Continuous Improvement and the Expansion of Quality ... - NCQA

Continuous Improvement
and the Expansion of
Quality Measurement
T h e S T a T e o f h e a l T h C a r e Q u a l i T y 2 0 1 1

Continuous Improvement
and the Expansion of
Quality Measurement
T h e S T a T e o f h e a l T h C a r e Q u a l i T y 2 0 1 1

2
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Unauthorized copying or use is prohibited.
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and Quality.
Portions of this report were prepared using select data provided by the Centers for Medicare & Medicaid Services
(CMS) pursuant to a data use agreement. The contents of the report represent the sole views of NCQA and have not
been approved, reviewed or endorsed by CMS or by any other federal agency.
© 2011 by the National Committee for Quality Assurance. All rights reserved.
Printed in the U.S.A.
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
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T h e S TaT e o f h e a l T h C a r e Q u a l i T y 2 0 1 1 • Ta b l e o f C o n T e n T S
President’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
executive suMMary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hedis Measures of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
safety and Potential Waste
avoidance of antibiotic Treatment in adults With acute bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . 26
use of imaging Studies for lower back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
relative resource use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Wellness and Prevention
adult bMi assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
flu Shots for adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
breast Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Cervical Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Medical assistance With Smoking and Tobacco use Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
chronic disease Management
Persistence of beta-blocker Treatment after a heart attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Comprehensive Diabetes Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Controlling high blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Cholesterol Management for Patients With Cardiovascular Conditions . . . . . . . . . . . . . . . . . . . . . . . 56
Disease Modifying anti-rheumatic Drug Therapy in rheumatoid arthritis . . . . . . . . . . . . . . . . . . . . . 58
use of appropriate Medications for People With asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
use of Spirometry Testing in the assessment and Diagnosis of CoPD . . . . . . . . . . . . . . . . . . . . . . . . 62
Pharmacotherapy Management of CoPD exacerbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
annual Monitoring for Patients on Persistent Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
antidepressant Medication Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
initiation and engagement of alcohol and other Drug Dependence Treatment . . . . . . . . . . . . . . . . . . 70
Measures targeted at children and adolescents
appropriate Treatment for Children With upper respiratory infection* . . . . . . . . . . . . . . . . . . . . . . . 72
lead Screening in Children* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
ambulatory Care: emergency Department Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Prenatal and Postpartum Care & frequency of ongoing Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . 77
Chlamydia Screening in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
follow-up after hospitalization for Mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
appropriate Testing for Children With Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Well-Child Visits in the first 15 Months of life and in the Third, fourth, fifth and Sixth years of life . . . 86
adolescent Well-Care Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Children and adolescents’ access to Primary Care Practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
follow-up Care for Children Prescribed aDhD Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Childhood immunization Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
immunizations for adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Weight assessment and Counseling for nutrition and Physical activity for Children/adolescents . . . 103
* As part of the Pediatric Quality Measures Program, states are working with AHRQ and CMS to report Children’s Initial Core Set measures at the
state level in order to assess the quality of Medicaid and CHIP. All measures in this section except the two noted are in the Children’s Initial Core Set.
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Measures targeted at older adults
fall Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Medication in the Elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Management of Urinary Incontinence in older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Physical Activity in older Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Glaucoma Screening in older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
osteoporosis Testing in older Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
osteoporosis Management in Women Who Had a fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
ConsuMEr and PatIEnt EngagEMEnt and ExPErIEnCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
MEtHodology ovErvIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
aPPEndICEs
HEDIS Effectiveness of Care Measures: 2010 National HMo Averages. . . . . . . . . . . . . . . . . . . . . . 130
HEDIS Effectiveness of Care Measures: 2010 National PPo Averages . . . . . . . . . . . . . . . . . . . . . . 134
CAHPS Member Satisfaction Measures: 2010 National HMo Averages . . . . . . . . . . . . . . . . . . . . . 137
CAHPS Member Satisfaction Measures: 2010 National PPo Averages . . . . . . . . . . . . . . . . . . . . . . 138
Accredited vs. Nonaccredited Plans: 2010 Commercial HMo Averages . . . . . . . . . . . . . . . . . . . . . 139
