adapted for 

this measure refinement consisted of the following categories: 

• Prevention, Early Detection 

• Therapeutic Intervention 

• Work-up at Initial Diagnosis 

• Follow-up, Monitoring, Continuing Care 

• Serious Clinical Manifestations of Disease. 

The clinical logic category was identified for each measure considered for the 

refined set. 

 

16
Expert Panel 

MedPAC and MagnaCare staff developed criteria for identifying organizations 

and individuals to be considered for inclusion on the expert panel. The original 

goal was to empanel 6 to 8 individuals with a mix of methodologic and clinical 

expertise. A particular premium was placed on expertise in the use of 

administrative data in quality measurement. 

Based upon knowledge of the measurement work of various national 

organizations a preliminary list of organization to consider included: Centers for 

Medicare and Medicaid Services, American Medical Association, Veterans 

Administration, National Committee for Quality Assurance, Joint Commission for 

the Accreditation of Healthcare Organizations, Agency for Healthcare Research 

and Quality, National Institutes of Health, National Quality Forum, American 

Heart Association, American College of Cardiology, American Health Quality 

Association, American Academy of Family Practice, American College of 

Physicians, and America’s Health Insurance Plans. After an iterative process of 

considering individuals’ strengths and organizational affiliations, a final panel of 

expert panelists were invited. The list below identifies those individuals who 

participated significantly in the evaluation of the candidate measures. 

MagnaCare staff (listed below) acted as facilitators of the session. 

MagnaCare staff provided the panelists with a packet of preparatory materials 

prior to an in-person meeting in May of 2004 at MedPAC offices. The materials 

included a summary of initial recommendations and relevant considerations 

(Appendix 2), and served as a guide for the panelist meeting. This meeting was 

additionally supplemented by information provided by MagnaCare staff via 

PowerPoint presentation. MedPAC and MagnaCare staff later met to review the 

meeting results, and a summary of initial recommendations was provided to the 

panelists for comment. 

17
Expert Panelists

Denise Remus, PhD, RN 

Senior Research Scientist, Quality Indicators 

Center for Organization and Delivery Studies 

Agency for Healthcare Research and Quality 

Steve Clauser, PhD 

Senior Scientist, Performance Measurement and Program Evaluation 

Applied Research Program

Division of Cancer Control and Population Sciences

National Cancer Institute

Karen Kmetik, PhD 

Director for Clinical Performance Evaluation and Improvement 

American Medical Association 

Kenneth Labresh, MD 

AHQA, AHA, MassPRO 

Cardiologist 

Phil Renner, MBA 

NCQA 

Director for Quality Measurement 

Lok Wong 

NCQA 

Senior Health Care Analyst 

MagnaCare staff

Stephen Kogut, PhD, MBA, RPh 

Epidemiologist 

Assistant Professor, University of Rhode Island 

Edward Westrick, MD, PhD 

Vice President of Medical Management 

UMass Memorial Health Care 

18
Refinement of the ACE-PRO Indicators: Evaluation and 

Recommendations of the Expert Panel 

The measures are presented below in groups organized by clinical condition. 

These groups include: diabetes mellitus, coronary artery disease, stroke and 

transient ischemia, heart failure, cancer, anemia and gastrointestinal bleeding, 

and miscellaneous. Within each group, all of the measures are listed, including 

those eliminated in intermediate steps of consideration and those identified as 

useful to MedPAC in current form but not requiring composition by MedPAC (i.e. 

AHRQ PQIs). The measures that were eliminated in intermediate steps were 

eliminated from further consideration for a variety of reasons, including: 

• insensitive to ambulatory care 

• data not available in claims database 

• problems with interpretation 

• reliability of the data source 

• require de novo measure development 

• timeframe too long 

• ceiling effects 

• lack of consensus among experts 

The considerations specific to particular measures can be found in the 

preparatory materials for the expert panel meeting at MedPAC (Appendix 2). 

For each measure that is considered for refinement the name, the clinical logic, 

the evidence and rationale, the known measure versions, the considerations for 

ACE-PRO refinement, and the final recommendations are presented. The final 

recommendations include a summary version of the analysis logic. The 

diagnosis and procedure codes required for the analyses are presented in 

appendix 6. General analytic rules include: the age range for measures is 65 or 

older unless otherwise specified; patients eligible for inclusion must be enrolled in 

Medicare Parts A and B, and continuously enrolled throughout the identified 

measurement periods. The measures were presented in clinical related groups. 

Examples appear below. The full set of measures is detailed in Appendix 5. 

Diabetes Mellitus Group 

Eye Exam 

A1C Testing 

Lipid Testing 

Clinical Assessment 

Follow-up After Hospitalization 

Serious Short Term Complication 

Serious Long Term Complications 

Coronary Artery Disease Group 

Lipid Testing 

Follow-up After Hospitalization 

19
Clinical Assessment 

Emergency Room Use 

Stroke/Transient Ischemia/Hypertension Group 

EKG 

Carotid Imaging 

Follow-up After Hospitalization 

Clinical Assessment 

Heart Failure Group 

LVEF Assessment 

Lab Testing 

EKG 

Chest X-ray 

Follow-up After Hospitalization 

Clinical Assessment 

Admissions 

Cancer Group 

Breast Cancer Screening 

Biopsy to Therapy Interval 

Chest X-ray 

Breast Imaging 

Mammographic Surveillance 

Colonoscopic Surveillance 

GI Tract Work-up in Iron Deficiency Anemia 

Anemia and GI Bleed Group 

Follow-up After Hospitalization 

Follow-up After Initial Diagnosis 

Lab Testing After Hospitalization 

Lab Testing After Initial Diagnosis 

GI Tract Work-up in Iron Deficiency Anemia 

Miscellaneous Group 

Clinical Assessment in COPD 

Admissions in COPD 

Admissions for Hypertension 

Follow-up After Hospitalization for Depression 

Annual Visit 

Recommendations were divided into three categories: (1) Useful measures, 

compose using Medicare claims data; (2) Exclude from further consideration; and 

(3) Useful measures, composed by AHRQ, no need to compose using Medicare 

data. The useful measures were later composed using Medicare data. Measures 

excluded from further consideration were not composed using Medicare data. 

20
Justifications for exclusion are provided in each disease/topic chapter. Useful 

measures composed by AHRQ were recommended for use via citations to 

AHRQ reports. These measures would not be composed using Medicare data. 

However, modified versions of some AHRQ-PQI measures were placed into 

category one, requiring composition using Medicare data because of the 

denominator modification. 

Indicator description and analytic logic are presented in Appendix 4. Further 

detail on code lists and results of testing can be obtained by request to MedPAC. 

21
Diabetes Mellitus 

Useful measures, compose using Medicare data:

• Eye Exam 

• A1C 

• Lipid Testing 

• Clinical Assessment 

• Follow-up after Hospitalization 

• Serious Short Term Complications 

• Serious Long Term Complications 

Exclude the following measures from further consideration:

• Visual acuity screening in general Medicare population 

• Nephropathy 

• BP Control 

• Foot Exam 

Cite AHRQ-PQI Measures 

• Uncontrolled diabetes admission rate 

• Short term complications admission rate 

• Long term complications admission rate 

• Rate of lower extremity amputations in diabetes 

22
Indicator Name: Eye Exam in Diabetes Mellitus 

Indicator Description: Comprehensive eye exam, at least every two years 

(measurement year or prior year), with 2 out-patient or 1 in-patient visits with 

diabetes mellitus codes, within a calendar year 

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Eye exam refers to a dilated funduscopic examination that is typically part of a 

comprehensive ophthalmologic examination. It is part of Early Detection 

because it is done in the pre-symptomatic stage in order to detect reversible 

disease early. Eye Exam is part of the FMCC because patients with known 

diabetes should continue to have dilated funduscopic exams with and without 

known retinopathy. Patients with known retinopathy will see the eye doctor to 

follow progression of disease. 

Evidence/Rationale: 

Early detection of diabetic retinopathy leads to timely laser photocoagulation 

delaying the progression to visual loss. The efficacy of laser photocoagulation is 

supported by well-controlled RCTs.9-11 Evidence supporting dilated and 

comprehensive eye exams comes from well-conducted cohort studies.12, 13

Measure Versions: ACE-PRO, NCQA, VA, CMS, Consortium, Alliance 

ACE-PRO

• Eye exam every year 

NCQA

• Eye exam every year 

• Or every 2 years with A1c < 8 and not using insulin 

• Age 18 to75 

• # diagnosis codes: 2 outpatient or 1 inpatient 

VA

• Eye exam every year 

• Or every 2 years with 2/3: A1c<8, not using insulin, and normal eye exam 

within 2 years 

• Age unspecified 

• # diagnosis codes: one 

CMS

• Eye exam every year 

• Or every 2 years with 2/3: A1c<8, not using insulin, and normal eye exam 

within 2 years 

• Age 18 to 75 

• # diagnosis codes: 2 outpatient or 1 inpatient 

Consortium

• Eye exam at initial assessment and annually 

23
• Age 18 to 75 

Alliance

• Eye exam every year 

• Or every 2 years with 3/3: A1c<8, not using insulin, and normal eye exam 

within 2 years 

Considerations for ACE-PRO Refinement 

Numerator

A comprehensive eye exam was used to satisfy the numerator in the original 

ACE-PRO set and by others who specify such measurement. 

Measurement Period

Arguments were made for a two year measurement period and for a one year 

measurement period. A two year measurement period is justified by other 

measure sets when patients are considered to be at low risk for retinopathy. A 

one year measurement period is justified for patients at unknown or higher risk. 

Risk factors are indicators of glycemic control, insulin use, and history of 

retinopathy. These risk factors are not accessible from claims data, however, it 

is assumed that a far greater proportion of cases are at low risk than at higher 

risk. Based upon the assumption that the proportion of patients on insulin was 

less than 80% the two year measurement period was selected. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. Consideration was 

given to modifying the age range to 65-75 for consistency with other measures. 

Evidence supporting age range comes from the ETDRS10 in which efficacy for 

treatment was established. Patients with diabetes mellitus up to age 69 were 

enrolled in this 7 year study. The ADA guideline does not specify an upper age 

limit. There are many Medicare beneficiaries with diabetes mellitus less than age 

65. However, the ACE-PRO measures are meant to be sensitive to care for the 

elderly. The panel expressed value in various age stratifications: 18-64, 65-75, 

76+, and 18+. 

Case ID

The original ACE-PRO set used one code for diabetes mellitus (in-patient or outpatient) during the measurement year to identify cases. All other measure sets 

use a common case identification algorithm that was validated since the original 

ACE-PRO set was developed. This case-ID algorithm calls for 2 out-patient or 1 

in-patient code for diabetes mellitus in a one year period of time. The 

requirement for an additional out-patient code reduces the risk for errors of 

inclusion due to coding for testing purposes. 

Exclusions

24
Consideration was given to using exclusion criteria of the NCQA. Polycystic 

ovarian syndrome, gestational diabetes, and steroid induced diabetes are not 

highly prevalent and are relatively inaccessible from claims data. 

Final Recommendation 

Modify the original ACE-PRO measure to be specified as: 

 

comprehensive eye exam, at least every two years (measurement year or 

prior year), with 2 out-patient or 1 in-patient visits with diabetes mellitus 

codes, within a calendar year 

The numerator specification and Case ID algorithm are consistent with other 

measures of this care process. The measurement period is consistent with the 

NCQA specification without the measurement of risk status. NCQA exclusion 

criteria not accessible from claims data were not included. 

25
Indicator Name: A1C Testing in Diabetes Mellitus 

Indicator Description: A1C test at least once per year (the measurement year), 

in patients with 2 out-patient or 1 in-patient visits with diabetes mellitus codes, 

within a calendar year.

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Hemoglobin A1C Testing refers to the common practice of testing for long-term 

glycemic control in patients with diabetes mellitus. A1C testing is part of the 

FMCC because glycemic monitoring is used to assess response to hypoglycemic 

therapy and to prompt adjustments in therapy. 

Evidence/Rationale: guideline (2004) 

Based upon expert consensus or clinical experience, the American Diabetes 

Association 14 recommends A1C testing at least twice yearly for patients at goal, 

and at least four times per year for patients not at goal. According to wellconducted RCTs, control of blood glucose (measured as A1C) is associated with 

reduction in incidence of diabetes-related complications.11, 15

Measure Versions: ACE-PRO, NCQA, VA, CMS, Consortium, Alliance 

ACE-PRO

• A1C or fructosamine every 6 months 

NCQA

• At least one A1C performed per year 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus (or) 

• Identification of diabetes mellitus status by use of pharmacy claims for 

glycemic lowering drugs 

• Exclude where: 

o Diagnosis of polycystic ovaries and < 2 face to face encounters with 

diagnosis of diabetes mellitus 

o Diagnosis of steroid-induced diabetes 

o Diagnosis of gestational diabetes 

 VA

• A1C test result > 11, or test not performed 

• Age unspecified 

• One outpatient code from specified clinic visit during measurement year 

CMS (DQIP)

• At least one A1C test performed during measurement year 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus 

Consortium

26
• At least one A1C test performed during initial assessment and during 

follow-up 

• Age 18 to 75 

 

Alliance

• At least one A1C test performed during measurement year 

Considerations for ACE-PRO Refinement: 

Numerator

Any glycosylated hemoglobin test was used to satisfy the numerator in the 

original ACE-PRO set. Hemoglobin A1C tests are used by the others who 

specify such measurement. 

Measurement Period

The measurement period used in the original ACE-PRO set was 6 months. The 

measurement period used by others who specify such measurement is one year. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. Consideration was 

given to modifying the age range to 65-75 for consistency with other measures. 

The study sample in UKPDS was age 25 to 65 at baseline and were followed for 

a median period of ten years. There are many Medicare beneficiaries with 

diabetes mellitus less than age 65. However, the ACE-PRO measures are 

meant to be sensitive to care for the elderly. The panel expressed value in 

various age stratifications: 18-64, 65-75, 76+, and 18+. 

Case ID

The original ACE-PRO set used one code for diabetes mellitus (in-patient or outpatient) during the measurement year to identify cases. All other measure sets 

use a common case identification algorithm that was validated since the original 

ACE-PRO set was developed. This case-ID algorithm calls for 2 out-patient or 1 

in-patient code for diabetes mellitus in a one year period of time. The 

requirement for an additional out-patient code reduces the risk for errors of 

inclusion due to coding for testing purposes. 

Exclusions

Consideration was given to using exclusion criteria of the NCQA. Polycystic 

ovarian syndrome, gestational diabetes, and steroid induced diabetes are not 

highly prevalent and are relatively inaccessible from claims data. 

Final Recommendation 

Modify the original ACE-PRO measure to be specified as: 

27
A1C test at least once per year (the measurement year), in patients with 2 

out-patient or 1 in-patient visits with diabetes mellitus codes, within a 

calendar year. 

The numerator specification and Case ID algorithm are consistent with other 

measures of this care process. The measurement period is consistent with the 

NCQA specification. NCQA exclusion criteria not accessible from claims data 

were not included. 

28
Indicator Name: Lipid Testing in Diabetes Mellitus 

Indicator Description: lipid profile, at least every year in patients with 2 outpatient or 1 in-patient visits with diabetes mellitus codes, within a calendar year.

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Lipid testing refers to cholesterol and lipoprotein analysis in patients with 

diabetes mellitus. It is part of Early Detection because it is done in the presymptomatic stage in order to detect dyslipidemia prior to the development of 

overt cardiovascular disease. Lipid testing part of the FMCC because patients 

with known dyslipidemia should continue to have lipid testing done to assess 

response to therapy and to prompt adjustments to therapy. 

Evidence / Rationale: 

Based upon expert consensus or clinical experience, the American Diabetes 

Association16 recommends lipid testing at least annually and more often if 

needed to achieve goals. In adults with low-risk values the ADA recommends 

repeat lipid assessments every two years. In well-conducted RCTs, lowering 

LDL-C cholesterol with diet or medication is associated with reduction in 

cardiovascular events.17 

Versions: NCQA, CMS, Consortium, Alliance 

 NCQA

• Lipid profile every 2 years 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus (or) 

• Identification of diabetes mellitus status by use of pharmacy claims for 

glycemic lowering drugs 

• Exclude where: 

o Diagnosis of polycystic ovaries and < 2 face to face encounters with 

diagnosis of diabetes mellitus 

o Diagnosis of steroid-induced diabetes 

o Diagnosis of gestational diabetes 

 CMS

• Lipid profile every 2 years 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus 

 Consortium

• Lipid profile, time not specified 

• Age 18 to 75 

 Alliance

• LDL-C, time not specified 

Considerations for ACE-PRO Refinement 

29
Numerator

LDL-C tests are used by the NCQA and the Alliance. Lipid Profile tests are used 

by CMS and the Consortium. 

Measurement Period

The measurement period used by the NCQA and CMS is two years. The 

measurement period used by the Consortium and the Alliance is one year. 

Panelist feedback suggests an impending agreement among the four to use one 

year. 

Age Range

NCQA, CMS, and the Consortium use the age range of 18 to 75. Risk reduction 

is similar in patients with diabetes, and patients older than 75 (heart protection 

study). 

Case ID

NCQA and CMS measure sets use a common case identification algorithm that 

was validated since the original ACE-PRO set was developed. This case-ID 

algorithm calls for 2 out-patient or 1 in-patient code for diabetes mellitus in a one 

year period of time. The requirement for an additional out-patient code reduces 

the risk for errors of inclusion due to coding for testing purposes. 

Exclusions

Consideration was given to using exclusion criteria of the NCQA. Polycystic 

ovarian syndrome, gestational diabetes, and steroid induced diabetes are not 

highly prevalent and are relatively inaccessible from claims data. 

Final Recommendations 

Include this measure in the Medicare Ambulatory Care Indicator set as specified: 

lipid profile, at least every year (the measurement year), in patients aged 65 

or older, with 2 out-patient or 1 in-patient visits with diabetes mellitus 

codes, within a calendar year. 

The numerator specification and Case ID algorithm are consistent with other 

measures of this care process. The measurement period is not consistent with 

the NCQA specification however anticipation of measure modification by other 

systems justified the change to a one year period. NCQA exclusion criteria not 

accessible from claims data were not included. 

30
Indicator Name: Clinical Assessment in Diabetes Mellitus 

Indicator Description: Two out-patient visits (with or without code for diabetes 

mellitus) during the measurement year, in patients identified as having diabetes 

mellitus in the year prior to the measurement year (with 2 out-patient or 1 inpatient visits)

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Clinical Assessment refers to office visits for the clinical management of diabetes 

mellitus. It is part of the FMCC because blood pressure monitoring, assessment 

of treatment progress and self-management training require frequent office visits. 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel justified office visits 

every three to six months. 

ACE-PRO Measure

Visit every 6 months 

Considerations for ACE-PRO Refinement 

Numerator

The original ACE-PRO measure accepted any out-patient visits with or without 

codes for diabetes mellitus as coding may not be adequately precise to demand 

a visit coded for diabetes mellitus. The out-patient visits could have been office 

visits, emergency room visits, nursing home visits, or home visits. Clinical 

assessment in emergency room visits is different from the clinical assessment 

that this measure is designed to detect (i.e. clinical assessment in chronic 

disease management). Two visits within one year would allow standardization 

on a one year measurement period (below) and retention of the logic of the 

original ACE-PRO measure. It is acknowledged that there are potential 

differences between these specifications but that these differences are not 

compelling enough to continue using one visit every six months. 

Measurement Period

The measurement period used in the original ACE-PRO set was 6 months. In 

order to standardize with other diabetes mellitus measures, a one year period 

would be required. Case identification (below) will specify the requirement of a 

visit for inclusion in the measurement sample. This visit should not count as 

satisfying the numerator as well. Therefore, the measurement period must be 

distinct from the case identification period. The measurement period 

(measurement year) will follow the one year case identification period. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

31
Case ID

The original ACE-PRO set used one code for diabetes mellitus (in-patient or outpatient) during the measurement year to identify cases. All other measure sets 

use a common case identification algorithm that was validated since the original 

ACE-PRO set was developed. This case-ID algorithm calls for 2 out-patient or 1 

in-patient code for diabetes mellitus in a one year period of time. The 

requirement for an additional out-patient code reduces the risk for errors of 

inclusion due to coding for testing purposes. Since case identification must 

precede clinical assessment, the case ID should occur in the year prior to the 

measurement year. 

Final Recommendation 

Modify the original ACE-PRO measure to be specified as: 

Two out-patient visits (with or without code for diabetes mellitus) during 

the measurement year, in patients identified as having diabetes mellitus in 

the year prior to the measurement year (with 2 out-patient or 1 in-patient 

visits). 

Two visits in one year was chosen over one visit in 6 months for denominator 

standardization purposes. Only non-emergent physician visits count in the 

numerator. 

32
Indicator Name: Visit after hospitalization 

Indicator Description: At least one visit within four weeks following discharge of 

patients, hospitalized for diabetes mellitus.

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Visit after hospitalization refers to an out-patient physician (or physician 

extender) office visit during the 4 week period after discharge from the 

hospitalization for diabetes mellitus. Visit after hospitalization is part of FMCC 

because post-discharge treatment plans require out-patient follow-up. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel established a standard 

for follow-up after hospitalization of four weeks. 

Version: 

ACE-PRO Measure 

Visit <= 4 weeks after discharge from hospital for patients hospitalized for 

diabetes mellitus 

Considerations for ACE-PRO Refinement 

Numerator

At least one office visit, emergency room visit, nursing home visit, or home visit. 

This does not include visits by home care providers or case managers. 

Measurement Period

The measurement period used in the original ACE-PRO set was 4 weeks postdischarge. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one hospitalization with a primary diagnosis 

code for diabetes mellitus to identify cases. 

Final Recommendations: 

Continue to use the original ACE-PRO measure as specified: 

At least one ambulatory, non-emergent visit (with or without code for 

diabetes mellitus) within four weeks following discharge of patients, 

hospitalized for diabetes mellitus. 

33
Indicator Name: Serious Short Term Complications of Diabetes Mellitus 

Indicator Description: Admissions for diabetic, hyperosmolar and ketotic coma 

and admissions for uncontrolled diabetes mellitus among patients with 2 outpatient or 1 in-patient visit with diabetes mellitus within a calendar year. 

Clinical Logic: Serious Clinical Manifestations of Disease 

Serious Short Term Complications refers to hospital admissions for diabetic, 

hyperosmolar, and ketotic coma, and uncontrolled diabetes mellitus. It is part of 

Serious Clinical Manifestations of Disease because all require hospitalization. 

Uncontrolled diabetes is included here but restricted to uncontrolled diabetes 

requiring hospitalization. 

Evidence/Rationale: 

It was the opinion of the original ACE-PRO panel that effective outpatient 

management of diabetes mellitus, infections and other stressors, may prevent 

hospitalizations for hyperosmolar and ketotic states. The AHRQ PQI report18

noted that high quality outpatient management of patients with diabetes has been 

shown to reduce almost all types of serious hospitalizations. 

