Montana Primary Care Association

Numerator:

Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:
Cervical cytology (pap test) performed during the measurement period or the two years prior to the measurement period for women who are >= 21 years old at the time of the test
Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are >=30 years old at the time of the test

Denominator:

Women 24-64 years of age with a visit during the measurement period.

QDI 2025 Statewide Goal 53%

Diabetes A1c or GMI > 9 or Untested (CMS 122v13)
Percentage of patients 18-75 years of age with diabetes who had glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period

Numerator:

Patients whose most recent glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period

Denominator:

Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period.

QDI 2025 Statewide Goal 22%

Colorectal Cancer Screening (CMS 130v13)

Adults 45-75 years of age who had appropriate screening for colorectal cancer.

Numerator:

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

Fecal Occult Blood test (FOBT) or FIT result during the measurement period

Stool DNA (sDNA) with FIT-DNA test during the measurement period or the 2 years prior to the measurement period

Flexible sigmoidoscopy during the measurement period or the 4 years prior to the measurement period

CT Colonography during the measurement period or the 4 years prior to the measurement period

Colonoscopy during the measurement period or the 9 years prior to the measurement period

Denominator:

Patients 46-75 years of age with a visit during the measurement period

QDI 2025 Statewide Goal 51%

Colorectal Cancer FIT Kit Resources.

Women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period.

Numerator:

Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period.

Denominator:

Women 52-74 years of age with a visit during the measurement period.

QDI 2025 Statewide Goal 52%

Screening for Depression and Follow-Up Plan (CMS 2v14)

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.

Numerator:

Patients screened for depression on the date of a qualifying encounter or 14 days prior to the date a qualifying encounter using an age appropriate standardized depression screening tool AND if positive, a follow up plan is documented on the date of or up to two days after the date of the qualifying encounter.

Standardized depression screening in the last 12 months from 14 days prior to a qualifying encounter up to the date of a qualifying encounter*, with

Negative result as determined by the interpretation of the score from a specific screening (see below), or as a “negative” result in documentation mapped as a “Standardized Depression Screen”

OR

Positive result as determined by the interpretation of the score from a specific screening (see below), or as a “positive” result in documentation mapped as a “Standardized Depression Screen”

AND

Follow-up at a qualifying depression screening encounter must include one or more of the following:

Referral to a practitioner who is qualified to diagnose and treat depression

Pharmacological interventions (prescription of medication)

Other interventions or follow-up for the diagnosis or treatment of depression, e.g. depression self-management

Thresholds for positive and negative interpretations of screening with a total score result.

 *This measure looks for the most recent depression screening, which is defined as a depression screening from 14 days prior to a qualifying encounter up to the date of a qualifying encounter. Depression screenings that are conducted at a non-qualifying encounter and are not performed within 14 days of a qualifying encounter are not counted toward this measure and have no impact on the numerator compliance of a patient.

Denominator:

All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period.

QDI 2025 Statewide Goals 75%

Numerator:

Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period*

Most recent systolic blood pressure in measurement period < 140 mmHg

Most recent diastolic blood pressure in measurement period < 90 mmHg

*If no blood pressure is recorded during the measurement period, the patient’s blood pressure is assumed “not controlled.” If multiple readings are taken on the same day, measure will look for the lowest diastolic and lowest systolic values from all readings. The Detail List includes a “Multiple BP” column that shows the lowest systolic and lowest diastolic readings. This means the final reported diastolic and systolic numbers may be a composite of values from different readings. For example, on reading of 150/95 and another of 135/100 would result in a reported value of 135/95.

Denominator:

Patients 18-85 years of age by the end of the measurement period who had a visit during the measurement period and diagnosis of essential hypertension starting before and continuing into or starting during the first six months of the measurement period.

QDI 2025 Statewide Goal 67%