Accredited vs. Nonaccredited Plans: 2010 Commercial PPo Averages . . . . . . . . . . . . . . . . . . . . . . 142
Accredited vs. Nonaccredited Plans: 2010 Medicaid HMo Averages . . . . . . . . . . . . . . . . . . . . . . . 145
Accredited vs. Nonaccredited Plans: 2010 Medicare HMo Averages. . . . . . . . . . . . . . . . . . . . . . . 148
Accredited vs. Nonaccredited Plans: 2010 Medicare PPo Averages. . . . . . . . . . . . . . . . . . . . . . . . 150
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial HMos. . . . . . . . . . . . . . . . . 152
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial PPos. . . . . . . . . . . . . . . . . . 155
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicaid HMos. . . . . . . . . . . . . . . . . . . 158
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare HMos. . . . . . . . . . . . . . . . . . . 161
Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare PPos . . . . . . . . . . . . . . . . . . . 163
HMos vs. PPos, Commercial Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
HMos vs. PPos, Medicare Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
HMos vs. PPos, Commercial Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
HMos vs. PPos, Medicare Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial HMos. . . . . 171
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial PPos. . . . . . 174
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicaid HMos . . . . . . 177
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare HMos . . . . . . 180
Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare PPos . . . . . . . 182
rEfErEnCEs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
aCknoWlEdgMEnts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

PRESIDENT’S MESSAGE
Dear Colleague:
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • P R E S I D E N T ’ S M E S S A G E
Every autumn, NCQA updates the nation on how consistently health plans deliver high-quality
care. This, our 15th State of Health Care Quality Report, is a snapshot of an industry that is
moving in the right direction, but has opportunities for further improvement.
We find encouraging signs of rising quality. Across diverse measures of care, performance
is improving, and insurers can be proud of what they have accomplished. We also note that
some insurers are not reporting and that for some measures, we have not seen the gains in
performance we would like.
Three features distinguish this year’s report. first, it is longer than in past years because it
includes, for the first time, comparisons between HMos and PPos across all measures.
That we are able to fill a report with PPo data tracked over time is a significant step in
quality’s story. Not long ago, few PPos quantified or disclosed results. Now, measurement and
transparency are more common, though there is room to add more PPo reporting.
The rising tide of PPo reporting is a credit to PPos that have worked hard to fashion themselves
into data-driven organizations that collect and report results. Their willingness to evaluate
themselves and be transparent is a boon to consumers, a third of whom are enrolled in PPos.
A second distinct feature of this report is a focus on longer-term trends—a departure from our
usual concentration on one-year changes in performance.
In a fast-paced society where attention spans seem to grow ever shorter, it’s easy to overlook
the cumulative benefits of determined, incremental gains. yet stepping back to look at the
long term confirms that the industry has come far. The data show that insurers’ commitment to
measurement, transparency and accountability has, over the years, improved care, saved lives
and reduced suffering.
finally, this report looks ahead to consider how quality measurement can help address what is
arguably our country’s most ominous long-term threat—ballooning health care costs.
It is important to grasp that the most insidious cost problems are often problems of quality—
extra costs resulting from preventable medical errors, overtreatment and ineffective care. An
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increasingly common response to the cost crisis is to drop coverage or increase deductibles,
a reaction that can also be understood as a quality issue. After all, not having coverage is the
ultimate quality gap.
Reducing care as the main strategy for containing costs is a siren’s song: it might seem irresistible
or inevitable, but it is ultimately destructive. A more sustainable approach is to stretch our health
care dollars and get better results by emphasizing a value agenda.
This report identifies ways that health plans can be catalysts to transform health care from a
system that prizes volume to one that emphasizes value. In particular, we call on health plans to
redefine their roles to take advantage of existing tools that can spur and complement delivery
system reforms. These changes are important because value’s delicate intersection of cost and
quality is no longer just nice to have; it’s a necessity.
Thank you for your interest in these vital topics. And thank you for doing all you can to improve
the state of health care quality.

INTRoDUCTIoN
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • I N T R o D U C T I o N
NCQA produces The State of Health Care Quality Report every year to call attention to key
quality issues the United States faces and to drive improvement in the delivery of evidence-based
medicine. This report documents performance trends over time, tracks variation in care and
recommends quality improvements.
Thousands of consumers, health insurance executives, benefits managers, policy makers,
academics, consultants and journalists read this report. More than 1,000 health plans voluntarily
disclose the clinical quality, customer experience and resource use data that are the report’s
foundation. All data are rigorously audited. Consumer experience information is independently
collected and verified.
We commend all the health plans that contributed data for this report, and for the commitment
to accountability and quality improvement that they show in opting to disclose their performance
results publicly.