Versions: 

ACE-PRO 

Admission for diabetic coma, hyperosmolar or ketotic coma 

 among patients with diabetes mellitus 

AHRQ PQI

Diabetes Short Term Complications Admission Rate 

Discharges for Ketoacidosis, Hyperosmolarity, Coma 

Per 100,000 in the population 

 

Considerations for ACE-PRO Refinement: 

Use numerator of PQI version and denominator of ACE-PRO version to restrict to 

population with diabetes 

Use in composite measure with Uncontrolled DM (below) 

Numerator

The original ACE-PRO measure uses admissions for diabetic coma, 

hyperosmolar or ketotic coma. The AHRQ PQI measure uses discharges for 

ketoacidosis, hyperosmolarity, and coma for the measure of serious short term 

complications. The AHRQ PQI measure for uncontrolled diabetes admission 

rate, uses discharges for uncontrolled diabetes mellitus without mention of short 

term or long term complications. The proposed measure combines the two 

numerators. 

34
Measurement Period

The measurement period used in the original ACE-PRO set is one year. The 

measurement period used by the AHRQ PQIs is one year. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. Age 18 or older was 

used in the AHRQ PQI measures. 

Case ID

The original ACE-PRO set used one code for diabetes mellitus (in-patient or outpatient) during the measurement year to identify cases. The AHRQ PQI 

measures use 100,000 in the population as the denominator. 

Exclusions

The AHRQ PQI measures excluded transfers from other institutions to avoid 

double-counting of cases, and hospitalizations associated with pregnancy and 

childbirth. 

Final Recommendation: 

Modify the original ACE-PRO measure to be specified as: 

Admissions for diabetic, hyperosmolar and ketotic coma and admissions 

for uncontrolled diabetes mellitus among patients with 2 out-patient or 1 inpatient visit with diabetes mellitus within a calendar year. 

Uses numerator consistent with AHRQ PQI and original ACE-PRO. Unlike 

AHRQ PQI version, denominator restricts measurement to population with 

diabetes mellitus. 

35
Indicator Name: Serious Long Term Complications of Diabetes Mellitus 

Indicator Description: hospitalizations for renal, ophthalmologic, neurologic and 

circulatory complications of diabetes mellitus and non-traumatic lower extremity 

amputation, in patients with 2 or more out-patient visits or 1 in-patient visit with a 

diagnosis code for diabetes mellitus within a calendar year.

Clinical Logic: Serious Clinical Manifestations of Disease 

Serious Long Term Complications of Diabetes Mellitus refers to renal, 

ophthalmologic, neurologic and circulatory complications. It is part of Serious 

Long Term Complications of Diabetes Melllitus because all are associated with 

significant morbidity or mortality and all are defined here as admissions for these 

complications. 

Evidence/Rationale: 

According to the AHRQ PQI report,18 long term complications of diabetes mellitus 

arise from sustained, long-term, poor control of diabetes mellitus and intensive 

treatment programs have been shown to decrease the incidence of long term 

complications in both type 111 and type 2 15 disease. Long term glycemic control, 

foot care, and diabetes education are interventions that can reduce the incidence 

of infection, neuropathy, and microvascular diseases.15

Versions: 

AHRQ PQI

Diabetes Long Term Complications Admission Rate 

Discharges for 

Renal, Eye, Neurological, Circulatory, & 

Complications not otherwise specified 

Per 100,000 in population 

Rate of LEA in Diabetes 

Discharges for LEA and Diagnosis of DM 

Per 100,000 in population 

Considerations for ACE-PRO Refinement: 

Numerator

The AHRQ PQI set includes two measures: 1) long term complications of 

diabetes mellitus admission rate; and 2) lower extremity amputation rate. The 

numerator of the former includes hospitalizations for renal, ophthalmologic, 

neurologic and circulatory complications of diabetes melllitus. The numerator of 

the latter includes amputations among patients with diabetes mellitus for nontraumatic indications. Lower extremity amputation is another long term 

complication of diabetes mellitus. Lower extremity amputation and the other long 

36
term complications are all consequences of the same processes of care. 

Therefore, the proposed measure combines these numerators. 

Measurement Period

The measurement period used in the AHRQ PQI measures is one year. 

Age Range

The age range used in the AHRQ PQI measures is 18 and older. 

 

Case ID

The population used for the denominator of the AHRQ PQI measures is 100,000. 

The common case identification algorithm used in the other refined measures is 

proposed here (i.e. 2 or more out-patient visits or 1 in-patient visit with a 

diagnosis code for diabetes mellitus within a calendar year). 

Exclusions

The AHRQ PQI measures excluded transfers from other institutions to avoid 

double-counting of cases, and hospitalizations associated with pregnancy and 

childbirth. Lower extremity amputations associated with trauma were excluded. 

Final Recommendations: 

Include in Medicare Ambulatory Care Indicator set to be specified as: 

Hospitalizations for renal, ophthalmologic, neurologic and circulatory 

complications of diabetes mellitus and non-traumatic lower extremity 

amputation, with 2 or more out-patient visits or 1 in-patient visit with a 

diagnosis code for diabetes mellitus within a calendar year. 

Combines numerators of AHRQ-PQI measures since both sets of complications 

are due to problems in long-term glycemic control. Denominator restricts 

measurement to patients with diabetes mellitus. 

37
Justification For Exclusion Of Measures From Further Consideration 

The analysis logic for visual acuity screening used procedure codes with more 

specificity than visual acuity screening and in the same time frame as eye exams 

for patients with diabetes mellitus. This was essentially a measure of 

comprehensive eye exams in the general Medicare population. 

Nephropathy monitoring was previously tested by CMS as an evaluation 

measure and eliminated for technical difficulties. Variation in reimbursement 

policies across carriers was an issue. Clinically, the case for nephropathy testing 

has become less compelling since ACEI utilization in diabetes mellitus is so 

common. 

BP Control and Foot Exam require chart abstraction for composition of these 

measures. 

38
Coronary Artery Disease 

Useful measures, compose using Medicare data:

• Lipid Testing in Coronary Artery Disease 

• Visit after Hospitalization for Acute MI 

• Clinical Assessment in CAD 

• ER Use for Unstable Angina 

Exclude the following measures from further consideration:

• Screening for Diabetes Mellitus in CAD 

• Follow-up after initial diagnosis of unstable angina 

• EKG in ER for Unstable Angina 

• Hospitalization for Angina (without procedures) 

Cite AHRQ-PQI Measures 

• Angina without procedure admission rate 

39
Indicator Name: Lipid Testing in Coronary Artery Disease 

Indicator Description: lipid profile, at least every year, in patients with 2 outpatient or 1 in-patient visits with coronary artery disease codes, within a calendar 

year. 

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Lipid Testing refers to cholesterol and lipoprotein analysis in patients with 

coronary artery disease (CAD). It is part of Early Detection because dyslipidemia 

is common in CAD and treatment requires identification. Lipid testing is part of 

the FMCC because patients with known dyslipidemia should continue to have 

lipid testing done to assess response to therapy and to prompt adjustments to 

therapy. 

Evidence / Rationale: 

Based upon expert consensus or clinical experience, the ACC/AHA Task Force 

on Practice Guidelines19, 20 recommends initial fasting lipid profile testing and 

treatment to achieve goals. Treatment to goal requires assessment of lipidemia 

status and modification of therapy. The National Cholesterol Education 

Program’s Adult Treatment Panel 17 recommends lipid profile testing at least 

annually in patients at goal. In well-conducted RCTs, lowering LDL cholesterol 

with medication is associated with reduction in cardiovascular events. 17

Versions: ACE-PRO, NCQA, Consortium 

ACE-PRO 

• Cholesterol test every 6 months after discharge for acute myocardial 

infarction with co-morbid dyslipidemia 

NCQA

• LDL-C 60 days to one year after acute coronary event 

• Age 18 to 75 

• Coronary event is acute myocardial infarction or revascularization 

procedure 

Consortium

• Annual lipid profile in patients with CAD 

• Age not specified 

Considerations for ACE-PRO Refinement 

Numerator

Cholesterol tests were used by the original ACE-PRO set. LDL-C tests are used 

by the NCQA. Lipid profile is used by the Consortium and for the refined ACEPRO measure on lipid testing in diabetes mellitus. Lipid profile testing is used to 

40
calculate LDL-C and to measure other targets of therapy: triglycerides and HDLC. Direct measurement of LDL-C is possible but is done infrequently. 

Measurement Period

The measurement period for the ACE-PRO measure was one year to identify 

cases and six months to identify cholesterol tests. The NCQA uses a one year 

time frame, following an acute cardiac event. The measurement period used by 

the Consortium is one year. 

Age Range

The age range used by the ACE-PRO measure was age 65 and older. The 

NCQA uses the age range of 18 to 75. The Consortium does not specify age 

range. Risk reduction is similar in patients older than 75 years21. 

Case ID

The original ACE-PRO measure identified cases as post-myocardial infarction 

with dyslipidemia. NCQA identifies cases as post-acute event alone. Acute 

events include acute myocardial infarctions and revascularization procedures. A 

large proportion of CAD cases will not experience an acute event within the 

timeframe and are worthy inclusions for this measure. One of the purposes of 

lipid profile measurement is to find dyslipidemia worthy of treatment. Requiring 

the presence of dyslipidemia in the case identification algorithm would defeat the 

measure’s ability to detect this practice. 

Final Recommendations 

Include this measure in the refined ACE-PRO set as specified: 

lipid profile, at least every year (the measurement year), in patients with 2 

out-patient or one in-patient visits with coronary artery disease codes, 

within a calendar year. 

Uses a one year time frame consistent with other existing measures. 

Denominator is broader than the NCQA version, including all patients with CAD, 

not just those after an acute event. 

41
Indicator Name: Follow-up after Hospitalization for Acute Myocardial Infarction 

Indicator Description: At least one out-patient visit within four weeks following 

discharge of patients, hospitalized for acute myocardial infarction. 

 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Follow-up after hospitalization refers to an out-patient physician (or physician 

extender) office visit during the 4 week period after discharge from the 

hospitalization for acute myocardial infarction. It is part of FMCC because postdischarge treatment plans require out-patient follow-up. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel established a standard 

for follow-up after hospitalization of four weeks. 

Version:

ACE-PRO Measure

Visit <= 4 weeks after discharge from hospital for patients hospitalized for acute 

myocardial infarction 

Considerations for ACE-PRO Refinement 

Numerator

at least one office visit, emergency room visit, nursing home visit, or home visit. 

This does not include visits by home care providers or case managers. 

Discussion on this topic appears in section XX. This is the same as the original 

ACE-PRO specification. 

Measurement Period

The measurement period used in the original ACE-PRO set was one year for 

identification of hospitalizations for acute myocardial infarction and 4 weeks for 

the post-discharge follow-up. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one hospitalization with a primary diagnosis 

code for acute myocardial infarction to identify cases. 

Final Recommendation 

Continue to use the original ACE-PRO measure as specified: 

At least one out-patient, non-emergent visit within four weeks following 

discharge of patients, hospitalized for acute myocardial infarction. 

42
Indicator Name: Clinical Assessment in Coronary Artery Disease 

Indicator Description: Two out-patient visits during the measurement year, in 

patients, identified as having CAD in the year prior to the measurement year 

(with 2 out-patient or in-patient visits). 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Clinical Assessment refers to office visits for the clinical management of coronary 

artery disease (CAD). It is part of the FMCC because regular symptom and 

activity assessment and risk factor modification require frequent office visits. 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel justified office visits 

every six months. 

ACE-PRO Measure

Visit every 6 months 

Considerations for ACE-PRO Refinement 

Numerator

The original ACE-PRO measure accepted any out-patient visits with or without 

codes for CAD as coding may not be adequately precise to demand a visit coded 

for CAD. The out-patient visits could have been office visits, emergency room 

visits, nursing home visits, or home visits. Clinical assessment in emergency 

room visits is different from the clinical assessment that this measure is designed 

to detect (i.e. clinical assessment in chronic disease management). Two visits 

within one year would allow standardization on a one year measurement period 

(below) and retention of the logic of the original ACE-PRO measure. It is 

acknowledged that there are potential differences between these specifications 

but that these differences are not compelling enough to continue using one visit 

every six months. 

Measurement Period

The measurement period used in the original ACE-PRO set was 6 months. In 

order to standardize with other clinical assessment measures, a one year period 

would be required. Case identification (below) will specify the requirement of a 

visit for inclusion in the measurement sample. This visit should not count as 

satisfying the numerator as well. Therefore, the measurement period must be 

distinct from the case identification period. The measurement period 

(measurement year) will follow the one year case identification period. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

43
Case ID

The original ACE-PRO set used one code for chronic stable angina (in-patient or 

out-patient) during the measurement year to identify cases. There are additional 

diagnosis codes that identify CAD. A stricter case identification algorithm 

(requiring at least two visits coded for CAD within a year) improves the predictive 

value significantly (SCRIPT). The requirement for an additional out-patient code 

reduces the risk for errors of inclusion due to coding for testing purposes. Since 

case identification must precede clinical assessment, the case ID should occur in 

the year prior to the measurement year. 

Final Recommendation 

Modify the original ACE-PRO measure to be specified as: 

Two out-patient visits during the measurement year, identified as having 

CAD in the year prior to the measurement year (with 2 out-patient or inpatient visits). 

Two visits in one year was chosen over one visit in 6 months for denominator 

standardization purposes. Only non-emergent physician visits count in the 

numerator. 

44
Indicator Name: Emergency Room Use for Unstable Angina 

Indicator Description: Three or more emergency department visits for coronary 

artery disease, unassociated with admission, identified with coronary artery 

disease (with 2 out-patient or in-patient visits with CAD codes) in the 

measurement year. 

Clinical Logic: Serious Clinical Manifestations of Disease 

Emergency Room use for Unstable Angina refers to emergency visits for 

cardiovascular related diagnoses in patients with coronary artery disease. It is 

part of Serious Clinical Manifestations of Disease because the morbidity requiring 

emergency utilization is serious. 

Evidence/Rationale: 

It was the opinion of the original ACE-PRO panel that effective outpatient 

management of angina should prevent multiple emergency department visits for 

unstable angina. According to the ACC/AHA/ACP-ASIM 19, 20... effective 

treatments for CAD reduce admissions for serious complications of ischemic 

heart disease including unstable angina. 

Versions: 

ACE-PRO

3 or more ER visits in one year for heart related diagnoses in unstable angina 

Exclude ER visits resulting in hospitalizations 

AHRQ-PQI

Admissions for Angina 

Per 100,000 in the population 

Exclude admissions with procedures 

Age >= 18 

 

Considerations for ACE-PRO Refinement: 

Numerator

The original ACE-PRO measure uses emergency department visits for heart 

related diagnoses. The heart related diagnoses specified in this measure include 

diseases of the respiratory system and vascular insufficiency of the intestines. 

These diagnoses are distantly related to the unstable angina. Elimination of 

these diagnoses from the numerator will make the measure more specific to its 

intent. The AHRQ-PQI measure uses admissions for angina. Hospital use in the 

treatment of unstable angina is complex. This complexity makes it difficult to 

interpret the quality of care based upon a measure of admissions for CAD. This 

issue is discussed in greater detail in section x. For this reason, only emergency 

department visits without associated admissions should be considered further. 

45
Measurement Period

The measurement period used in the original ACE-PRO set is one year. The 

measurement period used by the AHRQ PQI is one year. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. Age 18 or older was 

used in the AHRQ PQI measures. 

Case ID

The original ACE-PRO set used one code for stable or unstable angina (inpatient or out-patient) during the measurement year to identify cases. The 

AHRQ PQI measure uses 100,000 in the population as the denominator. 

Exclusions

The AHRQ PQI measure excludes admissions with procedures. The ACE-PRO 

measure excludes emergency department visits with admissions. 

Final Recommendations: 

Modify the original ACE-PRO measure to be specified as: 

Three or more emergency department visits for coronary artery disease, 

unassociated with admission, identified with coronary artery disease (with 

2 out-patient or one in-patient visits with CAD codes) in the measurement 

year. 

Eliminated diagnoses from the numerator specification of the original ACE-PRO 

version that are not closely related to complications of angina. 

46
Justification For Exclusion Of Measures From Further Consideration 

Screening for Diabetes Mellitus in CAD was excluded primarily because it would 

involve a three year measurement interval that poses problems in denominator 

standardization. These conditions are already well represented in set 

recommended for composition using Medicare claims data. 

Follow-up after initial diagnosis of unstable angina was excluded because of 

clinical relevance considerations. Initial diagnosis of unstable angina almost 

always leads to hospitalization. Previous compositions of this measure gave 

conflicting results. 

 

EKG in ER for Unstable Angina was excluded for two major reasons. It was 

deemed to be sensitive more to hospital care than ambulatory care and 

appeared to have reached a ceiling (>95%) in previous compositions of the 

measure. 

Hospitalization for Angina (without procedures) was excluded primarily because 

of the changing roles of procedures in coronary artery disease care. 

47
Stroke, Transient Ischemia, Atrial Fibrillation, Hypertension 

Useful measures, compose using Medicare data:

• EKG in Initial Diagnosis of Transient Ischemic Attack (TIA) 

• Carotid Imaging at Initial Diagnosis of Carotid Artery Stroke 

• Carotid Imaging in Carotid Territory Event 

• Follow-up after Hospitalization for Stroke/TIA 

• Clinical Assessment for History of Stroke/TIA 

• Hospitalization for Hypertension 

Exclude the following measures from further consideration:

• Other tests at Initial Dx of TIA 

• Anticoagulation in Atrial Fibrillation 

• Visit after Hospitalization for Hypertension 

Cite AHRQ-PQI Measures 

• Hypertension admission rate 

48
Indicator Name: EKG in Initial Diagnosis of TIA 

Indicator Description: EKG or Holter Monitor within 2 days of initial diagnosis of 

TIA, with a period of one year free of TIA codes prior to the diagnosis of TIA.

Clinical Logic: Work-up at initial diagnosis 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel identified a list of 

diagnostic tests that are part of the diagnostic work-up of all patients with a new 

presentation. This list is consistent with a more recent recommendation (AHA 

Stroke Guideline 2003 22). The list includes: ESR, EKG, CXR, echocardiogram, 

Holter monitoring, CT or MRI of the brain, CBC, electrolytes, renal function, blood 

glucose, and lipids. 

Measure Version: ACE-PRO 

EKG or Holter monitor within 2 days of initial diagnosis of TIA 

Considerations for ACE-PRO Refinement: 

Numerator

EKG or Holter Monitor 

Measurement Period

One year for case identification and two days post diagnosis for EKG or Holter 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

One code for TIA served as the index diagnosis. Initial diagnosis was defined by 

an accompanying lookback period of xxxx, free of TIA codes. 

Exclusions

TIAs associated with admissions 

Final Recommendations: 

Continue to use the original ACE-PRO measure as specified: 

EKG or Holter Monitor with 2 days of initial diagnosis of TIA, in patients 

with a period of one year free of TIA codes prior to the diagnosis of TIA. 

49
Indicator Name: Carotid Imaging at Initial Diagnosis of Carotid Artery Stroke 

Indicator Description: Carotid angiogram or non-invasive carotid imaging 

procedure within two week of initial diagnosis in patients, hospitalized for carotid 

artery stroke.

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

According to expert opinion, the original ACE-PRO panel cited strong evidence 

supporting efficacy of Carotid Endarterectomy (CEA) but weaker evidence 

demonstrating harm in delay greater than 30 days, and made the point that 

carotid imaging is necessary to establish candidacy for CEA. 

Measure Versions: ACE-PRO 

Carotid imaging within 2 weeks of initial diagnosis in patients hospitalized for 

carotid artery stroke 

Considerations for ACE-PRO Refinement: 

Numerator

The original ACE-PRO measures used carotid angiogram and non-invasive 

carotid imaging. 

Measurement Period

The measurement period used in the original ACE-PRO set was two years to 

identify carotid artery strokes and two weeks to identify imaging procedures post 

stroke. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

Patients hospitalized with a primary diagnosis of carotid territory stroke. 

Final Recommendation: 

Continue to use the original ACE-PRO measure as specified: 

Carotid angiogram or non-invasive carotid imaging procedure within two 

week of initial diagnosis in patients, hospitalized for carotid artery stroke. 

50
Indicator Name: Carotid Imaging in Carotid Endarterectomy 

Indicator Description: Carotid imaging to CEA interval less than 2 months, in 

patients with a hospitalization for stroke or TIA as a primary diagnosis prior to the 

CEA. 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel cited strong evidence 

supporting the efficacy of CEA, weaker evidence demonstrating harm in delay, 

and no argument for an optimal interval between imaging and CEA. The panel 

offered that the delay time between imaging and surgery could serve as a 

surrogate measure of access. 

Measure Versions: ACE-PRO 

Interval between carotid imaging and CEA less than 2 months in patients with 

TIA and eventual CEA 

Interval between carotid imaging and CEA less than 2 months in patients with 

stroke and eventual CEA 

Considerations for ACE-PRO Refinement: 

Numerator

Cases of CEA in which imaging to CEA interval was less than 2 months. 

Measurement Period

The measurement period used in the original ACE-PRO set was 2 years to 

identify cases of CEA and 2 months to identify carotid imaging pre-CEA. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used a CEA, a carotid imaging test and either a 

hospitalization for stroke or for TIA. The original ACE-PRO set used separate 

measures, one for TIA and one for stroke. Since the processes of care are the 

same in TIA and stroke these two measures should be combined into one with a 

denominator that consists of strokes and TIAs. 

Final Recommendation: 

Modify the original ACE-PRO measure to be specified as: 

Carotid imaging to CEA interval less than 2 months, in patients with a 

hospitalization for stroke or TIA as a primary diagnosis prior to the CEA. 

51
Indicator Name: Follow-up after Hospitalization for Stroke or TIA 

Indicator Description: At least one out-patient visit (with or without code for 

stroke or TIA) within four weeks following discharge of patients, hospitalized for 

stroke or TIA. 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Visit after hospitalization is part of FMCC because post-discharge treatment 

plans require out-patient follow-up. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel established a standard 

of follow-up after hospitalization within four weeks. 

Version:

ACE-PRO Measure

Visit <= 4 weeks after discharge from hospital for patients hospitalized for stroke 

or TIA 

Considerations for ACE-PRO Refinement 

Numerator

at least one office visit, emergency room visit, nursing home visit, or home visit. 

This does not include visits by home care providers or case managers. This is 

the same as the original ACE-PRO specification. 

Measurement Period

The measurement period used in the original ACE-PRO set was one year for 

identification of hospitalizations for acute myocardial infarction and 4 weeks for 

the post-discharge follow-up. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one hospitalization with a primary diagnosis 

code for cerebrovascular accident to identify cases. 

Final Recommendation 

Continue to use the original ACE-PRO measure as specified: 

At least one out-patient, non-emergent visit (with or without code for stroke 

or TIA) within four weeks following discharge of patients, hospitalized for 

stroke or TIA. 

