eMeasure Title

Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

eMeasure Identifier (Measure Authoring Tool) 167 eMeasure Version number 5.2.000
NQF Number 0088 GUID 50164228-9d64-4efc-af67-da0547ff61f1
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward PCPI(R) Foundation (PCPI[R])
Measure Developer American Medical Association (AMA)
Measure Developer PCPI(R) Foundation (PCPI[R])
Endorsed By National Quality Forum
Description
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months
Copyright
Copyright 2015 PCPI(R) Foundation and American Medical Association.  All Rights Reserved.
Disclaimer
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CPT(R) contained in the Measure specifications is copyright 2004-2015 American Medical Association. LOINC(R) is copyright 2004-2015 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT[R]) copyright 2004-2015 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2015 World Health Organization. All Rights Reserved.

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Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
Diabetic retinopathy is a leading cause of new cases of legal blindness among working-age Americans and represents a leading cause of blindness in this age group worldwide. (Klein, 2007). In 2005-2008, the estimated prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy was 28.5 percent among persons with diabetes aged 40 years and older (Zhang, 2010). Approximately 1.5% of adults with diabetes had proliferative diabetic retinopathy and 2.7% had clinically significant macular edema (Zhang, 2010). 

Several level 1 RCT studies demonstrate the ability of timely treatment to reduce the rate and severity of vision loss from diabetes (Diabetic Retinopathy Study -- DRS, Early Treatment Diabetic Retinopathy Study -- ETDRS). Necessary examination prerequisites to applying the study results are that the presence and severity of both peripheral diabetic retinopathy and macular edema be accurately documented. In the RAND chronic disease quality project, while administrative data indicated that roughly half of the patients had an eye exam in the recommended time period, chart review data indicated that only 19% had documented evidence of a dilated examination (McGlynn, 2003). Thus, ensuring timely treatment that could prevent 95% of the blindness due to diabetes requires the performance and documentation of key examination parameters. The documented level of severity of retinopathy and the documented presence or absence of macular edema assists with the on-going plan of care for the patient with diabetic retinopathy.
Clinical Recommendation Statement
Because treatment is effective in reducing the risk of visual loss, detailed examination is indicated to assess for the following features that often lead to visual impairment: presence of macular edema, optic nerve neovascularization and/or neovascularization elsewhere, signs of severe NPDR (extensive retinal hemorrhages/microaneurysms, venous beading, and IRMA), and vitreous or preretinal hemorrhage. (Good evidence; Strong recommendation) (AAO, 2014)
Improvement Notation
Higher score indicates better quality
Reference
American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2014.
Reference
Klein BE. Overview of epidemiologic studies of diabetic retinopathy. Ophthalmic Epidemiol. 2007;14:179-83. 
Reference
Zhang X, Saaddine JB, Chou CF, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. 2010;304:649-56. 
Reference
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45.
Definition
Documentation - The medical record must include: documentation of the level of severity of retinopathy AND documentation of whether macular edema was present or absent 

Macular Edema - Acceptable synonyms for macular edema include: macular thickening, intraretinal thickening, serous detachment of the retina, or pigment epithelial detachment 

Severity of Retinopathy - Mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative
Guidance
The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but ICD-9-CM and SNOMED-CT do not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible professional will record laterality in the patient medical record, as quality care and clinical documentation should include laterality.
Transmission Format
TBD
Initial Population
All patients aged 18 years and older with a diagnosis of diabetic retinopathy
Denominator
Equals Initial Population
Denominator Exclusions
None
Numerator
Patients who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months
Numerator Exclusions
Not Applicable
Denominator Exceptions
Documentation of medical reason(s) for not performing a dilated macular or fundus examination
Documentation of patient reason(s) for not performing a dilated macular or fundus examination
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None