Electronic copies of this report are available free of charge at NCQA’s Web site, www.ncqa.org.
Printed copies are available for purchase by calling 888-275-7585.
We appreciate your interest in these topics and welcome your feedback. you can reach us at
communications@ncqa.org.
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ExECUTIVE SUMMARy
The Healthcare Effectiveness Data and Information Set (HEDIS ® ) continually changes to capture
better information and new medical knowledge and to reflect purchaser and consumer needs.
HEDIS was developed by forward-thinking employers and quality experts in the late 1980s; since
the early 1990s, it has been the national standard for health plan performance reporting. NCQA’s
goal is for HEDIS measures to have strong evidence and be meaningful, valid and practical.
With the addition of preferred provider organization (PPo) performance results to HEDIS, we
can now compare PPos with HMos. We consider these comparisons—some surprising, many
encouraging—to be the key findings of this year’s State of Health Care Quality report.
PPos on the rise, show they Improve by Measuring, too
With some exceptions, commercial HMo performance is typically higher than PPo performance.
one reason may be that HMos have traditionally had more tools to manage care: care
coordination processes, selective contracting and more bargaining power over providers.
Differences in information collection or populations could be factors, as could benefit design.
HMos usually have lower cost sharing for services than PPos, and higher PPo cost sharing
might reduce use of recommended services. That said, some PPos offered by health plans that
also offer HMos perform very well.
Differences between HMos and PPos in how they collect data for hybrid measures have
traditionally made it difficult to compare results. but there are indicators where PPos perform
at virtually the same level as HMos—for example, in the Use of Appropriate Medications for
Asthma measure. PPos are catching up on other measures, as well, by making bigger year-toyear
gains.
Interestingly, there are also performance differences between commercial HMos and PPos for
some patient experience measures. Many readers will recall that health plan members preferred
PPos to HMos because of fewer restrictions and larger networks. In 2005, PPo members were
more likely to give a high rating than HMo members were. but times have changed, and there
is a widening gap in performance: in 2010, HMo results were 6 percentage points higher than
PPo results.
The gap might be related to the rise in cost sharing—including deductibles—for PPos.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
one example where HMo results are higher than PPo results is in the share of members who
rated their health plan a 9 or 10 on a 10-point scale.
100
90
80
70
60
50
40
30
20
10
0
fIgurE 1. PErCEntagE of CoMMErCIal HMo and PPo
MEMbErs WHo ratE tHEIr Plan 9 or 10, 2005–2010
2005 2006 2007 2008 2009 2010
HMO PPO
Performance patterns between Medicare HMos and PPos are quite different. While HMos
outperform PPos on some measures, PPos outperform HMos on several others, notably
on measures related to drug therapy and monitoring. for example, on Pharmacological
Management of COPD—Systemic Corticosteroids, the average Medicare PPo rate is 69.6
percent and the average Medicare HMo rate is 66.6 percent.
Medicare has required HMos and PPos to report the same quality measures. The Medicare star
rating system that will send additional payments to high-performing plans is neutral to whether
a plan is a HMo or PPo. These policies may be driving higher PPo performance in Medicare.
other reasons for higher PPo performance could be geographic differences or variations in the
nature of the participating PPos.
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Comparisons across product line—Commercial, Medicaid and Medicare product measures
reflect varying policy and population differences, but we can compare performance on measures
reported by all product lines. on these measures, Medicaid performance tends to be worse than
commercial or Medicare performance. Exceptions are Chlamydia Screening for Women and
Persistence of Beta-Blocker Treatment After a Heart Attack. one reason for Medicaid’s lower
performance might be that its population faces challenging economic circumstances; for example,
transportation to doctor appointments may be an issue. Even though this pattern holds for the
overall population, we do see some Medicaid plans with very high performance, suggesting that
some of the challenges of caring for this population may be surmountable.
Medicare and commercial performance relative to each other varies by measure. Medicare
outperforms commercial plans on several intermediate outcome measures and process measures.
Comparison With last year’s findings
Childhood immunizations—In last year’s State of Health Care Quality report, NCQA noted a
significant drop in childhood immunizations in commercial health plans. This drop also appeared
in the Centers for Disease Control and Prevention’s national data. Reasons for the drop include
widespread concern about the (disproven) potential for some immunizations to lead to autism;
other explanations were the rise in cost sharing and the economic downturn. The 2010 data do
not show a full recovery for commercial health plans. The Combination 2 Childhood Immunization
Rate for commercial HMos had a slight uptick, but the numbers were not statistically significant.