52
Indicator Name: Clinical Assessment for History of Stroke/TIA 

Indicator Description: Two out-patient visits (with or without code for stroke or 

TIA) during the measurement year, in patients, identified as having stroke or TIA 

in the year prior to the measurement year (with 2 out-patient or in-patient visits). 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Clinical Assessment is part of the FMCC because symptom assessment and risk 

factor modification require frequent office visits. 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel justified office visits two 

times a year. 

ACE-PRO Measure

Visit every year 

Considerations for ACE-PRO Refinement 

Numerator

The original ACE-PRO measure accepted any out-patient visits with or without 

codes for cerebrovascular disease as coding may not be adequately precise to 

demand a visit coded for cerebrovascular disease. Those out-patient visits could 

have been office visits, emergency room visits, nursing home visits, or home 

visits. Clinical assessment in emergency room visits is different from the clinical 

assessment that this measure is designed to detect (i.e. clinical assessment in 

chronic disease management). In order to standardize with other clinical 

assessment measures, two visits would be required. This standard is certainly 

consistent with the demands of managing such patients. 

Measurement Period

The measurement period used in the original ACE-PRO set was 1 year. Case 

identification (below) will specify the requirement of a visit for inclusion in the 

measurement sample. This visit should not count as satisfying the numerator as 

well. Therefore, the measurement period must be distinct from the case 

identification period. The measurement period (measurement year) will follow 

the one year case identification period. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one code for TIA (in-patient or out-patient) 

during the measurement year to identify cases. Patients with history of stroke 

should be included as well. A stricter case identification algorithm (requiring at 

least two visits coded for stroke or TIA within a year) should improve the 

53
predictive value significantly (SCRIPT). The requirement for an additional outpatient code reduces the risk for errors of inclusion due to coding for testing 

purposes. Since case identification must precede clinical assessment, the case 

ID should occur in the year prior to the measurement year. 

Final Recommendation 

Modify the original ACE-PRO measure to be specified as: 

Two out-patient visits (with or without code for stroke or TIA) during the 

measurement year, in patients, identified as having stroke or TIA in the 

year prior to the measurement year (with 2 out-patient or in-patient visits). 

Combined the denominators of separate Stroke and TIA measures. Only nonemergent physician visits count in the numerator. 

54
Indicator Name: Hospitalization for Hypertension 

Indicator Description: Hospitalizations for hypertension in patients with 2 or 

more out-patient visits or one in-patient visits with a diagnosis code for 

hypertension in the measurement year. 

Clinical Logic: Serious Clinical Manifestations of Disease 

Hospitalization for Hypertension is part of Serious Clinical Manifestations of 

Disease because the morbidity associated with hypertension requiring 

hospitalization is serious. 

Evidence/Rationale: 

The AHRQ-PQI authors 18 argued that hypertension can be controlled with 

appropriate use of drug therapy in the out-patient setting making this a measure 

sensitive to ambulatory care. 

Versions: 

AHRQ PQI

Admissions for hypertension 

Per 100,000 in the population 

 

Considerations for ACE-PRO Refinement: 

Numerator

The AHRQ-PQI measure used admissions for hypertension with associated ICD9 codes not including secondary and benign hypertension. 

Measurement Period

The measurement period used by the AHRQ PQI is one year. 

Age Range

Age 18 or older was used in the AHRQ PQI measure. 

Case ID

The AHRQ PQI measure uses 100,000 in the population as the denominator. 

This specification does not allow the identification of the higher risk population, 

patients with known hypertension and may be biased by differences in 

hypertension prevalence. Therefore, this measure should identify cases as those 

with known hypertension in the year prior to measurement. 

Exclusions

The AHRQ PQI measures excludes admissions with procedures, transfers from 

other institutions, and admissions associated with pregnancy and childbirth. 

Final Recommendation: 

55
Include a revised version of the AHRQ-PQI measure as specified: 

At least one hospitalization with hypertension as the primary diagnosis, in 

patients with 2 or more out-patient visits or one in-patient visits with a 

diagnosis code for hypertension in the measurement year. 

56
Justification For Exclusion Of Measures From Further Consideration 

Other Tests at Initial Diagnosis of TIA was eliminated as falling into the category 

of de novo measure development. There are additional tests recommended in 

the initial clinical work-up for TIA: ESR, CXR, Echocardiogram, Holter Monitor, 

CT/MRI, CBC, Electrolytes, Renal Function Tests, Glucose, and Lipids. 

However, a measure of such utilization does not currently exist. 

Anticoagulation in Atrial Fibrillation was eliminated because it requires data on 

medication use. This measure should become feasible when Part D data 

become available for this purpose. A potential proxy measure of INR testing was 

discussed but that fell into the category of de novo measure development. 

Visit after Hospitalization for Hypertension was excluded because of the low 

incidence of hospitalization for hypertension. 

 

57
Heart Failure 

Useful measures, compose using Medicare data:

• Left Ventricular Ejection Fraction (LVEF) Assessment in Heart Failure: at 

Initial Diagnosis 

• LVEF Assessment in Heart Failure: Associated with Hospitalization 

• Laboratory Testing in Heart Failure 

• EKG after Initial Diagnosis of Heart Failure 

• CXR after Initial Diagnosis of Heart Failure 

• Follow-up after Hospitalization for Heart Failure 

• Clinical Assessment in Heart Failure 

• Admissions for Heart Failure 

Exclude the following measures from further consideration:

• Weight measurement 

• BP measurement 

• Symptoms-activity assessment 

• Examination of the heart 

• Beta blocker therapy 

• ACEI therapy 

• Patient education 

• Warfarin in comorbid atrial fibrillation 

Cite AHRQ-PQI Measures 

• Admissions for Heart Failure 

58
Indicator Name: LVEF Assessment in Heart Failure: At Initial Diagnosis 

Indicator Description: Diagnostic ultrasound, Radionuclide Ventriculography 

(RVG) or Left Ventriculogram within 3 months, before or after, initial diagnosis of 

heart failure. Initial diagnosis defined by one year look back period free of 

diagnosis codes for heart failure. 

Indicator Name: LVEF Assessment in Heart Failure: Associated with 

Hospitalization 

Indicator Description: Diagnostic ultrasound, RVG or Left Ventriculogram within 

3 months, before or after, hospitalization for heart failure.

Clinical Logic: Work-up at initial diagnosis 

Evidence/Rationale: ACC/AHA Chronic Heart Failure Guideline 2001

Echo with Doppler or RVG to assess Left Ventricular Systolic Function 

expert opinion 

Measure Versions: Consortium, CMS 

Consortium

Quantitative or qualitative results of LVF assessment recorded in patients with 

heart failure, age >= 18 

CMS

LVEF assessment before arrival, during hospitalization, or planned for after 

discharge in patients admitted for heart failure, age >= 18 

Recommendations/Considerations: 

Consider adding measure(s) to ACE-PRO set: 

• Diagnostic ultrasound, RVG, or Left Ventriculogram in incident cases of 

heart failure 

o Look back to establish incident case 

 1 year 

o Look forward (and back) to detect LVEF assessment 

 3 months 

• Diagnostic ultrasound, RVG, or Left Ventriculogram in patients 

hospitalized for heart failure 

o Look back, look during, look after the hospitalization 

 3 months before and after 

• Consider case ID algorithm that requires 2 outpatient or 1 inpatient code 

Final Recommendation 

59
Test two new measures to be specified as: 

 

Diagnostic ultrasound, RVG or Left Ventriculogram within 3 months, before 

or after, initial diagnosis of heart failure. Initial diagnosis defined by one 

year look back period free of diagnosis codes for heart failure. 

Diagnostic ultrasound, RVG or Left Ventriculogram within 3 months, before 

or after, hospitalization for heart failure. 

60
Indicator Name: Laboratory Testing in Heart Failure 

Indicator Description: Measurement of electrolytes and renal function during 

the measurement in year in patients with 2 out-patient or 1 in-patient visits with 

heart failure codes, within the previous calendar year

Clinical Logic: Work-up at Initial Diagnosis and Follow-up, Monitoring, 

Continuing Care 

Evidence/Rationale: 

ACC/AHA Chronic Heart Failure Guideline 2001

Initial measurement of CBC, UA, electrolytes, renal function, blood glucose, 

LFTs, TFTs 

expert opinion 

ACC/AHA Chronic Heart Failure Guideline 2001 

Serial measurement of electrolytes and renal function 

expert opinion 

Measure Versions: Consortium, SCRIPT 

Consortium

Patients for whom initial lab testing was performed in patients with heart failure, 

age >= 18 

SCRIPT

Potassium and renal function testing annually in patients with heart failure on 

ACEI inhibitor therapy or digoxin 

Recommendations/Considerations: 

Consider adding measure(s) to ACE-PRO set 

• Annual measurement of electrolytes and renal function in patients with 

heart failure 

o High likelihood of treatment with ACEI, ARB, Digoxin or loop 

diuretic 

o High level of performance in SCRIPT 

o Suspect high numbers of non-discriminate testing 

• CBC, UA, electrolytes, renal function, blood glucose, LFTs, TFTs after 

initial diagnosis of heart failure 

o Same level recommendation and evidence as CXR and EKG 

Final Recommendation 

Test new measure to be specified as: 

 

61
Measurement of electrolytes and renal function during the measurement in 

year in patients with 2 out-patient or 1 in-patient visits with heart failure 

codes, within the previous calendar year 

 

62
Indicator Name: EKG after Initial Diagnosis of Heart Failure 

Indicator Description: EKG within one month prior or three months after initial 

diagnosis of heart failure. Initial diagnosis requires 12 month look back period 

free of heart failure codes.

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

ACE-PRO Original Panel 

AHCPR Heart Failure Guideline 1994 

ACC/AHA Chronic Heart Failure Guideline 2001 

expert opinion 

Recommendations/Considerations: 

Keep the measure in the ACE-PRO set to be specified as: 

EKG within one month prior or three months after initial diagnosis of heart failure. 

Initial diagnosis requires 12 month look back period free of heart failure codes. 

Remain aware of potential difficulty with establishing initial diagnosis via 

lookback.

63
Indicator Name: CXR after Initial Diagnosis of Heart Failure 

Indicator Description: CXR within one month prior or three months after initial 

diagnosis of heart failure. Initial diagnosis requires 12 month look back period 

free of heart failure codes.

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

ACE-PRO Original Panel 

AHCPR Heart Failure Guideline 1994 

ACC/AHA Chronic Heart Failure Guideline 2001 

expert opinion 

Recommendations/Considerations: 

Keep the measure in the ACE-PRO set to be specified as: 

CXR within one month prior or three months after initial diagnosis of heart 

failure. Initial diagnosis requires 12 month look back period free of heart 

failure codes. 

Remain aware of potential difficulty with establishing initial diagnosis via 

lookback. 

64
Indicator Name: Follow-up after hospitalization for heart failure 

Indicator Description: Visit within 4 weeks of discharge in patients hospitalized 

for heart failure

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Made argument for followup in 1 week 

expert opinion 

Measure Version: ACE-PRO 

Visit within 4 weeks of discharge in patients hospitalized for heart failure 

Numerator and denominators specified to be consistent with other Clinical 

Assessment indicators in other conditions. 

Final Recommendations: 

Keep measure in ACE-PRO set to be specified as: 

At least one ambulatory, non-emergent visit (with or without code for heart 

failure) within four weeks following discharge of patients, hospitalized for 

heart failure. 

Probably sensitive to discharge planning. Would be useful in a continuity of care 

composite. Non-emergent ambulatory physician visits count in the numerator. 

 

65
Indicator Name: Clinical Assessment in Heart Failure 

Indicator Description: At least two out-patient visits (with or without code for 

heart failure) during the measurement year, in patients identified as having heart 

failure in the year prior to the measurement year (with 2 out-patient or 1 in-patient 

visits)

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Most practitioners schedule follow-up visits for CHF patients at 2-4 month 

intervals. Panel recommends every 6 months as indicator of minimal care. 

expert opinion 

Measure Versions: 

ACE-PRO

Visit every 6 months in Heart Failure 

Consortium

Symptom-activity assessment 

BP measurement 

Weight measurement 

Examination of the heart 

Final Recommendations: 

Modify measure for inclusion in ACE-PRO set to be specified as: 

At least two out-patient visits (with or without code for heart failure) during 

the measurement year, in patients identified as having heart failure in the 

year prior to the measurement year (with 2 out-patient or 1 in-patient visits) 

Use 2 visits in one year to standardize denominator. Symptom and activity 

assessment, BP measurement, weight measurement, and examination of the 

heart cannot be directly measured but can be inferred to have occurred as part of 

“subjective” and “objective” assessments

66
Indicator Name: Hospitalization for Heart Failure

Indicator Description: Admissions for heart failure in the measurement year 

among patients with 2 out-patient or 1 in-patient visits with failure in the year prior 

to the measurement year. 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

ACE-PRO Original Panel and AHRQ PQI 

Timely out-patient therapy can eliminate the need for some hospitalizations for 

heart failure. 

expert opinion 

Measure Versions 

ACE-PRO

Non-elective admissions for heart failure 

AHRQ PQI

Admissions for Heart Failure 

Per 100,000 in the population 

Recommendations/Considerations: 

Keep the measure for the ACE-PRO set to be specified as: 

Admissions for heart failure in the measurement year among patients with 

2 out-patient or 1 in-patient visits with failure in the year prior to the 

measurement year. 

Consistent with AHRQ PQI version using known heart failure patients in the 

denominator. 

67
Justification For Exclusion Of Measures From Further Consideration 

Weight measurement, BP measurement, symptoms-activity assessment, 

examination of the heart, beta blocker therapy, ACEI therapy, patient education 

and warfarin in comorbid atrial fibrillation were all excluded for absence of 

adequate data elements in available source. BP measurement, symptom activity 

assessment, examination of the heart, and patient education were logically 

lumped into the clinical assessment variable, assuming these processes of care 

occur during out-patient visits. Beta blocker, ACEI and warfarin therapy 

indicators should become feasible when Part D data become available for this 

purpose. 

68
Cancer 

Use the following measures:

• Breast Cancer Screening 

• Bx to Rx Interval 

• CXR at Initial Dx 

• Breast Imaging at Initial Dx 

• Mammography Surveillance 

• Colonoscopic Surveillance after Colon Cancer 

• GI Tract Work-up after Dx of Iron Deficiency Anemia 

Eliminate the following measures from consideration:

• Colorectal Cancer Screening 

• Cervical Cancer Screening 

• Visit after Mastectomy 

• Staging in Colorectal Cancer 

• Stage at Dx 

• Death Rates 

69
Indicator Name: Screening for Breast Cancer 

Indicator Description: Mammogram every two years in female patients. 

Clinical Logic: Early Detection 

Screening for Breast Cancer is part of Early Detection because it is done in the 

pre-symptomatic stage in order to detect reversible disease early. 

Evidence/Rationale: 

The USPSTF 25 (2002) recommended screening mammography with or without 

clinical breast exam every one to two years for women age 40 and older based 

upon at least fair evidence that the service improves important health outcomes 

and concludes that benefits outweigh harms. Similar recommendations are 

made by the AMA, ACOG, ACR, ACS, NCI, CTFPHC, AAFP, and ACPM. These 

organizations differ only on ages and screening intervals. 

Measure Versions: ACE-PRO, NCQA, VA, CMS, Consortium, NHQR 

All measure versions below specify in female patients 

ACE-PRO

• Mammography every 2 years ages 65 to 75 

NCQA and Consortium

• Mammography every 2 years ages 50 to 69 

VA and CMS

• Mammography every 2 years ages 52 to 69 

NHQR

• Mammography every 2 years age >= 40 

Considerations for ACE-PRO Refinement 

Numerator

Mammography every two years is used by all who measure this process of 

care. 

Measurement Period

A two year measurement period is used by all who measure this process of 

care. 

Age Range

The original ACE-PRO measure used ages 65 to 75. Others who measure 

this process of care use ages less than 65 as the beginning of eligibility 

interval and ages less than 75 as the end of the eligibility interval. The refined 

ACE-PRO measure set will again be restricted to patients aged 65 and older. 

70
The rationale behind the use of 69 as the end of the eligibility interval is based 

upon better evidence than any other age ceiling. An age restriction so limited 

would compromise the utility of such an important measure. There are good 

studies that demonstrate the benefit of mammography in women up to age 

74. Clinical recommendations do not recommend against mammography 

screening in women older than 69. Given the evidence and 

recommendations consistent with older age screening it is reasonable to set 

the upper end of the eligibility interval at 74. 

Case ID

The original ACE-PRO set used female gender. 

Exclusions

History of breast cancer would be a reasonable exclusion from a measure of 

screening. However, this contribution to the denominator is assumed to be 

negligible by all organization that measure this process of care. 

Final Recommendation 

Use the original ACE-PRO measure to be specified as: 

 

Mammogram every two years in female patients age 65-74 

71
Indicator Name: Biopsy to Treatment Interval in Breast Cancer 

Indicator Description: Biopsy to definitive therapy (surgical, radiation, 

chemotherapy) interval less than 3 months in patients with breast cancer and 

eventual definitive therapy. 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Biopsy to Treatment Interval is part of FMCC because appropriate follow-up care 

after initial diagnosis is definitive therapy. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel established a standard 

for follow-up after biopsy of three months. 

Version:

ACE-PRO Measure

Interval from biopsy to definitive therapy less than three months in patients with 

breast cancer and eventual mastectomy. 

Considerations for ACE-PRO Refinement 

Numerator

Number of patients in which biopsy to mastectomy interval is less than 3 months. 

Definitive therapy in breast cancer can include interventions other than 

mastectomy. These interventions can be surgical, chemotherapeutic, and 

radiotherapeutic. In order to accommodate these additional forms of definitive 

therapy, the refined ACE-PRO measure should be modified to include other 

surgical interventions, chemotherapy, and radiation therapy in breast cancer. 

Measurement Period

The measurement period used in the original ACE-PRO set was 2 years 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used patients with breast cancer and eventual 

mastectomy to identify cases. 

Final Recommendation: 

Modify the original ACE-PRO measure as specified: 

Biopsy to definitive therapy (surgical, radiation, chemotherapy) interval 

less than 3 months in patients with breast cancer and eventual definitive 

72
therapy. Breast cancer is defined as a visit (in-patient or out-patient) for 

breast cancer. A biopsy is defined as a breast biopsy. 

73
Indicator Name: CXR in Breast Cancer 

Indicator Description: CXR within three months before or three months after 

initial diagnosis of breast cancer. 

Clinical Logic: Work-up at initial diagnosis 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel concluded that a CXR is 

part of the staging evaluation in breast cancer. 

Measure Version: ACE-PRO 

CXR within three months before or three months after initial diagnosis of breast 

cancer 

Considerations for ACE-PRO Refinement: 

Numerator

CXR within three months prior to or three months after the initial diagnosis of 

breast cancer 

Measurement Period

The original ACE-PRO measure uses two years as the measurement period. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

One out-patient or in-patient visit, coded for breast cancer served as the index 

diagnosis. Initial diagnosis was defined by an accompanying lookback period of 

12 months free of breast cancer codes. 

Final Recommendation: 

Use the original ACE-PRO measure as specified: 

CXR within three months before or three months after initial diagnosis of 

breast cancer. Index diagnosis of breast cancer must occur 3 months or 

longer prior to the end of the measurement year. Index diagnosis of breast 

cancer must be preceded by at least 12 months free of breast cancer 

codes. 

74
Indicator Name: Breast Imaging in Breast Cancer 

Indicator Description: Mammogram or other breast imaging within three 

months before or three months after initial diagnosis of breast cancer. 

Clinical Logic: Work-up at initial diagnosis 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel concluded that a 

contralateral mammogram is part of the staging evaluation in breast cancer. 

Measure Version: ACE-PRO 

Mammogram within three months before or three months after initial diagnosis of 

breast cancer 

Considerations for ACE-PRO Refinement: 

Numerator

Mammogram within three months prior to or three months after the initial 

diagnosis of breast cancer was used by the original ACE-PRO measure. Breast 

imaging has advanced during the past several years such that other imaging 

tests are often used. Therefore, a refined measure should include newer 

imaging tests as well as mammograms. 

Measurement Period

The original ACE-PRO measure uses two years as the measurement period. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

One out-patient or in-patient visit, coded for breast cancer served as the index 

diagnosis. Initial diagnosis was defined by an accompanying lookback period of 

12 months free of breast cancer codes. 

Final Recommendation: 

Modify the original ACE-PRO measure as specified: 

Mammogram or other breast imaging within three months before or three 

months after initial diagnosis of breast cancer. Index diagnosis of breast 

cancer must occur 3 months or longer prior to the end of the measurement 

year. Index diagnosis of breast cancer must be preceded by at least 12 

months free of breast cancer codes. 

75
Indicator Name: Surveillance Mammography with history of breast cancer 

Indicator Description: At least one mammogram (in-patient or out-patient) 

within a 12 month period that includes a visit (in-patient or out-patient) for breast 

cancer. 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Surveillance Mammography refers to mammography in patients after the 

treatment of breast cancer. It is part of FMCC because it is important in the 

detection of breast cancer recurrence. 

Evidence/Rationale: 

Based upon expert opinion and the control arm of the GIVIO trial,26 the original 

ACE-PRO panel established a standard of contralateral mammography within 

one year after the treatment of breast cancer. 

Version:

ACE-PRO Measure

Mammography every year for patients with history of breast cancer 

Considerations for ACE-PRO Refinement 

Numerator

Patients with mammogram every year with history of breast cancer 

Measurement Period

The measurement period used in the original ACE-PRO set was one year. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one visit for breast cancer (in-patient or outpatient). 

Final Recommendation 

Continue to use the original ACE-PRO measure as specified: 

At least one mammogram (in-patient or out-patient) within a 12 month 

period that includes a visit (in-patient or out-patient) for breast cancer. 

76
Indicator Name: Surveillance Colonoscopy in Colon Cancer 

Indicator Description: At least one visit (in-patient or out-patient) coded for 

colonoscopy within 12 months of visit (in-patient) coded for resection of colorectal 

cancer 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Surveillance Colonoscopy refers to colonoscopic follow-up in patients with known 

colon cancer. It is part of FMCC because it is important in the detection of colon 

cancer recurrence. 

Evidence/Rationale: 

Based upon expert opinion cited in the American Cancer Society Guideline,27

Screening and Surveillance, 28 Colon Cancer (2001) standards can be set for 

colonoscopy within 1 year of colon resection and within 3-6 years of 

polypectomy. 

Version:

None 

Considerations for ACE-PRO Refinement 

Numerator

Patients with colonoscopy within one year following resection of colorectal cancer 

Measurement Period

The measurement period will require one year of claims after the occurrence of 

the resection of colorectal cancer. 

Age Range

To be consistent with the other ACE-PRO measures, age 65 or older should be 

used. 

Case ID

patients with one code for resection of colon cancer 

Final Recommendation: 

Develop a new measure to be specified as: 

at least one visit (in-patient or out-patient) coded for colonoscopy within 12 

months of visit (in-patient) coded for resection of colorectal cancer 

77
Indicator Name: GI Tract Work-up in Iron Deficiency Anemia 

Indicator Description: Colonoscopy or barium enema within one month before 

or three months after the initial diagnosis of iron deficiency anemia. 

Clinical Logic: Work-up at initial diagnosis 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel concluded that imaging 

of the colon for the detection of colon cancer should be part of the work-up in iron 

deficiency anemia. 

Measure Version: ACE-PRO 

GI Work-up in patients with iron deficiency anemia 

Considerations for ACE-PRO Refinement: 

Numerator

The original ACE-PRO measure upper and lower endoscopy and barium enema 

within one month before and three months after initial diagnosis of iron deficiency 

anemia. An upper endoscopy will not detect colon cancer. The refined measure 

should be restricted to colonoscopy and barium enema. 

Measurement Period

The original ACE-PRO measure uses two years as the measurement period. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO measure used an index diagnosis of iron deficiency 

anemia with a one year lookback free of diagnoses of iron deficiency anemia to 

establish initial diagnosis. 

Final Recommendation: 

Modify the original ACE-PRO measure as specified: 

Colonoscopy or barium enema within one month before or three months 

after the initial diagnosis of iron deficiency anemia. The index diagnosis of 

iron deficiency anemia must be preceded by a 12 month period free of the 

diagnosis of iron deficiency anemia. 

78
Justification For Exclusion Of Measures From Further Consideration

Colorectal Cancer Screening and Cervical Cancer Screening were eliminated 

because of the need for lookbacks of several years duration. Staging measures 

and death rates were excluded for limited access to data elements in the source 

available. 

79
Anemia and GI Bleed 

Use the following measures:

• Visit after Hospitalization for GI Bleed 

• Visit after Initial Dx of GI Bleed 

• H/H after Hospitalization for GI Bleed 

• H/H after Initial Dx of Anemia 

• GI Tract Work-up after Initial Dx of Iron Deficiency Anemia * 

* Indicator workup in Cancer Chapter 

80
Indicator Name: Follow-up Visit after Hospitalization for GI Bleed 

Indicator Description: At least one visit (with or without code for GI bleed) 

within four weeks following discharge of patients, hospitalized for GI bleed. 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Visit after hospitalization is part of FMCC because post-discharge treatment 

plans require out-patient follow-up. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel established a standard 

for follow-up after hospitalization of four weeks. 

Version:

ACE-PRO Measure

Visit <= 4 weeks after discharge from hospital for patients hospitalized for GI 

bleed 

Considerations for ACE-PRO Refinement 

Numerator

at least one office visit, emergency room visit, nursing home visit, or home visit. 

This does not include visits by home care providers or case managers. 

Discussion on this topic appears in section XX. This is the same as the original 

ACE-PRO specification. 

Measurement Period

The measurement period used in the original ACE-PRO set was two years. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one hospitalization with a primary diagnosis 

code for GI bleed to identify cases. 

Final Recommendation 

Continue to use the original ACE-PRO measure as specified: 

At least one visit (with or without code for GI bleed) within four weeks 

following discharge of patients, hospitalized for GI bleed. 

81
Indicator Name: Follow-up Visit after Initial Diagnosis of GI Bleed 

Indicator Description: At least one visit, in-patient or out-patient, with or without 

code for GI bleed, within four weeks following initial diagnosis of GI bleed (outpatient only). 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Visit after initial diagnosis of GI bleed is part of FMCC because a clinical 

assessment if required to monitor patient status early in treatment. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel established a standard 

for follow-up after initial diagnosis of GI bleed of four weeks. 

Version:

ACE-PRO Measure

Visit <= 4 weeks after initial diagnosis of GI bleed 

Considerations for ACE-PRO Refinement 

Numerator

The original ACE-PRO measure used at least one office visit, emergency room 

visit, nursing home visit, or home visit. This does not include visits by home care 

providers or case managers. A hospitalization within the 4 week period of time 

would not be counted. These cases were not eliminated. Since GI bleed can 

have a high rate of hospitalization this may cause a significant bias in the 

measurement. The refined measure should acknowledge hospital-based care in 

the numerator. 

Measurement Period

The measurement period used in the original ACE-PRO set was two years. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used an index diagnosis of GI bleed in the out-patient 

setting with a lookback period of 12 months free of diagnoses of GI bleed to 

identify cases. 

Final Recommendation: 

Modify the original ACE-PRO measure as specified: 

At least one visit, in-patient or out-patient, with or without code for GI 

bleed, within four weeks following initial diagnosis of GI bleed (out-patient 

82
only). Index diagnosis of GI bleed must be preceded by a 12 month period 

free of diagnosis of GI bleed. 

83
Indicator Name: Follow-up Lab Test after Hospitalization for GI Bleed 

Indicator Description: At least one hemoglobin or hematocrit test within four 

weeks following discharge of patients, hospitalized for GI bleed. 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Hemoglobin/hematocrit after hospitalization is part of FMCC because postdischarge follow-up requires assessment of blood volume status. 

Evidence/Rationale: 

Based upon expert opinion and the possibility of recurrent bleed after discharge, 

the original ACE-PRO panel established a standard for hemoglobin/hematrocrit 

testing after hospitalization for GI bleed of four weeks. 

Version:

ACE-PRO Measure

Hemoglogin/hematocrit test <= 4 weeks after discharge from hospital for patients 

hospitalized for GI bleed 

Considerations for ACE-PRO Refinement 

Numerator

Hemoglobin or hematocrit test within four weeks of discharge after hospitalization 

for GI bleed. 

Measurement Period

The measurement period used in the original ACE-PRO set was two years. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one hospitalization with a primary diagnosis 

code for GI bleed to identify cases. 

Final Recommendation 

Continue to use the original ACE-PRO measure as specified: 

At least one hemoglobin or hematocrit test within four weeks following 

discharge of patients, hospitalized for (primary diagnosis of) GI bleed. 

84
Indicator Name: Follow-up Lab Test after Initial Diagnosis of Anemia 

Indicator Description: Hemoglobin or hematocrit test within one to six months 

after an initial diagnosis of anemia. 

Clinical Logic: Work-up at Initial Diagnosis 

Hemoglobin/hematocrit test in anemia is part of Work-up at Initial Diagnosis 

because it is part of a standardized diagnostic algorithm for anemia. 

Evidence/Rationale: 

The original ACE-PRO panel identified hemoglobin or hematocrit testing as part 

of a standardized diagnostic algorithm in the initial work-up of anemia. 

Version:

ACE-PRO Measure

Hemoglogin/hematocrit test one to six months after the initial diagnosis of 

anemia. 

Considerations for ACE-PRO Refinement 

Numerator

Hemoglobin or hematocrit test within one to six months after initial diagnosis of 

anemia 

Measurement Period

The measurement period used in the original ACE-PRO set was two years. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used an index diagnosis of anemia accompanied by a 

one year lookback free of codes for anemia in order to define initial diagnosis. 

Final Recommendation: 

Continue to use the original ACE-PRO measure as specified: 

Hemoglobin or hematocrit test within one to six months after an initial 

diagnosis of anemia. Index diagnosis of heart failure must occur 3 months 

or longer prior to the end of the measurement year. Index diagnosis of 

anemia must be preceded by at least 12 months free of anemia codes. 

85
Miscellaneous 

COPD 

Use the following measures: 

• Clinical Assessment in COPD/Asthma 

• Hospitalization for Respiratory Dx in COPD/Asthma 

Refer to the following measures as done by AHRQ-PQI

• COPD admission rate 

• Adult asthma admission rate 

Depression 

Use the following measures:

• Follow-up after Hospitalization for Depression 

Eliminate the following measures from consideration:

• Out-patient screening 

• Thyroid function testing 

• Psychotherapy 

• Follow-up after positive screen for depression 

• Deaths due to suicide 

Infectious Disease 

Refer to the following measures as done by AHRQ-PQI:

• Admissions for UTI 

• Admissions for Bacterial Pneumonia 

Eliminate the following measures from consideration:

• Influenza Immunization 

• Pneumococcal Immunization

Other 

Use the following measure:

• Annual visit 

Refer to the following measures as done by AHRQ-PQI

• Admissions for Dehydration 

Eliminate from consideration the following measures:

• H. pylori testing 

• Surgical repair of hip fx 

• Pain Management 

86
Indicator Name: Clinical Assessment in COPD/Asthma 

Indicator Description: At least two out-patient visits during the measurement 

year, in patients, identified as having COPD or asthma in the year prior to the 

measurement year.

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Clinical Assessment is part of the FMCC because regular symptom and activity 

assessment and risk factor modification require frequent office visits. 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel justified office visits 

every six months. 

ACE-PRO Measure

Visit every 6 months in patients with COPD (not asthma) 

Considerations for ACE-PRO Refinement 

Numerator

The original ACE-PRO measure accepted any out-patient visits with or without 

codes for COPD as coding may not be adequately precise to demand a visit 

coded for COPD. The out-patient visits could have been office visits, emergency 

room visits, nursing home visits, or home visits. Clinical assessment in 

emergency room visits is different from the clinical assessment that this measure 

is designed to detect (i.e. clinical assessment in chronic disease management). 

Two visits within one year would allow standardization on a one year 

measurement period (below) and retention of the logic of the original ACE-PRO 

measure. It is acknowledged that there are potential differences between these 

specifications but that these differences are not compelling enough to continue 

using one visit every six months. 

Measurement Period

The measurement period used in the original ACE-PRO set was 6 months. In 

order to standardize with other clinical assessment measures, a one year period 

would be required. Case identification (below) will specify the requirement of a 

visit for inclusion in the measurement sample. This visit should not count as 

satisfying the numerator as well. Therefore, the measurement period must be 

distinct from the case identification period. The measurement period 

(measurement year) will follow the one year case identification period. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

87
Case ID

The original ACE-PRO set used one code for COPD (in-patient or out-patient) 

during the measurement year to identify cases. A stricter case identification 

algorithm (requiring at least two visits coded for COPD within a year) could 

improve the predictive value significantly (SCRIPT). The requirement for an 

additional out-patient code reduces the risk for errors of inclusion due to coding 

for testing purposes. Since case identification must precede clinical assessment, 

the case ID should occur in the year prior to the measurement year. Asthma was 

not included in the original ACE-PRO specification. Asthma is a chronic 

obstructive pulmonary disease and not discretely separable from other COPD 

(chronic bronchitis and emphysema) in the elderly population. Broadening the 

denominator to include asthma increases the precision of the measure. 

Final Recommendation: 

Modify the original ACE-PRO measure to be specified as: 

At least two out-patient visits (with or without code for COPD or asthma) 

during the measurement year, in patients, identified as having COPD or 

asthma in the year prior to the measurement year (with 2 out-patient or inpatient visits). 

88
Indicator Name: Hospitalizations for COPD/Asthma 

Indicator Description: Admissions for respiratory diagnoses among patients 

with COPD or asthma 

Clinical Logic: Serious Clinical Manifestations of Disease 

Hospitalizations for COPD/Asthma is part of Serious Clinical Manifestations of 

Disease because hospital admissions for these respiratory diagnoses require 

significant deteriorations in clinical status. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel made the case that 

effective out-patient management can prevent hospitalizations for COPD. 

Versions: ACE-PRO, AHRQ-PQI

ACE-PRO 

Hospitalizations for respiratory diagnoses in patients with COPD 

AHRQ PQIs 

Admissions for COPD 

Per 100,000 in the population 

Admissions for Asthma (in adults) 

Per 100,000 in the population 

 

Considerations for ACE-PRO Refinement: 

Numerator

The original ACE-PRO measure uses admissions for respiratory diagnoses. The 

AHRQ PQI uses admissions for COPD and admissions for asthma in two 

separate measures. The respiratory diagnoses used by the original ACE-PRO 

measure are all potentially avoidable with effective out-patient management. 

Measurement Period

The measurement period used in the original ACE-PRO set is two years. The 

measurement period used by the AHRQ PQIs is one year. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. Age 18 or older was 

used in the AHRQ PQI measures. 

89
Case ID

The original ACE-PRO set used one code for COPD (in-patient or out-patient) 

during the measurement year to identify cases. The AHRQ PQI measures use 

100,000 in the population as the denominator. 

Exclusions

The AHRQ PQI measures excluded transfers from other institutions to avoid 

double-counting of cases, and hospitalizations associated with pregnancy and 

childbirth. 

Final Recommendations: 

Modify the original ACE-PRO measure to be specified as: 

Admissions for respiratory diagnoses among patients with COPD 

(including asthma) defined as 2 visits (out-patient or in-patient) with coded 

for COPD or asthma in the measurement year. 

90
Indicator Name: Visit After Hospitalization For Depression 

Indicator Description: Visit within two weeks following discharge of patients, 

hospitalized for depression. 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Visit after hospitalization is part of FMCC because post-discharge treatment 

plans require out-patient follow-up. 

Evidence/Rationale: 

Based upon expert opinion the original ACE-PRO panel established a standard 

for follow-up after hospitalization of 14 days. This opinion was supported by an 

AHCPR guideline.29 

Version:

ACE-PRO Measure

Visit <= 14 days after discharge from hospital for patients hospitalized for 

depression 

Considerations for ACE-PRO Refinement 

Numerator

at least one office visit, emergency room visit, nursing home visit, home visit, or 

psych visit. This does not include visits by home care providers or case 

managers. This is the same as the original ACE-PRO specification. 

Measurement Period

The measurement period used in the original ACE-PRO set was one year for 

identification of hospitalizations for depression and 14 days for the postdischarge follow-up. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set used one hospitalization with a primary diagnosis 

code for depression to identify cases. 

Final Recommendation: 

Continue to use the original ACE-PRO measure as specified: 

At least one out-patient visit (with or without code for depression) within 

two weeks following discharge of patients, hospitalized for depression. 

91
Indicator Name: Annual Visit 

Indicator Description: Out-patient visit during the measurement year, in 

patients identified as Medicare enrolled in the eligibility file. 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Annual Visit is part of the FMCC because routine monitoring and preventive 

services (e.g. blood pressure monitoring, immunizations, arrangements for 

screenings) requires annual contact. 

Evidence/Rationale: 

Based upon expert opinion, the original ACE-PRO panel justified annual visits. 

ACE-PRO Measure

Office visit every year 

Considerations for ACE-PRO Refinement 

Numerator

The original ACE-PRO measure accepted any out-patient visit. The out-patient 

visits could have been office visits, emergency room visits, nursing home visits, 

or home visits. Clinical assessment in emergency room visits is different from 

the clinical assessment that this measure is designed to detect (i.e. clinical 

assessment in chronic disease management). 

Measurement Period

The measurement period used in the original ACE-PRO set was one year. 

Age Range

Age greater than 65 was used in the original ACE-PRO set. 

Case ID

The original ACE-PRO set identified all patients as cases. This identification 

algorithm cannot rely upon visits to identify cases unless the cases are identified 

in the previous year. Case identification should come from an independent 

source (i.e. the eligibility file). 

Final Recommendation: 

Modify the original ACE-PRO measure to be specified as: 

At least one out-patient visit during the measurement year, in patients 

identified as Medicare enrolled in the eligibility file. 

92
Justification for exclusion of measures from further consideration 

Surgical repair of hip fracture was excluded for lack of sensitivity to ambulatory 

care. Influenza and pneumococcal immunization measures were excluded 

because of their known measurement reliability problems using claims data. 

Depression measures were excluded due to the known problems in using claims 

data to identify depression. H. pylori testing and pain management were 

excluded since both required de novo measure development. 

93
Measurement Issues and Recommendations 

Use of Composites

Various potential composites for measurement were identified. The expert panel 

recommended that MedPAC follow national guidance on the use of composite 

measures since there is a national workgroup studying the use of composites in 

performance measurement. 

 Potential Measure Composites 

Clinical Assessment in Chronic Disease 

Diabetes Mellitus 

CAD 

Stroke/TIA 

COPD/Asthma 

Heart Failure 

Follow-up After Hospitalization 

Diabetes Mellitus 

Acute MI 

Stroke/TIA 

Heart Failure 

Depression 

GI Bleed 

Avoidable Hospitalizations 

Diabetes Mellitus 

CAD (ER) 

Heart Failure 

COPD/Asthma 

AHRQ PQIs (cite) 

Work-up at Initial Dx 

EKG in TIA 

Carotid Imaging 

LVEF in Heart Failure 

EKG in Heart Failure 

CXR in Heart Failure 

Imaging in Breast Cancer 

GI Work-up in Iron Def Anemia 

94
Cancer Staging

The expert panel reinforced the need for improved coding in cancer diagnosis 

because many potential quality measures in cancer therapy require staging 

information. This would be particularly valuable in developing new measures 

using administrative data. 

Temporality

For some measures it is important to identify cases prior to the measurement 

year (e.g. Clinical Assessment). In other measures a period prevalence 

approach is justified in which the presence of the disease throughout the 

measurement period is inferred from the presence of defining codes any time 

within that measurement period (e.g. A1C testing in diabetes mellitus). 

Age Intervals

The expert panel reinforced the value of using age intervals other than 65 and 

older, since there are Medicare beneficiaries in younger age groups, and other 

performance measurement systems use different age ranges. However, since 

this measure set is designed for the elderly, the default age range starts at age 

65. Where evidence compels an age ceiling (e.g. screening for breast cancer) 

that age ceiling is specified in the measure specification. 

Follow-up intervals

Various follow-up intervals are used in the measure specifications. The evidence 

behind such intervals is often lacking. The expert panel suggested the testing of 

various intervals in search of potential thresholds that could inform future 

measurement specification decisions. 

Reliability of Codes

The original ACE-PRO measure set used the presence of one or more visits with 

a defining diagnosis code to establish cases. The SCRIPT project has 

demonstrated merit in enhanced predictive value of requiring at least two visits 

within a defining diagnosis code to establish cases. This algorithm eliminates 

potential false positives, enhancing specificity, due to coding for the purpose of 

diagnostic testing. Thus, it was decided that the refined ACE-PRO measure set 

use this stricter case identification algorithm. 

Coding in Mental Illness

Mental health diagnosis codes are often under-used due to decreased 

reimbursement given perceptions of payment policies. For the purposes of 

quality measurement this problem creates an under-identification bias and led to 

the disqualification of many potentially suitable measures. The expert panel 

recommended either correction of this misperception or modification of the 

payment policy. 

95
Uses of measures

Performance measures can be used for self-assessment or accountability 

purposes. These measures should be suitable for the following levels of 

analysis: national, regional, and certain sub-populations (rural/urban, dually 

enrolled). 

Relative weakness of the evidence

Ideally, quality measures should be supported by strong evidence. In the 

strength of evidence hierarchy randomized trials are considered to be the 

strongest from of support. Observational studies are not as strong, while expert 

opinion and current practice are considered weaker support. While reflecting 

standards of care, most of the measures recommended in this report, are based 

upon expert opinion. It is important to note that other measurement systems and 

the vast majority of clinical practice guidelines include recommendations 

supported by similar strength of evidence. 

Paucity of measures on interventions

The final list of recommended measures does not have any from the category of 

Therapeutic Intervention from the Clinical Logic. While some measures were 

considered (e.g. psychotherapy) and some were actually based upon very strong 

evidence (e.g. anticoagulation) all were eliminated for the lack of available data in 

claims databases. Medication use measures will have the potential to solve this 

problem after the Medicare Modernization Act of 2003 is fully implemented. 

Updating the measures

As performance measurement, clinical practice, and evidence evolve, quality 

measures need to be periodically updated. The expert panel reinforced this 

recommendation. 

Consistency with other measure sets

When performance measures have already been developed by other 

organizations, such specifications should be considered by MedPAC for the 

sakes of consistency and cost-effectiveness in measurement. 

Consistency with self for time series analyses

MedPAC has been using the original ACE-PRO measures for several years now. 

Consistency with original specifications has value in allowing time series 

analyses. As such, original specifications were given preferential consideration 

and were altered only after careful consideration by staff and expert panelists. It 

is possible to perform retrospective time series analyses using the refined 

measures. 

96
Measures to follow but not compose

Expert panelists and staff found the several measures useful in current form that 

would not require composition by MedPAC. The AHRQ PQIs are useful in this 

regard and can be cited by MedPAC without the burden of analysis. 