Medicaid results held steady. There was a drop in the H influenza type b (Hib) immunization
rate, which might have been caused by a temporary shortage of vaccine, and a small gain in the
polio (IPV) immunization rate.
overall pattern 2009 to 2010—Although several measures showed important gains—including
Colorectal Cancer Screening, Use of Spirometry Testing in the Assessment and Diagnosis of COPD
and Pharmacotherapy Management of COPD—many measures showed little meaningful change.
Commercial and Medicare PPos displayed significant performance improvement and showed
progress in closing the performance gap with HMos.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
HEdIs: responding to Evidence and to Purchaser needs
Early quality measures were developed specifically for HMos, and focused on use of recommended
services. Today, measures are reported by other types of health plans, as well as some fee-for-service
(ffS) programs like Medicaid. Public payers (Medicare, Medicaid and the federal Employees Health
benefit [fEHb] program) and private payers (including those in the Evalu8 tool) use HEDIS measures.
Screening Rate
80
70
60
50
40
30
20
10
0
2001
fIgurE 2. EyE ExaMs for dIabEtICs–MEdICarE
2002
2003
2004
2005
2006
HMO PPO
NCQA now specifies HEDIS measures for individual clinician and clinician groups, using
both conventional data sources and electronic health records (EHR). HEDIS—the most widely
used measures for ambulatory care—includes measures of outcome; measures of overuse and
resource use; and measures of care coordination.
outcome measures—NCQA measures of outcome include “intermediate outcome measures” that
reflect test results, as well as patient experience. They capture cholesterol control, blood pressure
control and blood sugar (HbA1c) control in diabetics. Patient experience of care—measured
through the Consumer Assessment of Healthcare Providers and Systems (CAHPS ® )—is another
important measure of outcome.
2007
2008
2009
2010
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top 10 and bottom 10 states
“location, location, location” is not only the mantra of the real estate industry—it’s relevant to health
care, too.
Past editions of the State of Health Care Quality Report showed that quality varies by Census bureau
region. This year’s analysis of top 10 and bottom 10 states is more specific: it shows that some states
are outliers within their own regions.
Cohort calculations of top 10, bottom 10 and middle 32 states include Puerto Rico and Washington,
D.C. The calculations are based on mean rates of four measures: Comprehensive Diabetes Care
(nine indicators), Controlling High Blood Pressure (one indicator), Persistence of Beta-Blocker
Treatment After a Heart Attack and Cholesterol Management for Patients With Cardiovascular
Conditions (two indicators).
No state went from the top cohort to the bottom cohort (or vice versa) from 2009 to 2010.
d
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Top 10 cohort Middle 32 cohort
bottom 10 cohort
d
d
d
d
d d
d
d
d
d
Rose to 2010 cohort from 2009
fell to 2010 cohort from 2009
d
d
d
!
d
d d

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
Quality Measurement and the Million Hearts Initiative
Gains in HEDIS measures relevant to heart disease provide momentum for CDC’s Million Hearts initiative.
Millions Hearts launched in September 2011 and aims to prevent 1 million heart attacks in five years.
Performance on six heart-related measures improved in the four years the measures held their
current specifications—five improved by almost three percentage points. These steady gains
confirm that what gets measured gets improved, especially when measurement becomes a habit
that insurers sustain.
Mean Rate
90
80
70
60
50
40
30
20
10
0
1999
2000
* Measure respecification in 2005 accounts for some of the 2005-2006 performance change.
overuse and resource use—HEDIS emerged during an era when consumers were concerned
that HMos would deny needed care. Initial HEDIS measures focused on transparency around the
use of proven therapies and preventive care.
IMProvEMEnt In MEasurEs rElatEd
to HEart dIsEasE—CoMMErCIal HMos
2001
2002
2003
2004
2005
2006
2007
2008
2009
Cholesterol Management for Patients With Cardiovascular Conditions—LDL Cholesterol Screening
Medical Assistance With Smoking and Tobacco Use Cessation—Advising Smokers and
Tobacco Users to Quit
Persistence of Beta-Blocker Treatment After a Heart Attack
Controlling High Blood Pressure*
Cholesterol Management for Patients With Cardiovascular Conditions—LDL Control
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As health care spending skyrocketed and recognition of wasteful spending caught the nation’s
attention, NCQA invested in measures to prevent overuse. Examples of these measures are
Imaging Studies for Low Back Pain and Avoidance of Antibiotic Treatments in Adults With Acute
Bronchitis. NCQA’s Relative Resource Use measures help purchasers determine which plans
provide the highest quality of care with the lowest use of resources.