97
Table 2: Measures Recommended for Inclusion in Medicare Ambulatory 

Care Indicators for the Elderly 

1. Eye Exam in Diabetes Mellitus 

2. A1C Testing in Diabetes Mellitus 

3. Lipid Testing in Diabetes Mellitus 

4. Clinical Assessment in Diabetes Mellitus 

5. Follow-up after Hospitalization for Diabetes Mellitus 

6. Serious Short Term Complications of Diabetes Mellitus 

7. Serious Long Term Complications of Diabetes Mellitus 

8. Lipid Testing in Coronary Artery Disease 

9. Follow-up after Hospitalization for Acute MI 

10. Clinical Assessment in Coronary Artery Disease 

11. ER Use for Unstable Angina 

12. Carotid Imaging at Initial Diagnosis of Carotid Artery Stroke 

13. Carotid Imaging in Carotid Endarterectomy 

14. Follow-up after Hospitalization for Stroke/TIA 

15. Clinical Assessment for History of Stroke/TIA 

16. Hospitalization for Hypertension 

17. LVEF Assessment in Heart Failure: at Initial Diagnosis 

18. LVEF Assessment in Heart Failure: Associated with Hospitalization 

19. Laboratory Testing in Heart Failure 

20. EKG after Initial Diagnosis of Heart Failure 

21. CXR after Initial Diagnosis of Heart Failure 

22. Follow-up after Hospitalization for Heart Failure 

23. Clinical Assessment in Heart Failure 

24. Admissions for Heart Failure 

25. Breast Cancer Screening 

26. Biopsy to Therapy Interval in Breast Cancer 

27. CXR at Initial Diagnosis of Breast Cancer 

28. Breast Imaging at Initial Dx of Breast Cancer 

29. Mammography Surveillance in Breast Cancer 

30. Colonoscopic Surveillance after Colon Cancer 

31. Follow-up Visit after Hospitalization for GI Bleed 

32. Follow-up Visit after Initial Diagnosis of GI Bleed 

33. Follow-up Lab Test after Hospitalization for GI Bleed 

34. Follow-up Lab Test after Initial Diagnosis of Anemia 

35. GI Tract Work-up after Initial Diagnosis of Iron Deficiency Anemia 

36. Clinical Assessment in COPD/Asthma 

37. Hospitalization for Respiratory Diagnosis in COPD/Asthma 

38. Follow-up after Hospitalization for Depression 

39. Annual visit 

98
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102

Appendices 

 1. Summary Matrix of Conditions / Topics Considered 

 2. Preparatory Materials for Expert Panel Meeting 

 3. Summary of Expert Panel Recommendations 

 4. Revised ACE-PRO Indicator Set: Measure Short Descriptions 

 5. Revised ACE-PRO Measures General Analytic Rules 

 6. Bibliography 
Appendix 1. Conditions / Topics of Priority 

CONDITION / TOPIC 

ACEPRO 

Priority 

Areas 

NatAction 

Amb. Care 

sensitive 

conditions 

AHRQ 

Inpt QI 

s 

HCQIP 

6th 

SoW 

IOM / 

MEPS NQF 

PM 

Clearinghouse JCAHO core NCQA AM

Diabetes Mellitus 1 1 1 1 1 1 1 1 CAD / Angina / IHD 1 1 1 1 1 1 1 1 Cerebrovascular Disease / Stroke 1 1 1 1 1 1 1 Heart Failure 1 1 1 1 1 1 1 Hypertension 1 1 1 1 1 1 1 Immunization / Preventive Care 1 1 1 1 1 1 1 1 Chronic Obstructive Pulm.Dis / Asthma 1 1 1 1 1 1 1 Depression 1 1 1 1 1 1 Bacterial Pneumonia 1 1 1 1 1 1 Breast Cancer / mammography 1 1 1 1 1 Myocardial Infarction 1 1 1 1 1 Dyslipidemia in CAD / AMI / DM 1 1 1 1 Appendicitis 1 1 1 1 GI Bleed / Ulcer Disease 1 1 1 1 Cholelithiasis 1 1 1 Hip Fracture 1 1 1 Anemia 1 1 Dyspepsia 1 Cancer (not specifically breast) 1 1 1 1 Tobacco Dependence 1 1 1 1 1 Arthritis 1 1 1 Medication Management 1 1 Pain Control 1 1 1 Osteoporosis 1 1 Severe and Persistent Mental Illness 1 1 1 Care Coordination 1 1 Chronic Back Problems 1 1 Dehydration 1 1 End of Life (CHF, COPD) 1 HIV Infection / AIDS 1 1 Incontinence 1 Lower Extremity Amputation 1 1 Urinary Tract Infections 1 1 Alzheimer's Disease 1 Anxiety Disorders 1 Emphysema 1 Frailty in Old Age 1 Hepatitis C 1 Nosocomial Infections 1 Obesity 1 Patient Safety 1 Renal Disease 1 Self-management/Health Literacy 1 
Intentionally left blank
Appendix 2. Preparatory Materials for Expert Panelist Meeting 
Refinement of ACE-PRO Indicators 

Preparatory Materials for Expert Panel 

Meeting at MedPAC 

May 17, 2004
Table of Contents 

Introduction 

Diabetes Mellitus 

Coronary Artery Disease 

Cerebrovascular Disease, Atrial Fibrillation and Hypertension 

Heart Failure 

Cancer 

COPD/Asthma 

Mental Health 

Infectious Disease 

Anemia, GI Bleed, and Miscellaneous 
Background 

MedPAC’s purpose for this project is to refine the Access to Care for the Elderly Project 

(ACE-PRO) indicators. These were originally developed by RAND for the Physician 

Payment Review Commission (PPRC) nearly ten years ago. They have been used to 

measure quality and access in national and sub-group analyses including comparisons 

among geographic locations and disadvantaged populations. Clinical science and 

quality measurement have advanced during the past decade presenting the need to 

modernize the measure set. 

Methods 

Measure development requires selection of topics, review of evidence, design of 

operational definitions, and testing. In preparation for testing, the current work on topic 

selection, guideline review, and measure definitions are presented in summary form in 

this document. During the panel meeting in which you will participate, details of this 

work will be presented along with recommendations for refinement of the measure set. 

We are interested in your opinions regarding the clinical logic, evidence support, 

recommendations for specification and for use of the measures in national and subgroup analyses. 

Condition/Topic Selection 

An initial list of conditions/topics for consideration was developed that included the 

original ACE-PRO topics, high priority conditions identified by the Institute of Medicine, 

and conditions used in existing measures. Specific conditions/topics and their sources 

are displayed in table 1. 

In prioritizing the conditions certain assumptions were made: 1) only claims data would 

be available for measurement; 2) medication data would not be available; 3) the 

population of focus would be community dwelling elderly (age >= 65); 4) special subpopulations (end stage renal disease, nursing home, disabled, dually enrolled, chronic 

and severe mental illness) would be included in analyses but not necessarily serve as a 

population of focus; 5) the indicators would measure ambulatory care processes directly 

or be sensitive to ambulatory care; 6) additions to the ACE-PRO measure set would be 

limited to measures currently in use by others. Justification for including and excluding 

conditions/topics will be presented during the panel meeting. 
Clinical Logic 

The conceptual framework for the presentation of measures was adapted from David 

Eddy’s “Clinical Logic” paradigm. The natural history of disease generally progresses 

from a pre-disease state, to a pre-symptomatic state, to diagnosis and management, 

and serious clinical manifestations. Process and outcome measures are localized 

within categories that follow this progression: prevention; early detection; work-up at 

initial diagnosis; therapeutic interventions; follow-up, monitoring, continuing care; and 

serious clinical manifestations of disease. 

The evidence review focused on existing guidelines and evidence that became 

available after the publication of the most recent guidelines. Sources of guidelines 

included: the National Guidelines Clearinghouse, the American Heart Association 

(AHA), US Preventive Services Task Force (USPSTF), the American Diabetes 

Association (ADA), the Institute for Clinical Systems Improvement (ICSI), the National 

Cholesterol Education Program’s Third Adult Treatment Panel (NCEP), and the National 

Cancer Institute (NCI). 

Measures Review 

In addition to the original ACE-PRO indicators, measures for consideration in the 

selected conditions/topics were identified from the following sources: the National 

Quality Measures Clearinghouse, the Physician Consortium for Performance 

Improvement (Consortium), the National Health Quality Report (NHQR), the 

Veterans Administration (VA), National Committee for Quality Assurance 

(NCQA), National Diabetes Quality Improvement Alliance (Alliance), ICSI, 

Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare 

Research and Quality (AHRQ), and the SCRIPT Project (SCRIPT). 

Orientation to the Materials 

Potential measures are organized into condition-specific chapters. Within each chapter, 

the locus within the clinical logic is identified for each process or outcome. Process 

measures that are obviously infeasible are identified. For each measure that is feasible, 

a title, clinical logic locus, evidence/rationale, measure versions (including source and 

description), and recommendations with considerations are presented. 

This packet of materials is designed to give a brief summary of the background work 

described above and to stimulate thought on these measures prior to the panel meeting. 

The rich discussion during the meeting will be the primary source of feedback. Feel free 

to jot down comments while you are reviewing this document for your own use during 

the panel meeting. Thank you for your participation. 
Diabetes Mellitus 

The Clinical Logic for diabetes mellitus is outlined here in greatest detail to establish the 

methodology. Here, examples of recommendations that fit the clinical logic are 

presented even where they are not under consideration for measurement. Only existing 

measures, either in the current ACE-PRO set or those currently in use elsewhere will be 

considered in this refinement. In subsequent chapters, identification of non-candidate 

measures will be minimized. The 2004 ADA guidelines served as the primary source 

for these processes of care recommendations. 

Clinical Logic 

Prevention 

Prevention of Diabetes Mellitus can be achieved through early identification of 

pre-diabetes and either intensive lifestyle modification or medication therapy. A fasting 

blood sugar is used for early identification of diabetes. 

Early detection of complications and co-morbidities 

• Retinopathy 

• Nephropathy 

• Neuropathy 

• Dyslipidemia 

• Hypertension 

• Coronary Artery Disease 

Work-up at initial diagnosis 

• Diagnosis 

• H & P 

• Laboratory Evaluation 

o A1C 

o Fasting Lipid Profile 

o Microalbuminuria 

o Creatinine 

o UA 

o ECG 

• Referrals 

o Eye Exam 

o Nutrition 

o Foot Specialist 

o Behavior Specialist 

o Diabetes Educator 

o Endocrinologist 

o Nephrologist 

o Cardiologist 
Therapeutic interventions 

• Glycemic control 

• Laser Photocoagulation 

• ACEI or ARB 

• Lipid Lowering 

• BP Control 

• Antiplatelet 

 

Follow-up, monitoring, continuing care 

• A1C testing 

• Lipid profile 

• Nephropathy 

• Eye exam 

• Visits 

Serious manifestations of disease 

 Hospitalizations 

 Short term complications 

 Uncontrolled DM 

 DKA, HONK, Coma 

 Long term complications 

• Renal, Eye, Neuro, Vasc 

• LEA 

 

Existing Measures

• Eye exam 

• A1C testing 

• Lipid testing 

• Nephropathy 

• BP 

• Foot exam 

• Visit 

• Visit after hospitalization 

• Diabetic coma 

• Short-term complications 

• Uncontrolled diabetes 

• Long-term complications 

• Lower extremity amputation 
Processes of care not candidates for measurement but supported by evidence or 

expert opinion 

Therapeutic Interventions

• Glycemic lowering therapy (Evidence A) 

– Medical Nutrition Therapy 

– Phamacotherapy 

• Multiple classes 

• Dyslipidemia 

– Lifestyle modification (Evidence A) 

– Pharmacotherapy if not enough (Evidence A) 

• LDL goal < 100 (Evidence B) 

– Statin therapy preferred (Evidence A) 

– Fibrates in patients with CVD and near-normal LDL (Evidence A) 

• Anti-platelet Therapy 

– Aspirin in comorbid CVD (Evidence A) 

– Aspirin in high-risk for CVD (Evidence A) 

• Smoking Cessation 

– Advise all patient not to smoke (Evidence A) 

• Hypertension 

– BP goal < 130/80 (Evidence B) 

– ACEI, ARB, thiazides 

• CAD 

– Cardiologist referral (Evidence E) 
Measure: Eye Exam 

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: ADA Guideline (2004) 

Dilated and comprehensive eye exam by ophthalmologist or optometrist annually 

Less often with advice from eye doctor in patients with normal exam 

well-conducted cohort studies 

Laser photocoagulation reduces risk of visual loss 

well-conducted RCTs 

Measure Versions: ACE-PRO, NCQA, VA, CMS, Consortium, Alliance 

ACE-PRO

• Eye exam every year 

NCQA

• Eye exam every year 

• Or every 2 years with A1c < 8 and not using insulin 

• Age 18 to75 

• # diagnosis codes: 2 outpatient or 1 inpatient 

VA

• Eye exam every year 

• Or every 2 years with 2/3: A1c<8, not using insulin, and normal eye exam within 

2 years 

• Age unspecified 

• # diagnosis codes: one 

CMS

• Eye exam every year 

• Or every 2 years with 2/3: A1c<8, not using insulin, and normal eye exam within 

2 years 

• Age 18 to 75 

• # diagnosis codes: 2 outpatient or 1 inpatient 

Consortium

• Eye exam at initial assessment and annually 

• Age 18 to 75 

Alliance

• Eye exam every year 

• Or every 2 years with 3/3: A1c<8, not using insulin, and normal eye exam within 

2 years 
Recommendations/Considerations for ACE-PRO Refinement 

• Keep ACE-PRO measure 

• Consider modifying age range to 65-75 for consistency with other measures 

• Consider using case ID algorithm of others for consistency 

o # diagnosis codes: 2 outpatient or 1 inpatient in 1 year 

• Eye exam every year 

o No access to data on glycemic control, insulin use, or results of previous 

eye exams 

o Could justify every 2 years since majority of cases are likely to be low risk 

– normal eye exam, not using insulin, A1c <8 

The case ID algorithm for diabetes mellitus will come up repeatedly throughout this 

chapter. We recommend a single approach to case ID across all diabetes measures. 

The use of 2 codes within a year increases positive predictive value, eliminating false 

positives likely associated with testing for diabetes mellitus. The case ID algorithm 

adopted by the other organizations is based upon a formal test of criterion validity. 

This issue will come up in many of the other chapters as well.
Measure: A1C Testing 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: American Diabetes Association guideline (2004)

• HgbA1c testing: Recommendation of A1C testing at least twice yearly for patients 

at goal, and at least four times per year for patients not at goal 

expert consensus or clinical experience

• Glycemic lowering therapy: Control of blood glucose (measured as A1C) is 

associated with reduction in incidence of diabetes-related complications 

well-conducted RCTs 

Measure Versions: 

ACE-PRO

• A1C or fructosamine every 6 months 

 

NCQA

• At least one A1C performed per year 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus (or) 

• Identification of diabetes mellitus status by use of pharmacy claims for glycemic 

lowering drugs 

• Exclude where: 

o Diagnosis of polycystic ovaries and < 2 face to face encounters with 

diagnosis of diabetes mellitus 

o Diagnosis of steroid-induced diabetes 

o Diagnosis of gestational diabetes 

 VA

• A1C test result > 11, or test not performed 

• Age unspecified 

• One outpatient code from specified clinic visit during measurement year 

 

CMS (DQIP)

• At least one A1C test performed during measurement year 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus 

 

Consortium

• At least one A1C test performed during initial assessment and during follow-up 

• Age 18 to 75 

 

Alliance

• At least one A1C test performed during measurement year 
Recommendations/Considerations: 

• Modify ACE-PRO measure to A1C test at least once per year to be consistent 

with other measures 

• Could justify 2 per year based upon guidelines and for more consistency with 

original ACE-PRO version 

• Consider using case ID algorithm of others for consistency 

 # diagnosis codes: 2 outpatient or 1 inpatient in 1 year 

 Restrict age group eligible for measure to those with diabetes 

mellitus age 65-75 years for consistency with others 

• Ignore polycystic ovaries, steroid-induced, gestational status (HEDIS exclusions) 
Measure: Lipid Testing 

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Evidence / Rationale: American Diabetes Association guideline (2004)

• Lipid monitoring: Test for lipid disorders at least annually and more often if 

needed to achieve goals. In adults with low-risk values repeat lipid assessments 

every two years 

expert consensus or clinical experience 

• Lipid lowering therapy: Lowering LDL-C cholesterol with diet or medication is 

associated with a reduction in cardiovascular events 

well-conducted RCTs 

Versions: 

 NCQA

• Lipid profile every 2 years 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus (or) 

• Identification of diabetes mellitus status by use of pharmacy claims for glycemic 

lowering drugs 

• Exclude where: 

o Diagnosis of polycystic ovaries and < 2 face to face encounters with 

diagnosis of diabetes mellitus 

o Diagnosis of steroid-induced diabetes 

o Diagnosis of gestational diabetes 

 CMS

• Lipid profile every 2 years 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus 

 Consortium

• Lipid profile, time not specified 

• Age 18 to 75 

 Alliance

• LDL-C, time not specified 

 Recommendations/Considerations 

• Include in ACE-PRO measure set as Lipid profile every 2 years 

• Consider using case ID algorithm of others for consistency 

# diagnosis codes: 2 outpatient or 1 inpatient in 1 year 

Include age 65 to 75 only (for consistency) 

• Ignore polycystic ovaries, steroid-induced, gestational status as exclusions 

• Could justify eliminating age ceiling, given demonstrated benefit of lipid lowering 

in older populations 
Measure: Nephropathy 

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: American Diabetes Association guideline (2004)

• Monitoring of Kidney Disease / Function: Test for microalbuminuria annually in 

patients with Type 2 diabetes mellitus. In patients with Type 1 disease, test 

annually after 6 years post-diagnosis 

expert consensus or clinical experience

• Treatment with ACEIs/ARBs: In hypertensive type 1 DM patients with any degree 

of albuminuria, ACEIs have been shown to delay the progression of nephropathy. 

In hypertensive Type 2 patients with microalbuminuria, ACEIs and ARBs have 

been shown to delay the progression to microalbuminuria and nephropathy 

(ARBs only) 

well-conducted RCTs 

• Blood Pressure Control: To reduce risk and/or slow the progression of 

nephropathy, optimize blood pressure control 

well-conducted RCTs 

Versions: NCQA, CMS, Consortium, Alliance 

 NCQA

• Screening for nephropathy, or diagnosis of nephropathy, or evidence of 

macroalbuminuria in measurement year 

• Screening in previous year acceptable if patient not receiving insulin and if A1C < 

8 

• Age 18 to 75 

• 2 outpatient or 1 inpatient code for diabetes mellitus (or) 

• Identification of diabetes mellitus status by use of pharmacy claims for glycemic 

lowering drugs 

• Exclude where: 

o Diagnosis of polycystic ovaries and < 2 face to face encounters with 

diagnosis of diabetes mellitus 

o Diagnosis of steroid-induced diabetes 

o Diagnosis of gestational diabetes 

 CMS

• Eliminated this measure from 6th SoW due to coding and clinical issues 

o Microalbuminuria testing reimbursement 

o Use of ACEI therapy 

 Consortium

• Any test for microalbuminuria 

• In urinalysis negative or urinalysis absent 

• Age 18 to 75 
 Alliance

• Screening for nephropathy, or diagnosis of nephropathy, or evidence of 

macroalbuminuria in measurement year 

• Omitted the complex 2 year option 

• Age 18 to 75 

Recommendations/Considerations 

• Consider including in ACE-PRO 

o Microalbuminuria test or diagnosis of nephropathy during 12 month period 

o Ignore insulin and A1C status as allowance for two-year timeframe 

o Age 18 to 75 

o 2 outpatient or 1 inpatient code for diabetes mellitus 

• Could justify not adopting the measure 

• Coding issues from 6th SoW 

• Clinical issues 

o Increasing prevalence of ACEI and ARB use 
Measure: Blood Pressure Control 

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Evidence: 

• Blood pressure control: ADA guideline (2004). BP control decreases morbidity 

and mortality in diabetes mellitus. 

well-conducted RCTs 

Versions: 

 Consortium

• Check blood pressure at initial visit and all follow-up assessments 

 Alliance

• Percent of patients with most recent BP < 140/90 

 DQIP

• Percent of patients with most recent BP < 140/90 

Recommendations/Considerations: 

• Despite strength of evidence and use of measure, do not adopt due to lack of 

relevant data from claims 

• Consider use of visit (an existing ACE-PRO measure) as proxy for BP check 

------------------------------------------------------------------------------------------------------------ 

Measure: Foot Exam 

Clinical Logic: Early Detection and Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ADA Guideline 2004 

Visual inspection of feet at each visit 

expert consensus or clinical experience 

Comprehensive foot exam annually 

expert consensus or clinical experience 

Versions: 

VA

• Sensory foot exam annually 

Consortium

• Comprehensive foot exam during follow-up assessments 

Alliance and CMS

• Comprehensive foot exam annually 

Recommendations/Considerations: 

Despite use of measure by others do not adopt due to lack of relevant data from claims. 
Measure: Visit every 6 months 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

AACE Guideline 2002 

ADA Guideline (old) cited by Original ACE-PRO Panel 

expert opinion 

ACE-PRO Measure

Visit every 6 months 

Recommendations/Considerations 

Modify measure to 2 visits per year 

• Despite lack of strong current guideline support, complexity of management 

including BP control, assessment of treatment progress and self-management 

training requires frequent office visits 

• Standardize denominator on 1 year 

------------------------------------------------------------------------------------------------------------ 

Measure: Visit after hospitalization 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

Original ACE-PRO Panel

expert opinion 

ACE-PRO Measure

Visit <= 4 weeks after discharge from hospital for patients hospitalized for diabetes 

mellitus 

Performance score: 43% in Asch et al 2000 

Recommendations/Considerations 

• Modify the measure to exclude patients discharged to other facilities, and 

patients who died 

• Consider for inclusion in continuity of care composite 
Measure: Serious Short Term Complications of Diabetes Mellitus 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

Original ACE-PRO Panel 

Effective outpatient management of diabetes mellitus, infections and other stressors, 

may prevent hospitalizations for hyperosmolar and ketotic states 

AHRQ PQI 

High quality outpatient management of patients with diabetes has been shown to 

reduce almost all types of serious hospitalizations 

Versions: 

ACE-PRO

• Admission for diabetic coma, hyperosmolar or ketotic coma 

 among patients with diabetes mellitus 

AHRQ PQI

• Diabetes Short Term Complications Admission Rate 

Discharges for Ketoacidosis, Hyperosmolarity, Coma 

Per 100,000 in the population 

 

Recommendations/Considerations: 

• Use numerator of PQI version and denominator of ACE-PRO version to restrict to 

population with diabetes

• Use in composite measure with Uncontrolled DM (below)
Measure: Uncontrolled Diabetes Mellitus

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: AHRQ PQI 

High quality outpatient management of diabetic patients has been shown to lead 

to reductions in almost all types of serious hospitalizations. 

Version: 

AHRQ PQI

Uncontrolled Diabetes Admission Rate 

Discharges 

Uncontrolled DM without mention of ST or LT complications 

Per 100,000 in population 

Recommendations/Considerations 

• Use numerator of PQI and denominator of ACE-PRO (above) 

o Restrict to population with diabetes 

• Consider combining numerators with short term serious complications (above) 

o Both outcomes due to same processes of care 

o Would provide for more statistically useful numerator 
Measure: Serious Long Term Complications of Diabetes Mellitus 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

AHRQ PQI 

long term complications of diabetes mellitus arise from sustained, long-term, poor 

control of diabetes mellitus 

intensive treatment programs have been shown to decrease the incidence of 

long term complications in both type 1 and type 2 (UKPDS, DCCT) 

AHRQ PQI

Long term glycemic control, foot care, and diabetes education are interventions that can 

reduce the incidence of infection, neuropathy, and microvascular diseases 

Versions: 

AHRQ PQI

• Diabetes Long Term Complications Admission Rate 

Discharges for 

Renal, Eye, Neurological, Circulatory, & 

Complications not otherwise specified 

Per 100,000 in population 

• Rate of LEA in Diabetes 

Discharges for LEA and Diagnosis of DM 

Per 100,000 in population 

Recommendations/Considerations 

• Use numerators of PQIs and denominator of ACE-PRO version (above) 

o Restrict to population with diabetes 

• Combine numerators long term complications and LEAs 

o Both outcomes due to same processes of care 

o Would provide for more statistically useful numerator 

• Combine numerators with long term complications 

o Both outcomes due to same processes of care 

o Would provide for more statistically useful numerator 
Coronary Artery Disease 

Prevention 

• Cholesterol Screening 

Early Detection 

• Screening for diabetes mellitus in CAD 

• Lipid Testing 

• LDL-C after acute cardiovascular event (MI, CABG, PCI) 

Work-up at Initial Diagnosis 

• EKG in ER for Unstable Angina 

Therapeutic Interventions 

• Smoking Cessation Counseling 

• Anti-platelet therapy 

• Beta blocker therapy 

• Statin therapy 

• ACEI therapy 

Follow-up, Monitoring, Continuing Care 

• Follow-up visit or hospitalization within 1 week of initial diagnosis of Unstable 

Angina 

• Cholesterol Test every 6 months post discharge for AMI with comorbid 

dyslipidemia 

• Visit within 4 weeks of hospitalization for MI 

• Follow-up visit or hospitalization within 1 week of initial diagnosis of Unstable 

Angina 

• Visit every 6 months in Stable Angina 

• Symptom-activity assessment 

• BP measurement 

Serious Clinical Manifestations of Disease 

• 3 or more ER visits in one year for heart related diagnoses 

• Angina Admission Rate 

------------------------------------------------------------------------------------------------------------ 

Eliminate for Data Access Limitations 

• Smoking Cessation Counseling 

• Anti-platelet therapy 

• Beta blocker therapy 

• Statin therapy 

• ACEI therapy 

• Symptom-activity assessment (visit) 

• BP measurement (visit) 

Cholesterol screening considered and eliminated by original ACE-PRO panel for 

recommended 5-year interval. This creates difficulty in composing and interpreting an 

annual indicator. Current recommendations do not specify a more useful interval for 

such measurement purposes. 
Measure: Screening for diabetes mellitus in CAD 

Clinical Logic: Early detection (of diabetes mellitus) 

Evidence/Rationale: 

ADA guideline 2003 

American College of Endocrinology Consensus Statement 

Screening for diabetes is recommended in patients who are considered high risk (e.g. 

coronary artery disease) 

Diabetes is associated with poor outcomes in patients with established coronary 

disease (ACC/AHA/ACP-ASIM Guidelines for ... Chronic Stable Angina) 

Measure Version: Physician Consortium for Performance Measurement 

Screen for diabetes mellitus (FBS or 2 hr GTT) every 3 years 

in patients with coronary artery disease 

Recommendations/Considerations: 

• Consider adding to ACE-PRO measure set 

o Data are available, codes for FBS and GTT 

o Three year time frame inconsistent with denominator standardization and 

for use in trend analyses 

o Clinical recommended indicates screening should be considered at three 

year intervals 

o Use 2 year as in lipid profile and expect lower proportion 
Measure: Lipid Testing 

Clinical Logic: Early detection and Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACC/AHA/ACP-ASIM Guidelines for ... Chronic Stable Angina 

o Measurement of LDL cholesterol is warranted in all patients with coronary 

disease 

expert opinion 

o Lipid lowering therapy prevents death in coronary artery disease 

well-conducted RCTs 

NCEP ATP III 

o LDL is the primary target of lipid lowering therapy 

Management may require attention to other lipid components 

Measure Versions: ACE-PRO, Consortium, NCQA 

ACE-PRO

Cholesterol Test every 6 months post discharge for AMI with comorbid dyslipidemia 

Age > 65 

Consortium

Annual lipid profile in patients with CAD 

Age not specified 

Exclusions none 

NCQA

LDL-C 60 days to 1 year after acute coronary event (Acute MI, CABG, PTCA) 

Age 18 to 75 

Exclusions none 

Recommendations/Considerations: 

Modify ACE-PRO version 

o Use broader denominator from Consortium 

o Use lipid profile from Consortium 

o Consider using 2 outpatient or 1 inpatient code 

o No upper age limit 
Measure: Follow-Up After Initial Diagnosis Of Unstable Angina 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Patients with unstable angina not hospitalized require aggressive outpatient treatment. 

expert opinion 

Recommendations/Considerations: 

Exclude measure. 