Care coordination—Many experts point to duplicate procedures and poor transitions between
providers and settings as examples of wasteful spending and poor quality. Several HEDIS
measures capture the results of care coordination and chronic disease management: Annual
Monitoring of Patients on Persistent Medications and Follow-Up After Hospitalization for Mental
Illness are two of them.
NCQA is also developing measures, standards and programs to assess and recognize care
coordination and case management. NCQA’s Patient-Centered Medical Home (PCMH) program
and new Accountable Care organization (ACo) program aim to improve care coordination.
They target the clinical practices and delivery system levels.
responding to the evidence—NCQA works with clinical experts to develop and revise HEDIS
measures based on evidence. Measures start with guidelines grounded in robust findings. When
the evidence base changes, so do the measures.
HEdIs measures for clinicians—In response to requests for measures below the health plan
level, NCQA collaborated with the American Medical Association to develop HEDIS physician
measures that assess clinical performance of ambulatory practices. These measures are widely
used in the Medicare Physician Quality Reporting System, the Meaningful Use programs and
NCQA’s Clinical Practice Recognition programs. The NCQA Diabetes Recognition program is
supported by private sector initiatives, including the New york State Diabetes Campaign, led by
the New york State Health foundation.
EHr measures—NCQA is working closely with the office of the National Coordinator for Health
Information Technology, the Centers for Medicare & Medicaid Services (CMS) and the National
Quality forum (NQf) to translate HEDIS measures into electronic formats. EHRs will simplify
reporting of quality measures. They have the potential to apply clinical logic, based on quality
measures, to improve care in different settings. They also create opportunities for developing
measures that were previously set aside because of the burden of data collection.

100
90
80
70
60
50
40
30
20
10
0
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
fIgurE 3. trEnds In ColorECtal CanCEr sCrEEnIng
for CoMMErCIal HMos, 2004–2010
2004 2005 2006 2007 2008 2009 2010
the Importance of Public reporting in Improving Health Plan Performance
Many health plans have stepped up to the challenge of collecting, reporting performance data
and being held accountable. Plans’ disclosure of quality information using reliable, audited,
standardized measures helps purchasers and consumers learn which plans and clinicians have
the best results. NCQA credits public reporting and plans’ commitment to improving for the
progress we have seen overall.
The next section highlights significant gains in performance over time. our discussion focuses on
commercial HMos, for which we have the longest series of data. We compare trends across plan
types and product lines.
of the 32 HEDIS Effectiveness of Care measures, 23 show clear trends of improvement. While
year-to-year gains are often quite small, they are steady over time. only one measure showed
unmistakable signs of worsening—Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis.
one example of progress is Colorectal Cancer Screening, with an almost 2 percentage point
increase (to 62.6 percent) between 2009 and 2010 for commercial HMos. Introduced in 2004,
15

16
this measure has shown steady gains. Similar gains have transpired for Medicare HMos,
although they have not reached the same level overall.
100
90
80
70
60
50
40
30
20
10
0
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
fIgurE 4. trEnds In Hba1C sCrEEnIng for PEoPlE WItH
dIabEtEs for CoMMErCIal HMos, 1999–2010
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
HbA1c Screening for People With Diabetes, introduced with a suite of diabetes measures in
1999, is another example of growth. The screening rate has risen steadily over the past 11 years,
progressing from 75 percent in 1999 to almost 90 percent in 2010 for commercial HMos. We
have seen similar gains across HMos, PPos and product lines, with Medicare performing best.
Performance on Medical Attention for Nephropathy has more than doubled for commercial
HMos. from 36 percent in the first year, it rose to almost 84 percent in 2010. (The 2005
addition of ACE/ARb therapy to the measure’s qualifying criteria accounts for some of the
performance gain.) like the HbA1c screening measure, all plan types, in all product lines, have
experienced gains. Medicare HMos had the strongest performance of all groups (89.2 percent)
in 2010.

100
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
fIgurE 5. trEnds In MEdICal attEntIon for nEPHroPatHy for
PEoPlE WItH dIabEtEs for CoMMErCIal HMos, 1999–2010
90
80
70
60
50
40
30
20
10
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Health plans have shown steady increases on most consumer experience measures, which are based
on a rating scale of 0–10. of seven CAHPS indicators, six showed consistent, gradual improvement.