• It’s hard to imagine patients with UA not being sent to the hospital these days. A 

one week delay would be cause for concern. In the Asch paper the performance 

level was 89%. 

• Establishing incident cases (initial diagnosis) of UA will be quite difficult to 

interpret. 

------------------------------------------------------------------------------------------------------------ 

Measure: Visit after hospitalization for MI 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

“Although not specifically recommended by the ACC/AHA, it seems reasonable that all 

patients discharged with acute MI should have an office visit within four weeks of 

leaving the hospital.” 

expert opinion 

Measure Version: ACE-PRO 

Visit within 4 weeks of discharge in patients hospitalized for acute MI 

Recommendations/Considerations: 

o Keep measure. 

o Probably sensitive to discharge planning. 

o Would be useful in a continuity of care composite. 

 
Measure: Clinical Assessment in CAD 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Management of CAD requires risk factor modification, symptom and activity 

assessment. 

expert opinion 

Measure Versions: 

ACE-PRO

Visit every 6 months in Stable Angina 

Consortium

Regular symptom & activity assessment in CAD 

BP measurement 

Recommendations/Considerations: 

o Modify measure to 2 visits in one year to standardize denominator. 

o Symptom and activity assessment cannot be directly measured but can be 

inferred to have occurred as part of “subjective” assessment. 

o BP measurement cannot be directly ascertained but can be inferred to have 

occurred as part of “objective” assessment. 
Measure: Hospital Use in Unstable Angina 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

ACE-PRO Original Panel 

After one ER visit patients should have access to treatment that would prevent 

subsequent ER visits. Hospitalization is often necessary and should not be considered 

avoidable. 

expert opinion 

AHRQ PQI 

(ACC/AHA/ACP-ASIM Guideline ... Chronic Stable Angina) 

Effective treatments for CAD reduce admissions for serious complications of ischemic 

heart disease including unstable angina 

Measure Versions 

ACE-PRO

3 or more ER visits in one year for heart related diagnoses in unstable angina 

Exclude ER visits resulting in hospitalizations 

AHRQ PQI

Admissions for Angina 

Per 100,000 in the population 

Exclude admissions with procedures 

Age >= 18 

Recommendations/Considerations: 

Keep ACE-PRO Version 

Add AHRQ PQI measure with modification 

• Admissions for angina (without procedures) 

o Use CAD denominator 

------------------------------------------------------------------------------------------------------------ 

Measure: EKG in ER for Unstable Angina 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

ACE-PRO Original Panel 

EKG to rule out MI is considered necessary care. 

expert opinion 

Measure Versions 

ACE-PRO

EKG during emergency department visit for unstable angina 

Recommendations/Considerations: 

Eliminate the measure. Sensitive to hospital-based care, not ambulatory care. 

Performance in Asch paper was > 97%. 
Stroke, TIA, Atrial Fibrillation, Hypertension 

Prevention 

• 

Early Detection 

• 

Work-up at Initial Diagnosis 

• EKG within 2 days of initial diagnosis of TIA 

• Carotid imaging within 2 weeks of initial diagnosis in patients hospitalized for 

carotid artery stroke 

Therapeutic Interventions 

• Antiplatelet therapy 

• BP lowering therapy 

• Anticoagulation in atrial fibrillation 

Follow-up, Monitoring, Continuing Care 

• Carotid imaging to carotid endarterectomy interval less than 2 months 

o TIA 

o Stroke 

• Visit within 4 weeks of hospitalization for 

o Stroke 

o TIA 

• Visit every year for patients with TIA 

• Visit within 4 weeks of hospitalization for malignant or otherwise severe 

hypertension 

Serious Clinical Manifestations of Disease 

• Hypertension Admission 

------------------------------------------------------------------------------------------------------------ 

Eliminate for Data Access Limitations 

• Antiplatelet therapy 

• BP lowering therapy 

• Anticoagulation therapy 
Measure: EKG within 2 days of initial diagnosis of TIA 

Clinical Logic: Work-up at initial diagnosis 

Evidence/Rationale: 

Original ACE-PRO panel 

AHA Stroke Guideline 2003 

EKG on the list of recommended tests for TIA: ESR, EKG, CXR, echo, Holter, CT/MRI, 

CBC, electrolytes, renal function, blood glucose, and lipids 

expert opinion 

Measure Version: ACE-PRO 

Recommendations/Considerations: 

Keep measure. Consider other tests on list. 

Difficulty identifying initial diagnosis could justify elimination of measure. 

------------------------------------------------------------------------------------------------------------ 

Measure: Carotid imaging at initial diagnosis of carotid artery stroke 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

Original ACE-PRO Panel 

Strong evidence supporting efficacy of CEA, weaker evidence demonstrating harm in 

delay > 30 days, carotid imaging is necessary to establish candidacy for CEA. 

expert opinion 

Measure Versions: ACE-PRO 

Carotid imaging within 2 weeks of initial diagnosis in patients hospitalized for carotid 

artery stroke 

Recommendations/Considerations: 

Consider keeping measure. 

• Seems sensitive to post-discharge follow-up. 

• However, may have difficulty establishing initial diagnosis 
Measure: Carotid imaging in carotid territory event 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

Original ACE-PRO Panel 

Strong evidence supporting efficacy of CEA, weaker evidence demonstrating harm in 

delay > 30 days, ? evidence for optimal interval between imaging and surgery 

non-randomized trial 

Measure Versions: ACE-PRO 

Interval between carotid imaging and CEA less than 2 months in patients with TIA and 

eventual CEA 

Interval between carotid imaging and CEA less than 2 months in patients with stroke 

and eventual CEA 

Recommendations/Considerations: 

• Currently 2 measures in ACE-PRO, one with TIA denominator, one with stroke 

• Consider keeping measures and combining denominators to create 1 measure 

• Consider dropping measure 

o Rationale for interval not clear 
Measure: Anticoagulation therapy in atrial fibrillation 

Clinical Logic: Therapeutic intervention 

Evidence/Rationale: 

multiple RCTs 

Measure Versions 

Consortium

Warfarin therapy in heart failure with comorbid atrial fibrillation 

SCRIPT

Warfarin therapy in atrial fibrillation 

Recommendations/Considerations: 

• Consider INR monitoring as proxy for anticoagulation therapy 

o Drug use data not available 

o High proportion of INR monitoring in anticoagulation therapy 

 ~ 90% in SCRIPT Project 

o Contraindications to anticoagulation can be identified from codes 

• However, this would be a measure development exercise 
Measures: 

Visit after hospitalization for stroke 

Visit after hospitalization for TIA 

Visit after hospitalization for hypertension 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Recommended by panel as minimum standard 

expert opinion 

Measure Versions: ACE-PRO 

Visit within 4 weeks of hospitalization for stroke 

Visit within 4 weeks of hospitalization for TIA 

Visit within 4 weeks of hospitalization for malignant or otherwise severe hypertension 

Recommendations/Considerations: 

• Keep measures 

• Consider combining the denominators for stroke and TIA into one measure. 

• Consider dropping hypertension measure due to infrequency of such 

hospitalizations 

• Consider as part of composite measure of continuity of care. 

----------------------------------------------------------------------------------------------------------- 

Measure: Clinical Assessment in TIA 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Minimum standard 

expert opinion 

Measure Versions: 

ACE-PRO

Visit every year in TIA 

Recommendations/Considerations: 

• Keep measure 

• Consider modifications 

o 2 visits per year 

o Case ID algorithm that requires 2 codes in one year 
Measure: Admissions for Hypertension

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

AHRQ PQI

Hypertension is controllable in the out-patient setting 

Measure Version: 

Admissions for hypertension per 100,000 in the population 

Recommendations/Considerations: 

• Consider not adding the measure to ACE-PRO 

o Infrequency of admissions for hypertension 

• Consider changing to denominator of patients with hypertension 

• Would be useful in composite measure of continuity of care
Heart Failure 

Prevention 

• 

Early Detection 

• 

Work-up at Initial Diagnosis 

• LVEF assessment 

• Lab testing 

• EKG 

• CXR 

• Weight measurement 

• BP measurement 

• Symptoms-activity assessment 

• Examination of the heart 

Therapeutic Interventions 

• Beta blocker therapy 

• ACEI therapy 

• Patient education 

• Warfarin in comorbid atrial fibrillation 

Follow-up, Monitoring, Continuing Care 

• Visit within 4 weeks of hospitalization for heart failure 

• Visit every 6 months in Heart Failure 

• Weight measurement 

• BP measurement 

• Symptoms-activity assessment 

• Examination of the heart 

Serious Clinical Manifestations of Disease 

• Admission for Heart Failure 

• Admission Rate for Heart Failure 

------------------------------------------------------------------------------------------------------------ 

Eliminate for Data Access Limitations 

• Beta blocker therapy 

• ACEI therapy 

• Warfarin therapy 

• Patient education 

• Symptom-activity assessment (visit) 

• BP measurement (visit) 

• Weight measurement (visit) 

• Examination of the heart (visit) 
Measure: LVEF Assessment 

Clinical Logic: Work-up at initial diagnosis 

Evidence/Rationale: 

ACC/AHA Chronic Heart Failure Guideline 2001

Echo with Doppler or RVG to assess Left Ventricular Systolic Function 

expert opinion 

Measure Versions: Consortium, CMS 

Consortium

Quantitative or qualitative results of LVF assessment recorded in patients with heart 

failure, age >= 18 

CMS

LVEF assessment before arrival, during hospitalization, or planned for after discharge in 

patients admitted for heart failure, age >= 18 

Recommendations/Considerations: 

Consider adding measure(s) to ACE-PRO set: 

• Diagnostic ultrasound, RVG, or Left Ventriculogram in incident cases of heart 

failure 

o Look back to establish incident case 

 1 year 

o Look forward (and back) to detect LVEF assessment 

 3 months 

• Diagnostic ultrasound, RVG, or Left Ventriculogram in patients hospitalized for 

heart failure 

o Look back, look during, look after the hospitalization 

 3 months before and after 

• Consider case ID algorithm that requires 2 outpatient or 1 inpatient code 
Measure: Laboratory Testing 

Clinical Logic: Work-up at Initial Diagnosis and Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACC/AHA Chronic Heart Failure Guideline 2001

Initial measurement of CBC, UA, electrolytes, renal function, blood glucose, LFTs, TFTs 

expert opinion 

ACC/AHA Chronic Heart Failure Guideline 2001 

Serial measurement of electrolytes and renal function 

expert opinion 

Measure Versions: Consortium, SCRIPT 

Consortium

Patients for whom initial lab testing was performed in patients with heart failure, age >= 

18 

SCRIPT

Potassium and renal function testing annually in patients with heart failure on ACEI 

inhibitor therapy or digoxin 

Recommendations/Considerations: 

Consider adding measure(s) to ACE-PRO set 

• Annual measurement of electrolytes and renal function in patients with heart 

failure 

o High likelihood of treatment with ACEI, ARB, Digoxin or loop diuretic 

o High level of performance in SCRIPT 

o Suspect high numbers of non-discriminate testing 

• CBC, UA, electrolytes, renal function, blood glucose, LFTs, TFTs after initial 

diagnosis of heart failure 

o Same level recommendation and evidence as CXR and EKG (below) 
Measure: EKG after Initial Diagnosis of Heart Failure 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

ACE-PRO Original Panel 

AHCPR Heart Failure Guideline 1994 

ACC/AHA Chronic Heart Failure Guideline 2001 

expert opinion 

Recommendations/Considerations: 

Keep the measure in the ACE-PRO set 

• Despite difficulty with establishing initial diagnosis 

o Look-back

• Consider combing with CXR (below)

------------------------------------------------------------------------------------------------------------ 

Measure: CXR after Initial Diagnosis of Heart Failure 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

ACE-PRO Original Panel 

AHCPR Heart Failure Guideline 1994 

ACC/AHA Chronic Heart Failure Guideline 2001 

expert opinion 

Recommendations/Considerations: 

Keep the measure in the ACE-PRO set 

• Despite difficulty with establishing initial diagnosis

o Look-back 

• Consider combining with EKG (above) 
Measure: Visit after hospitalization for heart failure 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Made argument for followup in 1 week 

expert opinion 

Measure Version: ACE-PRO 

Visit within 4 weeks of discharge in patients hospitalized for heart failure 

Recommendations/Considerations: 

Keep measure in ACE-PRO set. 

• Probably sensitive to discharge planning. 

• Would be useful in a continuity of care composite. 

 

----------------------------------------------------------------------------------------------------------- 

Measure: Clinical Assessment in Heart Failure 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Most practitioners schedule follow-up visits for CHF patients at 2-4 month intervals. 

Panel recommends every 6 months as indicator of minimal care. 

expert opinion 

Measure Versions: 

ACE-PRO

Visit every 6 months in Heart Failure 

Consortium

Symptom-activity assessment 

BP measurement 

Weight measurement 

Examination of the heart 

Recommendations/Considerations: 

Modify measure for inclusion in ACE-PRO set 

• 2 visits in one year to standardize denominator 

• Symptom and activity assessment, BP measurement, weight measurement, and 

examination of the heart cannot be directly measured but can be inferred to have 

occurred as part of “subjective” and “objective” assessments
Measure: Hospital admissions for heart failure 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

ACE-PRO Original Panel and AHRQ PQI 

Timely out-patient therapy can eliminate the need for some hospitalizations for heart 

failure. 

expert opinion 

Measure Versions 

ACE-PRO

Non-elective admissions for heart failure 

AHRQ PQI

Admissions for Heart Failure 

Per 100,000 in the population 

Recommendations/Considerations: 

Keep the measure for the ACE-PRO set with heart failure patients in denominator 
Cancer 

Prevention 

• 

Early Detection 

• Breast Cancer Screening 

• Cervical Cancer Screening 

• Colon Cancer Screening 

• GI Work-up in Iron Deficiency Anemia (in Anemia Chapter) 

• Prostate Cancer Screening 

• Lung Cancer Screening 

• Stage at Diagnosis 

o Breast Cancer 

o Cervical Cancer 

o Colorectal Cancer 

Work-up at Initial Diagnosis (Staging) 

• Staging in Breast Cancer 

• Staging Colon Cancer 

Therapeutic Intervention 

• Chemo 

• Radiation 

• Surgery 

Follow-up, Monitoring, Continuing Care 

• Surveillance 

• Imaging 

• Visits 

Serious Clinical Manifestations of Disease 

• Death rates 

--------------------------------------------------------------------------------------------------------- 

Prostate Cancer Screening

No current measures and the U.S. Preventive Services Task Force (USPSTF) 

concludes that the evidence is insufficient to recommend for or against routine 

screening for prostate cancer using prostate specific antigen (PSA) testing or digital 

rectal examination (DRE). 

 

Lung Cancer Screening

No current measures and the USPSTF statement that routine screening for lung cancer 

with chest radiography or sputum cytology in asymptomatic persons is not 

recommended. 

No existing measures for therapeutic interventions. Interventions are highly stagespecific and stage information will not be available from claims. No such measures will 

be presented.
Measure: Breast Cancer Screening 

Clinical Logic: Early Detection 

Evidence/Rationale: 

USPSTF 2002

Screening mammography with or without clinical breast exam every one to two years for 

women age 40 and older. 

at least fair evidence that [the service] improves important health outcomes and 

concludes that benefits outweigh harms. 

AMA, ACOG, ACR, ACS, NCI

all support mammography with CBE starting at age 40 

CTFPHC, AAFP, ACPM recommend mammography starting at age 50 for average risk, 

40 for high risk 

Annual screening recommended by AMA, ACR, ACS 

Every one to two years recommended by AAFP, ACPM, CTFPHC, NCI 

Every year age 50 and older recommended by ACOG 

Measure Version: 

ACE-PRO

Mammography every 2 years in female patients 

Age < 75 (in sub-analysis) 

CMS, VA

Mammography every 2 years in female patients 

Ages 52-69 

NCQA, Consortium

Mammography every 2 years in female patients 

Ages 50-69 

NHQR (Healthy People 2010)

Mammography every 2 years in female patients 

Age >= 40 

Recommendations/Considerations: 

Keep the measure in the ACE-PRO set. 

Consider modifying the denominator to use common age range up to age 69 
Measure: Colorectal Cancer Screening 

Clinical Logic: Early Detection 

Evidence/Rationale: 

USPSTF Guideline 2002 

Strongly recommends screening men and women age 50 and older 

good evidence that [the service] improves important health outcomes and concludes 

that benefits substantially outweigh harms. 

NCI

FOBT 

well-conducted RCT 

Sigmoidoscopy 

well-conducted cohort or case-control studies, multiple-time series studies, expert 

opinion 

Measure Versions: 

NHQR (Healthy People 2010)

• Proportion of men and women ages 50 and older who reported ever having a 

flexible sigmoidoscopy or colonoscopy 

• Proportion of men and women ages 50 and older who reported having a FOBT 

within the past 2 years 

Consortium

• Percentage of patients aged 50 or older screened for colorectal cancer (FOBT 

annually, sigmoidoscopy every 5 years, double contrast barium enema every 5 

years, colonoscopy every 10 years 

NCQA

• One or more screenings for colorectal cancer 

o FOBT in one year or 

o Sigmoidoscopy in 5 years or 

o DCBE in 5 years or 

o Colonoscopy in 10 years 

o Ages 52-80 

o Exclusions: Colorectal cancer 

VA

• Percent of patients receiving timely colorectal cancer screening 

o FOBT 3 samples in 12 months 

o Sigmoidoscopy in 5 years 

o Colonoscopy in 10 years 

o Exclusions: malignancy, short life-expectancy 

Recommendations/Considerations: 

A measure worth developing. Data access and enrollment limitations may preclude 5 

year and 10 year look backs. Consider waiting for NCQA experience. 
Measure: Cervical Cancer Screening 

Clinical Logic: Early Detection 

Evidence/Rationale: 

USPSTF 2003

• recommends against routinely screening women older than age 65 for cervical 

cancer if they have had adequate recent screening with normal Pap smears and 

are not otherwise at high risk for cervical cancer. 

• recommends against routine Pap smear screening in women who have had a 

total hysterectomy for benign disease. 

Measure Versions: 

NCQA

PAP test within 3 years for women ages 18-65 

NHQR (Healthy People 2010) 

PAP test within 3 years on survey, age > 18 

Recommendations/Considerations: 

Do not use this measure. 

• It could be composed using 3 year look backs to identify women who shouldn’t 

have PAP smear. 

• Probably too complex to justify. 
Measure: Staging in Breast Cancer 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

Original ACE-PRO Panel 

Surgery delay time and timeliness of staging 

non-randomized trial 

Measure Versions: 

ACE-PRO

Interval from biopsy to definitive therapy < 3 months 

Recommendations/Considerations: 

Keep the measure. 

------------------------------------------------------------------------------------------------------------ 

Measures: 

CXR at Initial Diagnosis 

Mammography at Initial Diagnosis 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

ACE-PRO Original Panel 

Part of Staging Evaluation 

expert opinion 

Measure Version: 

ACE-PRO 

Recommendations/Considerations: 

Keep measures in the ACE-PRO set. 

• Although recommendations may be dependent upon stage and stage will not be 

accessible in claims database, these measures seem to be sensitive to 

thoroughness in staging work-up. 
Measures: 

Visit after Mastectomy with Cytotoxic Chemotherapy 

 without Cytotoxic Chemotherapy 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO Original Panel 

Follow-up schedules in controlled trial (GIVIO) 

expert opinion 

Measure Versions: 

ACE-PRO

Visit every year after Mastectomy without Chemo 

Visit every six months after Mastectomy with Chemo 

Recommendations/Considerations: 

Keep measures in ACE-PRO set. 

• Consider combining measures into one. 

o Very high rates in Asch paper, 99-100% and in Hogan paper 92-100%. 

o Denominator size potentially too small for subgroup analyses. 