Health plans that report quality publicly and have earned NCQA Accreditation based on their
performance should be applauded for achieving these gains. Public and private purchasers,
including Medicare, have contributed to this effort by offering incentives for plans and providers
to report and improve quality.
Complementary policies can create even stronger improvement incentives. NCQA incorporates
HEDIS results into accreditation levels and health plan rankings. Differentiating among health
plans gives credit to the work of excellent performers—and signals the results to consumers and
purchasers.
Even stronger incentives can flow from pay-for-performance programs, which are used by many
Medicaid agencies and the Medicare Advantage (MA) program. Health plans with the best
performance on quality might win additional payments; Medicaid plans might be assigned more
17

18
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
members. Purchasers that want to expedite performance gains may want to create incentives
around measures where there has been little progress.
Public reporting alone might not be a strong enough incentive to lead to change. The record on overuse
measures is disappointing, and suggests other factors are at play. for example, we have seen virtually
no change during the six-year history of Use of Imaging Studies for Low Back Pain. And although
overuse of antibiotics leads to development of antibiotic-resistant strains of bacteria, performance on
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis has worsened, falling from almost
29 percent (successful avoidance) to 22.5 percent for commercial HMos in 2010. one reason for this
might be that providers have difficulty resisting patients’ demand for a pill to address symptoms.
Implications: a vision of High-value Health Plans
In the 1990s, many policy makers thought health plans were the vehicle to better quality of care
and lower costs. The notion of “managed competition” underpinned the Clinton health reform
proposals. Proponents envisioned that health plans would compete on cost, and drive consumer
choice through transparency. HMos would combine their insurance function with active
management of patient care. Advocates saw opportunities to avoid emergency room use and
hospital care by improving benefit design, networks and other programs.
What happened instead was “managed care backlash”: members rebelled against limited
provider networks and utilization review. 1 And the rise of self-insured employers led to increased
contracting with PPo networks, rather than with full-risk-bearing HMos.
one big difference between earlier ideas about health reform and the 2010 Patient Protection
and Affordable Care Act (PPACA) is an expectation that change should happen in the health
care delivery system. The locus is the clinician’s office—and, to a lesser extent, the hospital.
Programs like PCMH and the Meaningful Use of Health Information Technology (HIT) initiative
push small practices to track patients’ care over time and across settings and to report and
benchmark their performance against quality measures derived from medical evidence.
The ACo program reflects this vision on a larger scale. The model involves a collection of
clinician practices (and possibly hospitals) taking collective responsibility for improving patient
care and lowering costs.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
Changes to payment incentives will allow organizations to share savings for reducing
unnecessary care. Proponents hope ACos will invest in strategies and technologies to help
patients manage chronic disease. The goal is to avoid emergency room and hospital care.
Some might ask, if the delivery system embraces better coordination, patient management and
integration, why do we need health plans? How do health plans add value if physicians and
hospitals deliver better care?
What can health plans do?
It is worth noting that health plans will continue to be the entities holding insurance risk.
organizations committed to delivery system innovations will likely be wary of holding full
insurance risk and managing population health. Thus, health plans will continue to serve this
important purpose for some payers.
Health plans have experience managing insurance risk and are regulated by states to ensure
stability and financial soundness. They hold reserves and have processes to account for claims
that have been incurred but not recorded; they can pool risk and access commercial reinsurance
policies. They have data that enable analysis of services and use predictive modeling to target
interventions—like case management—to high-risk populations.
Health plans offering coverage in Medicaid, Medicare and Exchanges (2014) will have to bear
financial risk. They also will have roles in benefit and coverage design, as well as collecting and
reporting quality results.
The following section describes a value agenda for health plans and suggests a vision for highvalue
health plans. NCQA sees a strong role for health plans to nurture and promote changes at
the delivery-system level.
fostering delivery-system reforms—Health plans can lead or partner with other payers
(employers, Medicaid, Medicare) to sponsor PCMH and ACo projects. They can change payment
methods to encourage these programs, set participation standards and offer technical support.
Health plans can also work with hospitals to implement safety initiatives and reduce readmissions.
Health plans can provide data to practices to help them manage and coordinate care. They can
offer incentives to invest in and use HIT, can explain the benefits of these innovations to members
and can identify participating providers.
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N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
designing benefits and coverage—Most recent changes in benefit design have involved setting
coverage limits and increasing cost sharing through higher deductibles. However, health plans
and purchasers can collaborate to develop benefits that encourage members to select care that
improves their health and deter members from using services that are dangerous or ineffective.
An application of this idea is value-based insurance design. It reduces cost sharing for services
with the greatest value; for example, proven preventive care and maintenance therapies for chronic
conditions. Another example is reference pricing, which steers physicians and patients to the most
effective treatments by tying reimbursement for an item or service to the price of the most effective
treatment. less effective treatments are still covered by the plan, but members pay more for them.
Collecting data from claims, enrollment, patients and medical records—Health plans’ ability to
aggregate data creates opportunities to report on care for their populations and for practices.
because of their size and experience, health plans can manage a diverse group of patients
across sites of care. 2 George Isham, medical director of Health Partners in Minnesota, identified
key areas where health plans contribute:
• Paying, collecting and aggregating bills. billing records describe patients’ conditions and the
care they received. Combined with enrollment information from pharmacies and laboratories,
and extracts from medical records, these records form the basis of quality measurement.
• Collecting data and using it to inform the three-part aim in the National Quality Strategy
(better care, healthy people/healthy communities and affordable care). Plans know how to
turn information into quality measures.
• Cultivating transparency and displaying information for the public. Hospitals and nursing homes
are becoming accustomed to transparency, but it is still rare among physicians and in outpatient
settings. Small numbers and a lack of specialty care measures have hindered progress.
Physicians and their representatives have not embraced public performance reporting.
• Developing quality improvement projects. Health plans have significant experience helping
providers improve care.
• Collaborating to develop innovations in performance measurement and data analysis. Health
plans have had success identifying high-risk patients and deploying inventive case management.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
Putting the network together—ACos may eventually become health plans. Short of that, they
may serve as the provider network for an employer- or provider-sponsored Medicare Advantage
or Medicaid plan. but many purchasers need to offer coverage across a state—or even across
the country—and health plans must assemble entire networks to meet this need.
Health plans can use cost sharing to guide patients to high-value hospitals and providers. They
can identify hospitals that are “Centers of Excellence” for treating high-cost or high-risk conditions.
Then, they can make them preferred providers with the lowest cost sharing for patients. This
approach could also reward hospitals or other providers that have strong patient safety records.
The high-value plan of the future should rely heavily on value metrics to select its network.
Ensuring that members have access to physicians with good credentials is an important part of
consumer protection—and of NCQA Health Plan Accreditation. but excellent health plans must
also measure the performance of providers. They must use that information to build networks and
report the information to consumers.
activating patients—because health plans will continue to hold risk and enroll members, they
are uniquely situated to connect with patients and make them active partners in their health and
wellness. Plans could pursue the following strategies to engage patients.
• Conduct wellness and health promotion through health appraisals and other strategies. Use
financial incentives to encourage participation in programs designed to improve health.
Smoking cessation and weight loss are two examples.
• Incorporate benefit design incentives that promote the best care and providers.
• Publicly report provider performance and involvement in delivery system reforms.
• Provide members with incentives to use decision aids to choose therapies.
• Cover palliative and end-of-life care and implement strategies to ensure that providers know
and follow patient preferences and decisions.
• Survey enrollees about their experiences and how they rate providers. Then, use this
information to provide feedback to physicians and construct networks.
• Make other options available to patients who opt out of ACos.
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N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Health plans serving low-income patients and those with multiple chronic conditions also can invest
in care management, which concentrates the focus on providing or connecting patients to health
care and other service providers. While some of this work is moving to the delivery system, small
clinical practices may not have the resources to invest in dedicated staff to do this work; health
plans can either provide it or make available care coordination to share across multiple practices.
How do we get health plans to high value?
NCQA’s experience has demonstrated that “what gets measured gets improved.” Many of our
expectations for health plans could be turned into performance measures or standards, allowing
health plans to review programs and policies against clear, detailed program elements.
We have developed several programs that let high-performing health plans earn NCQA
Recognition or NCQA Distinction. Most recently we created a distinction program for plans
committed to improving multicultural care.
Pay for performance might be successful in furthering the value agenda by awarding higher
payments to plans that demonstrate high value. Many state Medicaid agencies have such
programs; the Medicare Advantage program will soon, as well. Measures of health plan value
could be added to that program or used to give health plans extra credit.
Additionally, the Exchanges created by the PPACA could direct participants into plans that offer
value. High-value plans could be visibly rewarded on the Exchanges’ report cards—or listed
prominently on the national Web portal.