------------------------------------------------------------------------------------------------------------ 

Measure: Mammography surveillance with history of breast cancer

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

Original ACE-PRO panel 

Standard of control arm of GIVIO 

non-randomized trial 

Measure Version: 

Annual mammogram after diagnosis of breast cancer 

Recommendations/Considerations: 

Keep the measure in the ACE-PRO set. 
Measure: Colonoscopic surveillance with a history of colon caner 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACS Guideline, Screening and Surveillance, Colon CA (2001) 

Colonoscopy 1 year after resection 

Colonoscopy 3-6 years after polypectomy 

Measure Version: None 

Recommendation: 

Consider testing a measure looking at colonoscopy 1 year after resection 

------------------------------------------------------------------------------------------------------------ 

Measure: Staging in colorectal cancer

Clinical Logic: Work-up at Initial Diagnosis

Evidence/Rationale: 

ACR Appropriateness Criteria For Pretreatment Staging Of Colorectal Cancer (1999) 

TRUS, CT or MRI in initial staging of colorectal cancer 

Measure Version: None 

Recommendation: Consider testing a measure looking at TRUS, CT or MRI in initial 

staging of colorectal cancer
Measure: Stage at diagnosis of breast cancer, cervical cancer, colorectal cancer

Clinical Logic: Early detection (failure of) 

Evidence/Rationale: 

Late stage diagnosis should be inversely associated with effectiveness of early 

detection. 

Measure Version: 

NHQR 

Rate of cancers (breast, cervical, colorectal) diagnosed at late stage 

Uses SEER 

Recommendations/Considerations: 

Data not accessible from claims. Cite SEER statistics rather than attempting 

measurement. Could use to validate screening measures. Improvements in screening 

should lead to decreases in late stage diagnosis. 

------------------------------------------------------------------------------------------------------------ 

Measures: 

Death rate for all cancers 

Death rate for individual cancers 

Prostate 

Breast 

Lung 

Colorectal 

Clinical Logic: Serious Clinical Manifestations of Disease 

Measure Version: 

NHQR (Healthy People 2010) 

Recommendations/Considerations: 

Data not accessible from claims. Questionable sensitivity to ambulatory care process. 

Cite NHQR in providing overall picture of cancer care. 
COPD/Asthma 

Prevention 

• Smoking Cessation Advice 

Early Detection 

• 

Work-up at Initial Diagnosis 

• PFTs 

• Sleep study 

• Oxygenation assessment 

Therapeutic Interventions 

• Pharmacotherapy 

• O2 therapy 

Follow-up, Monitoring, Continuing Care 

• Visits 

• Oxygenation assessment 

• Compliance 

• Symptom assessment 

• Smoking cessation advice 

Serious Clinical Manifestations of Disease 

• Hospitalizations 

------------------------------------------------------------------------------------------------------------ 

Eliminate for Data Access Limitations 

• Smoking cessation advice 

• Pharmacotherapy 

• Symptom assessment 

• Compliance assessment 

Eliminate, No Current Measure 

• PFTs 

• Sleep study 

• Oxygenation assessment 

 
Measure: Clinical Assessement in COPD 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

Original ACE-PRO Panel 

Cites guideline recommending at least quarterly visits. Sets 6 month interval as 

minimum standard. 

expert opinion 

Measure Version: 

ACE-PRO

Visit every 6 months for COPD 

Consortium

Asthma assessment 

Symptom assessment during at least one office visit in a year 

Recommendations/Considerations: 

Modify ACE-PRO measure. 

• Original ACE-PRO measure used COPD as denominator. 

o Expand to include asthma diagnoses 

o Consider 2 visits/year to keep standard denominator of one year. 

• Symptom assessment data not available without chart review. 

o Can infer as part of “subjective” assessment of visit. 
Measure: Hospitalization in COPD 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

Original ACE-PRO Panel and AHRQ PQI 

• Proper management of symptoms of COPD can reduce admissions. 

• Appropriate out-patient treatment and compliance can reduce hospitalizations for 

COPD exacerbations and decline in lung function. 

expert opinion 

Measure Versions: 

ACE-PRO 

Admission for respiratory diagnosis in patients with known COPD 

AHRQP QI 

Admissions for COPD per 100,000 in the population 

Admissions for Asthma per 100,000 in the population 

Recommendations: 

Modify measure for inclusion in measure set. 

• Consider adding asthma to denominator. 
Depression and Other Mental Illness 

Prevention 

• 

Early Detection 

• Out-patient screening 

Work-up at Initial Diagnosis 

• Diagnostic Evaluation 

• Severity Classification 

• Medication history 

• Lab 

o TSH 

Therapeutic Interventions 

• Pharmacotherapy 

• Psychotherapy 

Follow-up, Monitoring, Continuing Care 

• Out-patient follow-up after hospitalization 

• Suicide Risk Assessment 

Serious Clinical Manifestations of Disease 

• Hospitalizations 

• Suicides 

------------------------------------------------------------------------------------------------------------ 

Eliminate for Data Access Limitations 

• Out-patient screening 

• Symptom assessment in diagnostic evaluation 

• Severity classification in diagnostic evaluation 

• Medication history 

• Pharmacotherapy 

• Suicide risk assessment 

Hospitalizations for depression not an existing measure. 

 
Measure: Out-patient screening 

Clinical Logic: Early detection 

Evidence/Rationale: 

ICSI 

Presentation for depression typically includes multiple somatic complaints, weight gain 

or loss, mild dementia, fatigue, sleep disturbances 

expert opinion 

Measure Version: ICSI 

Screen for depression in patients newly seen for fatigue 

Recommendations/Considerations: 

Do not adopt measure for reasons of data access limitation.

• Although fatigue can be identified by diagnosis code, screen for depression relies 

upon chart abstraction. A visit could serve as a proxy for such a clinical 

assessment. Such an assumption would deserve some validation. 

------------------------------------------------------------------------------------------------------------ 

Measure: Thyroid function testing in depression 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

Original ACE-PRO Panel, AHCPR Guideline 1993 

Hypothyroidism is potential secondary cause of depression. 

non-randomized trial

Measure Versions: ACE-PRO 

TSH within 1 month of initial diagnosis for depression 

Recommendations/Considerations: 

Do not include in ACE-PRO set. 

• Deemed unsuitable by Original ACE-PRO Panel. 

• Anticipate difficulty with establishing initial diagnosis. 

• Recommendation not as strong for men. 

• Consider testing such a measure. 
Measure: Psychotherapy 

Clinical Logic: Therapeutic Intervention 

Evidence/Rationale: 

Psychotherapy alone or in combination with pharmacotherapy improves clinical 

condition in depression. 

Measure Versions: 

Consortium 

Therapy appropriate to classification in depression 

• Psychotherapy 

• Medication management 

• ECT 

Recommendations/Considerations: 

Data access and validity problems. Chart review would be necessary for establishing 

classification in depression, therapeutic monitoring in medication management, and 

specifics of psychotherapy. Reliability of depression identification using codes is 

questionable. Underuse of depression codes is driven by reimbursement rules that 

substantially decrease reimbursement when depression is included as a diagnosis. 

Do not adopt such measures. Consider a recommendation to modify coding 

reimbursement policy in the future. 

------------------------------------------------------------------------------------------------------------ 

Measures: 

Follow-up after positive screen for depression 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

VA/DoD guideline on depression 

Screening identifies potential cases, needs more specific diagnostic evaluation 

Measure Version: 

VA/DoD 

Follow-up assessment or referral after positive screen for depression 

Recommendations: 

Measure composition would require chart abstraction. Do not adopt measure. 
Measure: Out-patient follow-up after hospitalization 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACE-PRO and NCQA 

Follow-up for readmission prevention, transitional care 

Continuation of therapy 

expert opinion 

Measure Versions 

NCQA

• Out-patient follow-up within 7 days of hospital discharge for depression and other 

mental health diagnoses 

• Out-patient follow-up within 30 days of hospital discharge for depression and 

other mental health diagnoses 

Age 6 and older 

Exclusions: rehospitalizations 

ACE-PRO 

Out-patient follow-up within 14 days of hospital discharge for depression 

Recommendations/Considerations: 

Keep measure without modification unless compelling reason to modify 

• Choose among 7 day, 14 day, and 30 day thresholds. 

• Ceiling effect in Asch et al 2000 (95% performance) 

• The addition of other mental health diagnoses should increase denominator size 

although many of the other diagnoses are specific to children and adolescents 

and many of the other diagnoses are infrequently associated with hospitalization. 

Consider testing multiple approaches. 

------------------------------------------------------------------------------------------------------------ 

7 days 14 days 30 days 

Depression ACE-PRO 

Depression and 

other mental 

health diagnoses 

NCQA NCQA 

 

Other Mental Health Diagnoses

Schizophrenia, Other Psychotic Disorders, OCD, Personality Disorders, Acute 

Reactions To Stress, Adjustment Reactions, Disorders Of Childhood And Adolescence 
Measure: Deaths due to suicide 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

Original ACE-PRO Panel 

Suicide attempts may indicate inadequate prior therapy 

Versions: 

NHQR/Healthy People 2010

National Vital Statistics System 

Deaths due to suicide per 100,000 in population 

Recommendations: 

Do not develop measure. Refer to NHQR. 

• Measure is already part of NHQR via NVSS. 

• Consider building measure specific to population with depression. 

o Could identify deaths due to suicide that included hospitalizations. 

o Anticipate problem identifying denominator of depression due to 

undercoding. 
Infectious Diseases 

Prevention 

• Influenza Immunization 

• Pneumococcal Immunization 

Early Detection 

• 

Work-up at Initial Diagnosis 

• Cultures 

• Imaging 

Therapeutic Interventions 

• Antibiotic Therapy 

• Surgery 

o Cholecystectomy 

Follow-up, Monitoring, Continuing Care 

• 

Serious Clinical Manifestations of Disease 

• Admissions for Urinary Tract Infection 

• Admissions for Perforated Appendix 

• Admissions for Bacterial Pneumonia 

• Empyema or Lung Abscess 

• Perforated Gall Bladder 

Eliminate for Data Access Limitations 

• Antibiotic Therapy 

Eliminate, no existing measures 

• Cultures and Imaging 

Eliminate, not sensitive to ambulatory care 

• Cholecystectomy 

• Admission for Perforated Appendix 

• Empyema or Lung Abscess 

• Perforated Gall Bladder 
Measure: Influenza Immunization 

Clinical Logic: Prevention 

Evidence/Rationale: 

USPSTF (1996) 

Annual influenza vaccine is recommended for all persons aged 65 and older and 

persons in selected high-risk groups. 

Consortium

Annual influenza immunization is recommended for all groups who are at increased risk 

for complications from influenza including persons age >= 50 years, B 

Recommendation, Evidence Level I, II-2 

NCQA, ACP, CDC ACIP, IDSA

Annual influenza immunization for age >= 65 

Measure Version: 

CMS

Percentage of persons >= 65 reporting influenza immunization within the last 12 months 

(BRFSS) 

NHQR

Percentage of persons >= 65 reporting influenza immunization within the last 12 months 

(BRFSS) 

Has a diabetes mellitus subgroup 

Has high risk subgroup for ages 18-64 

NCQA

Percentage of members >= 65 reporting influenza immunization during September 

through December. 

Consortium

Percentage of patients >= 50 and others at increased risk, receiving an annual influenza 

immunization. 

Has a diabetes mellitus denominator 
Recommendations/Considerations: 

Do not add measure to ACE-PRO set. Refer to survey results. 

o There are claims for immunizations available for analysis. 

o The analysis methodology is quite simple. 

o The population at risk is large. 

o However, CMS considered a claims based analysis a few years ago but decided 

to go with the survey methodology instead. 

o There is widespread belief that measurement based upon billing for 

immunizations is unreliable. 

o Claims based analyses yield smaller percentages than do survey methodologies. 

Consider using claims-based measure with survey methodology 

o Claims based analysis can serve as a lower bound and the survey based 

methodology as the upper bound on the estimate. 

------------------------------------------------------------------------------------------------------------ 

Measure: Pneumococcal Immunization 

Clinical Logic: Prevention 

Evidence/Rationale: 

USPSTF (1996)

recommended for all immunocompetent individuals who are age 65 years and older or 

otherwise at increased risk for pneumococcal disease 

Measure Versions: 

CMS

Percentage of persons >= 65 reporting ever having received a pneumococcal 

vaccination (BRFSS) 

NHQR

Percentage of persons >= 65 reporting ever having received a pneumococcal 

vaccination (BRFSS) 

NCQA

Medicare members age >= 65 who reported ever having a pneumococcal vaccination. 

Recommendations/Considerations: 

Do not add to ACE-PRO measure set. 

o Analytically more complex than influenza vaccination requiring multi-year look 

backs. 

o Same concerns exist regarding validity of claims. 
Measure: Admissions for Urinary Tract Infection 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

AHRQ PQI

Inappropriate treatment of uncomplicated urinary tract infections can lead to more 

serious complications. 

Measure Versions: 

AHRQ PQI

Admissions for Urinary Tract Infection per 100,000 in the population. 

Recommendations/Considerations: 

Add to ACE-PRO measure set. 

o There is no easily identifiable subset for a denominator. 

o Use measure in a composite of avoidable hospitalizations. 

------------------------------------------------------------------------------------------------------------ 

Measure: Admissions for Bacterial Pneumonia 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

AHRQ PQI

“Vaccination for pneumococcal pneumonia in the elderly and early management of 

bacterial respiratory infections on an ambulatory basis may reduce admissions with 

pneumonia.” 

Measure Versions: 

AHRQ PQI

Admissions for Bacterial Pneumonia per 100,000 in the population. 

Recommendations/Considerations: 

Add to ACE-PRO measure set. 

o There is no easily identifiable subset for a denominator. 

o Use measure in a composite of avoidable hospitalizations. 
Anemia, GI Bleed, Miscellaneous 

Prevention 

• 

Early Detection 

• 

Work-up at Initial Diagnosis 

• H pylori Testing in Dyspepsia 

Therapeutic Interventions 

• Surgical Repair of Hip Fracture 

Follow-up, Monitoring, Continuing Care 

• Visit After Hospitalization for GI Bleeding 

• Visit After Initial Diagnosis of GI Bleeding 

• Hematocrit After Hospitalization for GI Bleeding 

• Hematocrit After Initial Diagnosis of Anemia 

• GI Tract Work Up After Diagnosis Of Iron Deficiency Anemia 

• Assessment in Chronic Pain 

Serious Clinical Manifestations of Disease 

• Admissions for Dehydration 

------------------------------------------------------------------------------------------------------------ 

Measure: Admissions for Dehydration 

Clinical Logic: Serious Clinical Manifestations of Disease 

Evidence/Rationale: 

AHRQ PQI

Appropriate attention to fluid status can prevent dehydration, a potentially fatal 

condition. 

Admissions for Dehydration per 100,000 in the population 

Recommendations/Considerations: 

Add to ACE-PRO measure set. 

o There is no easily identifiable subset for a denominator. 

o Use measure in a composite of avoidable hospitalizations. 
Measure: H pylori Testing in Dyspepsia 

Clinical Logic: Work-up at Initial Diagnosis 

Evidence/Rationale: 

H pylori eradication can cure PUD, reducing the need for acid suppression therapy. 

Measure Version: 

Rejected by Original ACE-PRO Panel for lack of evidence. 

Recommendations/Considerations: 

Specificity of PUD, distinct from GERD and dyspepsia is clinically complicated, often 

requiring endoscopic evaluation. Empiric therapy is a common and justifiable practice. 

Wait for science on H pylori in dyspepsia to be further developed. Wait for measure 

development from another source. 

------------------------------------------------------------------------------------------------------------ 

Measure: Surgical Repair of Hip Fracture 

Clinical Logic: Therapeutic Intervention 

Evidence/Rationale: 

Original ACE-PRO Panel

“Surgical treatment is associated with survival benefits in patients with fractures of the 

femoral neck.” 

Measure Version: 

Arthroplasty or Internal Fixation of Hip During Hospital Stay for Fracture 

88% in Asch et al 2000 

Recommendations/Considerations: 

Eliminate measure. 

Not sensitive to ambulatory care. 
Measure: Visits for GI Bleed 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

Original ACE-PRO Panel

Minimum standards of care 

Measure Versions: 

ACE-PRO

o Visit Within 4 Weeks Of Discharge For Patients Hospitalized For GI Bleed 

o Visit Within 4 Weeks Of Initial Diagnosis Of GI Bleed 

Recommendations/Considerations: 

Keep both measures. 

Use in continuity of care composite. 

------------------------------------------------------------------------------------------------------------ 

Measure: Hematocrits in Anemia and GI Bleed 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

Original ACE-PRO Panel

Minimum standards of care 

Measure Versions: 

o Hematocrit/Hemoglobin Test Within 4 Weeks Of Discharge For Patients 

Hospitalized With GI Bleeding. 

o Hematocrit/Hemoglobin Test 1 To 6 Months After Initial Diagnosis Of Anemia. 

Recommendations/Considerations: 

Keep both measures. 

Use in continuity of care composite.
Measure: GI Tract Work Up After Diagnosis of Iron Deficiency Anemia 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

Original ACE-PRO Panel

Detect underlying GI malignancy 

Measure Versions: 

ACE-PRO

GI Tract Work Up After Initial Diagnosis of Iron Deficiency Anemia 

(1 month before to 3 months after initial diagnosis) 

Recommendations/Considerations: 

Keep measure. 

Use in cancer chapter as well 

------------------------------------------------------------------------------------------------------------ 

Measure: Pain Management 

Clinical Logic: Follow-up, Monitoring, Continuing Care 

Evidence/Rationale: 

ACOVE

If a vulnerable elder is treated for a chronic painful condition then he or she should be 

assessed for a response within 6 months. 

Recommendations: 

Do not add to ACE-PRO set. 

o Designed for medical record abstraction. 

o A visit could serve as the proxy for assessment. 

Consider testing a measure: Visit within 6 months for patients diagnosed with chronic 

pain conditions. 
Appendix 3. Summary of Expert Panel Recommendations 
Refinement of ACE-PRO Indicators 

Recommendations of the Expert Panel 

from the Meeting of 

May 17, 2004
The purpose of this document is to aid in confirming that we have correctly interpreted 

the guidance provided during the expert panel meeting. Please review this summary of 

the recommendations and share any additional thoughts you would like to express. 

Again, thank you for your participation. 

Edward Westrick, MD PhD 

Stephen Kogut, PhD MBA 

-MagnaCare HSI, Inc. 

Overview 

Measures are presented in order of condition/topic as reviewed during the expert 

panelist meeting. Within each topic/condition is presented a listing of measures 

recommended to be included in the ACE-PRO set, and those recommended to be 

excluded from consideration. General recommendations regarding case identification 

are described (where relevant), followed by definitions and general specifications for 

each measure. 

Conditions/topics 

Diabetes Mellitus 

Coronary Artery Disease 

Cerebrovascular Disease, Atrial Fibrillation and Hypertension 

Heart Failure 

Cancer 

COPD/Asthma 

Mental Health 

Infectious Disease 

Anemia, GI Bleed, and Miscellaneous 
Diabetes Mellitus 

Use the following measures:

• Eye Exam 

• A1C 

• Lipid Testing 

• Clinical Assessment 

• Follow-up after Hospitalization 

• Serious Short Term Complications 

• Serious Long Term Complications 

Eliminate the following measures from consideration:

• Visual acuity screening in general Medicare population 

• Nephropathy 

• BP Control 

• Foot Exam 

Denominators:

 Unless otherwise specified use the following Case ID rules: 

1. No age ceiling, no age floor, 

(would be useful to stratify) 

18-64 

65-75 

76+ 

65+ 

2. Use 2 out-patient or 1 in-patient code within 12 months (per Alliance 

specifications) 

3. Ignore HEDIS exclusions: PCOS, gestational diabetes mellitus, and steroid 

induced diabetes. 

MEASURES 

Eye Exam in Diabetes Mellitus 

Comprehensive eye exam every 2 years presuming that prevalence of high risk* 

is less than 80% 

*operationally defined as insulin users 
A1C Testing 

Annual A1C test 

Lipid Testing 

Lipid Profile every 2 years 

Clinical Assessment in Diabetes Mellitus 

2 out-patient visits for any diagnosis in year following case identification of 

diabetes mellitus 

Visit after Hospitalization for Diabetes Mellitus 

Denominator: Patients with one or more hospitalizations for diabetes mellitus, 

discharged home 

Numerator: Out-patient visit for any diagnosis within 4 weeks of discharge 

Question about home health, case management, etc. (see last page: general 

issues and recommendations)

Serious Short Term Complications of Diabetes Mellitus 

Denominator: 2 out-patient or 1 in-patient code within 12 months 

Numerator: Hospitalizations for uncontrolled diabetes mellitus, hyperosmolar and 

ketotic states, coma 

Note: This is a combination of the AHRQ PQI numerators with a diabetes specific 

denominator. 

In addition, continue to refer to AHRQ PQIs using per 100,000 in the population 

as denominator. 

Serious Long Term Complications of Diabetes Mellitus 

Denominator: 2 out-patient or 1 in-patient code within 12 months 

Numerator: Hospitalizations for renal, eye, neurological, 

circulatory and other complications not specified (per AHRQ PQI definition) 

 

? include lower extremity amputations in this numerator 
In addition, continue to refer to AHRQ PQIs using per 100,000 in the population 

as denominator. 

Coronary Artery Disease 

Use the following measures:

• Lipid Testing 

• Visit after hospitalization for Acute MI 

• Clinical Assessment in CAD 

• ER Use for Unstable Angina 

Eliminate the following measures from consideration:

• Screening for Diabetes Mellitus in CAD 

• Follow-up after initial diagnosis of unstable angina 

• EKG in ER for Unstable Angina 

• Hospitalization for Angina (without procedures) 

Denominators:

 Unless otherwise specified use the following Case ID rules: 

1. No age ceiling, no age floor, 

2. Use 2 codes (out-patient or in-patient) within 12 months 

MEASURES 

Lipid Testing 

Denominator: Broader CAD denominator (from Consortium) 

(not specific to co-morbid dyslipidemia) 

Numerator: Lipid profile every year 

Visit after Hospitalization for Acute MI 

Denominator: Patients with one or more hospitalizations for Acute MI 

Numerator: Out-patient visit for any diagnosis within 4 weeks of discharge 
Question about home health, case management, etc. (see last page: general 

issues and recommendations)

Clinical Assessment in CAD 

Denominator: Broad CAD denominator (from Consortium) 

Numerator: 2 out-patient visits for any diagnosis in year following case 

identification of CAD 
ER use in Unstable Angina 

Denominator: Broad CAD denominator 

Numerator: 3 or more ER visits for heart-related diagnoses, in the year following 

case identification of CAD 

Stroke, TIA, Atrial Fibrillation, Hypertension 

Use the following measures:

• EKG within 2 days of Initial Dx of TIA 

• Carotid imaging at Initial Dx of Carotid Artery Stroke 

• Carotid imaging in Carotid Territory Event 

• Visit after Hospitalization for Stroke/TIA 

• Clinical Assessment after Stroke/TIA 

• Hospitalizations for Hypertension 

Eliminate the following measures from consideration:

• Other tests at Initial Dx of TIA 

• Anticoagulation in Atrial Fibrillation 

• Visit after Hospitalization for Hypertension 

Denominators:

 Unless otherwise specified use the following Case ID rules: 

1. No age ceiling, no age floor 

2. Use 2 codes (out-patient or in-patient) within 12 months 

MEASURES 

EKG within 2 days of Initial Dx of TIA 

Denominator: 1 code for initial dx with 1 year look-back to establish as initial 

diagnosis 

Numerator: Code for EKG within 2 days of initial dx 
Carotid Imaging at Initial Dx of Carotid Artery Stroke 

Denominator: 1 (hospitalization) code for initial dx with 1 year look-back to 

establish as initial diagnosis 

Numerator: Carotid Imaging within 2 weeks of initial dx of carotid artery stroke 

Carotid Imaging in Carotid Territory Event 

Denominator: Patients with Carotid Endarterectomy after TIA or Stroke 

Numerator: Interval between Carotid Imaging and CEA less than two months 

Visit after Hospitalization for Stroke/TIA 

Denominator: Patients hospitalized for stroke or TIA 

 

Numerator: Out-patient visit for any diagnosis within 4 weeks of discharge 

Question about home health, case management, etc. 

Clinical Assessment after Stroke/TIA 

Denominator: 2 visits for stroke/TIA within 12 months 

Numerator: 2 out-patient visits for any diagnosis in 12 month period following 

case identification 

Admissions for Hypertension 

Denominator: 2 codes for hypertension within 12 months 

Numerator: Admissions for hypertension in 12 months following case 

identification 

In addition, continue to refer to AHRQ PQIs using per 100,000 in the population 

as denominator. 
Heart Failure 

Use the following measures:

• LVEF Assessment in Heart Failure 

• Laboratory Testing in Heart Failure 

• EKG after Initial Dx of Heart Failure 

• CXR after Initial Dx of Heart Failure 

• Visits after Hospitalization for Heart Failure 

• Clinical Assessment in Heart Failure 

• Admissions for Heart Failure 

Eliminate the following measures from consideration:

• Lab tests at initial dx 

Denominators:

 Unless otherwise specified use the following Case ID rules: 

1. No age ceiling, no age floor 

2. Use 2 codes (out-patient or in-patient) within 12 months 

MEASURES 

LVEF Assessment in Heart Failure 

Denominator 1: Hospitalizations for Heart Failure 

Denominator 2: Initial Dx of Heart Failure, 2 codes for case ID, one year lookback to establish initial dx 

Numerator 1: echo, RVG, or LV gram 3 months before or after hospitalization 

Numerator 2: echo, RVG, or LV gram 3 months before or after initial dx 

Laboratory Testing in Heart Failure 

Potassium and renal function test within the year of case identification 

EKG after Initial Dx of Heart Failure 

Denominator: 2 codes for case ID, one year look-back to establish initial dx 

Numerator: EKG within 3 months of initial dx 
CXR after Initial Dx of Heart Failure 

Denominator: 2 codes for case ID, one year look-back to establish initial dx 

 

Numerator: CXR within 3 months of initial dx 

Visits after Hospitalization for Heart Failure 

Denominator: Hospitalizations for Heart Failure 

Numerator: Out-patient visit for any diagnosis within 4 weeks of discharge 

Question about home health, case management, etc. (see last page: general 

issues and recommendations)

Clinical Assessment in Heart Failure 

2 out-patient visits for any diagnosis in year following case identification of heart 

failure 

Admissions for Heart Failure 

Admissions for heart failure in 12 months following case identification

In addition, continue to refer to AHRQ PQIs using per 100,000 in the population 

as denominator. 

Cancer 

Use the following measures:

• Breast Cancer Screening 

• Staging in Breast Cancer (Bx to Rx Interval) 

• CXR at Initial Dx 

• Breast Imaging at Initial Dx 

• Mammography Surveillance 

• Colonoscopic Surveillance after Colon Cancer 

• GI Tract Work-up after Dx of Iron Deficiency Anemia 

Eliminate the following measures from consideration:

• Colorectal Cancer Screening 

• Cervical Cancer Screening 

• Visit after Mastectomy 
• Staging in Colorectal Cancer 

• Stage at Dx 

• Death Rates 

Breast Cancer Screening 

Denominator: Age 50 to 74, Female 

Numerator: Mammogram within 2 year timeframe 

Staging in Breast Cancer (Bx to Rx Interval) 

Denominator: Diagnosis of Breast Cancer with surgical, chemo, or radiation 

therapy 

Numerator: Interval from biopsy to beginning of therapy less than 3 months 

CXR at Initial Dx 

Denominator: Diagnosis of Breast Cancer with one year look-back to establish 

initial dx 

Numerator: CXR within 3 months before or after initial dx 

Breast Imaging at Initial Dx 

Denominator: Diagnosis of Breast Cancer with one year look-back to establish 

initial dx 

Numerator: Breast Imaging (Mammogram or other) within 3 months before or 

after initial dx 

Mammography Surveillance 

Denominator: 2 codes for breast cancer in 12 months 

Numerator: Mammogram in 12 months of case identification 

Colonoscopic Surveillance after Colon Cancer 

Denominator: Resection for Colon Cancer 

(not polypectomy) 

Numerator: Colonoscopy within 1 year of resection 
GI Tract Work-up after Dx of Iron Deficiency Anemia 

Denominator: Dx of iron deficiency anemia, one year look-back to establish 

initial dx 

Numerator: Colonoscopy or Double Contrast Barium Enema within 1 month 

before or 3 months after initial dx 

COPD/Asthma 

Use the following measures

• Clinical Assessment in COPD/Asthma 

• Hospitalization for Respiratory Dx in COPD/Asthma 

MEASURES 

Clinical Assessment in COPD/Asthma 

Denominator: No age ceiling, no age floor, 2 codes (out-patient or in-patient) 

within 12 months for COPD or Asthma diagnoses 

Numerator: 2 out-patient visits for any diagnosis in year following case 

identification of diabetes mellitus 

Hospitalization for Respiratory Dx in COPD/Asthma 

Denominator: 2 codes for COPD or Asthma diagnoses in 12 months 

Numerator: Hospitalization for respiratory diagnoses 

In addition, continue to refer to AHRQ PQIs using per 100,000 in the population 

as denominator. 
Depression/Other Mental Illness 

Use the following measures:

• Follow-up after Hospitalization for Depression 

Eliminate the following measures from consideration:

• Out-patient screening 

• Thyroid function testing 

• Psychotherapy 

• Follow-up after positive screen for depression 

• Deaths due to suicide 
MEASURES 

Follow-up after Hospitalization for Depression 

Denominator: Patients hospitalized for depression 

Numerator: Out-patient visit for any diagnosis within 14 days of discharge after 

hospitalization for depression 

Infectious Disease 

Use the following measures:

• Admissions for UTI 

• Admissions for Bacterial Pneumonia 

Eliminate the following measures from consideration:

• Influenza Immunization 

• Pneumococcal Immunization 

MEASURES 

Admissions for UTI 

Continue to refer to AHRQ PQIs using per 100,000 in the population as 

denominator. 

Admissions for Bacterial Pneumonia 

Continue to refer to AHRQ PQIs using per 100,000 in the population as 

denominator. 
Anemia, GI Bleed, Misc 

Use the following measures:

• Admissions for Dehydration 

• Annual Visit 

• Visit after Hospitalization for GI Bleed 

• Visit after Initial Dx of GI Bleed 

• H/H after Hospitalization for GI Bleed 

• H/H after Initial Dx of Anemia 

• GI Tract Work-up after Initial Dx of Iron Deficiency Anemia 

Eliminate from consideration the following measures:

• H. pylori testing 

• Surgical repair of hip fx 

• Pain Management 

MEASURES 

Admissions for Dehydration 

Continue to refer to AHRQ PQIs using per 100,000 in the population as 

denominator. 

Annual Visit 

Denominator: Medicare eligibility 

Numerator: One out-patient visit for any diagnosis 

Visit after Hospitalization for GI Bleed 

Denominator: Hospitalization for GI Bleed 

Numerator: Visit for any dx within 4 weeks if discharge 

Question about home health, case management, etc. (see last page: general 

issues and recommendations)

Visit after Initial Dx of GI Bleed 

Denominator: One year look-back to establish initial dx 

Numerator: Visit for any dx after initial dx of GI Bleed 

? 4 weeks 
H/H after Hospitalization for GI Bleed 

Denominator: Hospitalization for GI Bleed 

Numerator: Hemoglobin or hematocrit within 4 weeks of discharge after 

hospitalization for GI Bleed 

H/H after Initial Dx of Anemia 

Denominator: One year look back to establish initial dx 

Numerator: Hemoglobin or hematocrit 1 to 6 months after initial dx 

GI Tract Work-up after Initial Dx of Iron Deficiency Anemia 

Denominator: Dx of iron deficiency anemia, one year look-back to establish 

initial dx 

Numerator: Colonoscopy or Double Contrast Barium Enema within 1 month 

before or 3 months after initial dx 
Composites 

Clinical Assessment in Chronic Disease 

Diabetes Mellitus 

CAD 

Stroke/TIA 

COPD/Asthma 

Heart Failure 

Follow-up After Hospitalization 

Diabetes Mellitus 

Acute MI 

Stroke/TIA 

Heart Failure 

Depression 

GI Bleed 

Avoidable Hospitalizations 

Diabetes Mellitus 

 Multiple 

CAD (ER) 

Heart Failure 

COPD/Asthma 

AHRQ PQIs 

Work-up at Initial Dx 

EKG in TIA 

Carotid Imaging 

LVEF in Heart Failure 

EKG in Heart Failure 

CXR in Heart Failure 

Imaging in Breast Cancer 

GI Work-up in Iron Def Anemia 
General Issues / Panel Recommendations 

• Follow national guidance on use of composites 

o National workgroup studying use of composites in performance 

measurement. Question: Name of entity? 

• Coding for mental illnesses 

o Mental health diagnosis codes under-used due to decreased 

reimbursement given perceptions of payment policies. 

o Recommendation to correct misperception or change policy 

• Identification of cancer stage in coding 

o Many potential cancer measures require staging information 

o Would be useful for new measures using administrative data 

• Sub-group analyses by age 

(would be useful to stratify for diabetes measures) 

18-64; 65-75; 65+; 76+ 

Further Research 

• Home care, case management, other follow-up after hospitalizations 

o For measures of follow-up after hospitalization: 

 Should home care visits count as follow-up? 

 What proportion of hospitalizations have home care discharge 

dispositions? 

 How does home care or case management affect measurement? 

• Distribution of scores by various intervals 

o In measures where evidence is lacking regarding interval (in days or 

weeks, months) recommended for follow-up: 

 Distribution of the time between event (diagnosis, hospitalization, 

etc.) and follow-up may identify critical threshold 

• e.g. Staging in Breast Cancer: Bx to Rx interval less than 3 

months 

• Validity testing 

o Further validation of measures would be useful, including: 

 Specificity and positive predictive value of case identification 

algorithms 

 Construct validity: Use longitudinal data to determine if 

improvement in measures leads to improved health outcomes 

 NCI to report on results of validity testing of colon cancer screening 

measure 
Appendix 4. Revised ACE-PRO Indicator Set: Measure Short 

Descriptions 

Diabetes Mellitus 

D1. Eye Exam

comprehensive eye exam, at least every two years (measurement year or prior year), 

with 2 out-patient or 1 in-patient visits with diabetes mellitus codes, within a calendar 

year. 

D2. A1C

A1C test at least once per year (the measurement year), in patients with 2 out-patient or 

1 in-patient visits with diabetes mellitus codes, within a calendar year. 

D3. Lipid Testing

lipid profile, at least every year (the measurement year), in patients aged 65 or older, 

with 2 out-patient or 1 in-patient visits with diabetes mellitus codes, within a calendar 

year. 

D4. Clinical Assessment

Two out-patient visits (with or without code for diabetes mellitus) during the 

measurement year, in patients identified as having diabetes mellitus in the year prior to 

the measurement year (with 2 out-patient or 1 in-patient visits). 

D5. Follow-up after Hospitalization

At least one out-patient visit (with or without code for diabetes mellitus) within four 

weeks following discharge of patients, 65 or older, hospitalized for diabetes mellitus. 

D6. Serious Short Term Complications

Use numerator of PQI version and denominator of ACE-PRO version to restrict to 

population with diabetes 

Admissions for diabetic, hyperosmolar and ketotic coma and admissions for 

uncontrolled diabetes mellitus among patients with 2 out-patient or 1 in-patient visit with 

diabetes mellitus within a calendar year. 

D7. Serious Long Term Complications

hospitalizations for renal, ophthalmologic, neurologic and circulatory complications of 

diabetes mellitus and non-traumatic lower extremity amputation, in patients aged 65 and 

older, with 2 or more out-patient visits or 1 in-patient visit with a diagnosis code for 

diabetes mellitus within a calendar year.
Coronary Artery Disease 

C1. Lipid Testing

lipid profile, at least every year (the measurement year), in patients with 2 out-patient or 

in-patient visits with coronary artery disease codes, within a calendar year. 

C2. Visit after hospitalization for Acute MI

At least one out-patient visit (with or without code for coronary artery disease) within 

four weeks following discharge of patients, hospitalized for acute myocardial infarction. 

C3. Clinical Assessment in CAD

Two out-patient visits (with or without code for CAD) during the measurement year, in 

patients, 65 or older, identified as having CAD in the year prior to the measurement year 

(with 2 out-patient or in-patient visits). 

C4. ER Use for Unstable Angina

Three or more emergency department visits for coronary artery disease, unassociated 

with admission, identified with coronary artery disease (with 2 out-patient or in-patient 

visits with CAD codes) in the measurement year. 

Stroke, Transient Ischemia 

S1. Carotid imaging at Initial Dx of Carotid Artery Stroke

Carotid angiogram or non-invasive carotid imaging procedure within two week of initial 

diagnosis in patients, age 65 or older, hospitalized for carotid artery stroke. 

S2. Carotid imaging in Carotid Territory Event

Carotid imaging to CEA interval less than 2 months, in patients age 65 or older, with a 

hospitalization for stroke or TIA as a primary diagnosis prior to the CEA. 

S3. Visit after Hospitalization for Stroke/TIA

At least one out-patient visit (with or without code for stroke or TIA) within four weeks 

following discharge of patients, 65 or older, hospitalized for stroke or TIA. 

S4. Clinical Assessment after Stroke/TIA

Two out-patient visits (with or without code for stroke or TIA) during the measurement 

year, in patients, 65 or older, identified as having stroke or TIA in the year prior to the 

measurement year (with 2 out-patient or in-patient visits). 
Heart Failure 

H1, H2. LVEF Assessment in Heart Failure

H1 Initial Diagnosis Version:

LVEF assessment (diagnostic ultrasound, RVG, or LVG) within three months before or 

after the initial diagnosis of heart failure. One out-patient visit, coded for heart failure 

serves as the index diagnosis. Initial diagnosis is defined by an accompanying 

lookback period of 12 months free of heart failure codes. 

H2 Hospitalization Version:

LVEF assessment (diagnostic ultrasound, RVG, or LVG) within three months before or 

after hospitalization for heart failure. Hospitalization for heart failure is defined as one 

hospital visit for (primary diagnosis of ) heart failure. For multiple hospitalizations for 

heart failure in one patient, only the first hospitalization should be used. 

H3. Laboratory Testing in Heart Failure

Test for potassium and renal function (BUN and/or Creatinine) at least once during the 

measurement year in patients identified as having heart failure by 2 visits (in-patient or 

out-patient) coded for heart failure in the measurement year. 

H4. EKG after Initial Dx of Heart Failure

EKG or Holter Monitor within one month before or three months after initial diagnosis of 

heart failure. Index diagnosis of heart failure must occur 3 months or longer prior to the 

end of the measurement year. Index diagnosis of heart failure must be preceded by at 

least 12 months free of heart failure codes. 

H5. CXR after Initial Dx of Heart Failure

CXR within one month before or three months after initial diagnosis of heart failure. 

Index diagnosis of heart failure must occur 3 months or longer prior to the end of the 

measurement year. Index diagnosis of heart failure must be preceded by at least 12 

months free of heart failure codes. 

H6. Visits after Hospitalization for Heart Failure

At least one out-patient visit (with or without code for heart failure) within four weeks 

following discharge of patients hospitalized for (with a primary diagnosis of) heart 

failure. 

H7. Clinical Assessment in Heart Failure

Two out-patient visits (with or without code for heart failure) during the measurement 

year, in patients identified as having heart failure in the year prior to the measurement 

year (with 2 out-patient or in-patient visits). 

H8. Admissions for Heart Failure
Admissions for (primary diagnosis of) heart failure among patients with known heart 

failure (2 out-patient or in-patient visits with heart failure) within a calendar year. 

Cancer 

B1. Breast Cancer Screening

Mammogram every two years in female patients. Set the upper end of the eligibility 

interval at 74. 

B2. Bx to Rx Interval

Biopsy to definitive therapy (surgical, radiation, chemotherapy) interval less than 3 

months in patients with breast cancer and eventual definitive therapy. Breast cancer is 

defined as a visit (in-patient or out-patient) for breast cancer. A biopsy is defined as a 

breast biopsy. 

B3. CXR at Initial Dx

CXR within three months before or three months after initial diagnosis of breast cancer. 

Index diagnosis of breast cancer must occur 3 months or longer prior to the end of the 

measurement year. Index diagnosis of breast cancer must be preceded by at least 12 

months free of breast cancer codes. 

B4. Breast Imaging at Initial Dx

Mammogram or other breast imaging within three months before or three months after 

initial diagnosis of breast cancer. Index diagnosis of breast cancer must occur 3 

months or longer prior to the end of the measurement year. Index diagnosis of breast 

cancer must be preceded by at least 12 months free of breast cancer codes. 

B5. Mammography Surveillance

At least one mammogram (in-patient or out-patient) within a 12 month period that 

includes a visit (in-patient or out-patient) for breast cancer. 

B6. Colonoscopic Surveillance after Colon Cancer

at least one visit (in-patient or out-patient) coded for colonoscopy within 12 months of 

visit (in-patient) coded for resection of colorectal cancer 

B7. GI Tract Work-up after Dx of Iron Deficiency Anemia

Colonoscopy or barium enema within one month before or three months after the initial 

diagnosis of iron deficiency anemia. The index diagnosis of iron deficiency anemia 

must be preceded by a 12 month period free of the diagnosis of iron deficiency anemia. 
Anemia and GI Bleed 

A1. Visit after Hospitalization for GI Bleed

At least one visit (with or without code for GI bleed) within four weeks following 

discharge of patients, hospitalized for GI bleed. 

A2. Visit after Initial Dx of GI Bleed

At least one visit, in-patient or out-patient, with or without code for GI bleed, within four 

weeks following initial diagnosis of GI bleed (out-patient only). Index 

A3. H/H after Hospitalization for GI Bleed

At least one hemoglobin or hematocrit test within four weeks following discharge of 

patients, hospitalized for (primary diagnosis of) GI bleed. 

A4. H/H after Initial Dx of Anemia

Hemoglobin or hematocrit test within one to six months after an initial diagnosis of 

anemia. Index diagnosis of heart failure must occur 3 months or longer prior to the end 

of the measurement year. Index diagnosis of heart failure must be preceded by at least 

12 months free of heart failure codes. 

A5. GI Tract Work-up after Initial Dx of Iron Deficiency Anemia

Colonoscopy or barium enema within one month before or three months after the initial 

diagnosis of iron deficiency anemia. The index diagnosis of iron deficiency anemia 

must be preceded by a 12 month period free of the diagnosis of iron deficiency anemia. 

Miscellaneous 

COPD 

P1. Clinical Assessment in COPD/Asthma

Two out-patient visits (with or without code for COPD or asthma) during the 

measurement year, in patients, identified as having COPD or asthma in the year prior to 

the measurement year (with 2 out-patient or in-patient visits). 

P2. Hospitalization for Respiratory Dx in COPD/Asthma

Admissions for respiratory diagnoses among patients with COPD (including asthma) 

defined as 2 visits (out-patient or in-patient) with coded for COPD or asthma in the 

measurement year. 
Depression 

M1. Follow-up after Hospitalization for Depression

At least one out-patient visit (with or without code for depression) within two weeks 

following discharge of patients, hospitalized for depression. 

Hypertension

H1. Hospitalizations for Hypertension

hospitalizations with hypertension as the primary diagnosis, in patients aged 65 and 

older, with 2 or more out-patient visits or in-patient visits with a diagnosis code for 

hypertension in the measurement year. 

Other

V1. Annual visit

One out-patient visit during the measurement year, in patients, 65 or older, identified as 

Medicare enrolled in the eligibility file. 
Appendix 5. Revised ACE-PRO Measures General Analytic Rules 

Case Eligibility

Within a two year timeframe beneficiary cases are included if: 

• The beneficiaries are age 65 or older as of the beginning of the two year 

timeframe. 

• Enrolled in Parts A and B for the entire two year timeframe. 

• Not receiving hospice care during the two year timeframe. 

• Remained alive during the two year time frame. 

• Living in the United States during the two year time frame. 

• Not enrolled in managed care during the two year time frame. 

Case ID general rules

The index visit is the first (physician or extender) coded visit with one or more of the 

target ICD-9 codes in the measurement year. The index visit may occur in the inpatient or out-patient setting. Index visits define the case without a confirmatory visit 

when the index visit occurs in the in-patient setting. Confirmatory visits are required to 

define cases when the index visit occurs in the out-patient setting. The confirmatory 

visit must occur within the measurement year. 

Case ID in Follow-up after Hospitalization measures

The index visit is the first hospital admission with the principle diagnosis (ICD-9 code 

for defining disease) during the measurement year. The discharge date for the index 

visit must occur early enough in the measurement year to allow a full detection period 

(as specified in the measure) to follow the discharge date. 

e.g. Follow-up after hospitalization in CHF – discharge date for the index visit for CHF 

must occur no later than December 3 to provide for a 4 week detection period for the 

follow-up visit. 

Case ID in Initial Diagnosis measures

The index visit is the first (physician or extender) coded visit with one or more of the 

target ICD-9 codes in the measurement year. The index visit may occur in the inpatient or out-patient setting. Index visits define the case without a confirmatory visit 

when the index visit occurs in the in-patient setting. Confirmatory visits are required to 

define cases when the index visit occurs in the out-patient setting. The confirmatory 

visit must occur within the measurement year. 
Initial diagnosis is defined when an index visit is preceded by a one year period free of 

in-patient or out-patient visits coded for the target diagnosis. 

The index visit must occur early enough in the measurement year to allow a full 

detection period (as specified in the measure) to follow the index visit. 

e.g. EKG in CHF – index visit for CHF must occur no later than September 30th to 

provide for a 3 month detection period for the EKG. 

Case ID in Clinical Assessment

The index visit is the first (physician or extender) coded visit with one or more of the 

target ICD-9 codes in the case identification year (the year prior to the measurement 

year). The index visit may occur in the in-patient or out-patient setting. Index visits 

define the case without a confirmatory visit when the index visit occurs in the inpatient setting. Confirmatory visits are required to define cases when the index visit 

occurs in the out-patient setting. The confirmatory visit must occur within the case 

identification year. The detection period for clinical assessment measures is the 

measurement year.

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