Information about high-value plans could be presented when consumers are first comparing
plans. However, Exchanges must be mindful of “choice fatigue,” which can result from
consumers’ having too much information and too many options. Exchanges can be architects
of choice that guide people toward better value and quality, but the success of health reform
depends on galvanizing consumers, not overwhelming them.
Regardless of the specific approach, policy makers and purchasers should seize opportunities to
work with health plans. Collaboration can improve health care and markets.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • E x E C U T I V E S U M M A R y
Conclusion
The Dartmouth Group has shown that cost and quality do not have to be a trade-off, but how do
we get to affordable, quality health care?
We must focus on buying value in health care, but the politics are challenging. our current marketplace
is fractured; providers have different approaches for working with each sector. Patients are confused
and vulnerable, and appeals to their fears have succeeded. It is challenging in this environment to
implement strong, synchronized strategies to improve coordination and delivery of care.
Health plans can be drivers of improvements to cost and quality in health care markets. As
“market makers,” they should pursue strategies to activate and engage members.
leading-edge health plans devote significant resources to keeping their members healthy. Health
plans need to construct “value choices” at the provider level so patients do not overpay and are
not over-treated or victims of medical errors. NCQA’s objective in seeking a value agenda is
to advance the triple aim—improving the individual’s experience of care and the population’s
health, and reducing the overall cost of care.
Ultimately, consumers hold the power to reshape insurance markets. The concept of a new insurance
marketplace, facilitated by Exchanges, flows from the premise that consumers will be motivated to
compare health plans. Measures based on CAHPS and HEDIS are a logical place to start.
EndnotEs
1. Draper, D.A., R.E. Hurley, C.S. lesser, b.C. Strunk. 202. The Changing face of Managed Care. Health Affairs, Jan-feb;21(1):11–23.
2. Enthoven, A. 1993. The History and Principles of Managed Competition. Health Affairs, Vol 12, Supplement 1, 24–48.
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HEDIS MEASURES of CARE
about HEdIs
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by most HMos and
PPos plans to measure performance on important dimensions of care and service. by providing
objective, clinical performance data measures against a detailed set of measurement criteria,
HEDIS helps purchasers and consumers compare health plans’ performance.
HEDIS measures address a broad range of important health issues:
• Antibiotic use
• Asthma
• breast, cervical and colorectal cancers
• Care for older adults
• Childhood immunizations
• Cholesterol management
HEDIS includes the Consumer Assessment of Healthcare Providers and Systems (CAHPS) 4.0
Survey. The CAHPS survey measures members’ experiences with their health care in areas such
as claims processing and getting needed care quickly, and asks them to rate their health plan on
a scale of 0–10.
HEDIS 2011 data collected for this report generally reflect services delivered during calendar
year 2010. To ensure validity of HEDIS results, certified analysts rigorously audit all data, using
a process NCQA designed. See the appendices for more details about national averages and
performance trends.
Hos Measures
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
• Diabetes
• High blood pressure
• Medication management
• Mental illness
• Smoking
• Prenatal and postpartum care
Medicare Health outcomes Survey (HoS) measures evaluate the physical and mental health
of seniors enrolled in Medicare and are the first patient-based self-report of health status as a
measure of quality of care in elderly populations. Including HoS in HEDIS measurement creates
a broader scope of measures to evaluate the quality of care provided by health plans for the
Medicare population. Included in this report are four HoS measures:

• fall Risk Management
• Management of Urinary Incontinence in older Adults
• osteoporosis Testing in older Adults
• Physical Activity in older Adults.
terms
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E 25
NA: Measure rates have no available data. In some instances, data are not collected for a
measure in a product line.
Rate: The statistical mean for reported data. Each measure is described by an average rate for
each applicable product line.
a note on Medicare survey data
Medicare CAHPS survey data of consumer experience and HEDIS measures collected through
the survey (such as flu Shots for Adults and Medical Assistance With Smoking and Tobacco
Use Cessation) are not available when NCQA prints the State of Health Care Quality Report
in September. NCQA will issue an updated version of this report that includes those data in
November.

S A f E T y A N D P o T E N T I A l W A S T E
26
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
AVoIDANCE of ANTIbIoTIC TREATMENT
IN ADUlTS WITH ACUTE bRoNCHITIS
Acute bronchitis clinically presents as a cough lasting more than five days (typically, from
one to three weeks). About 90 percent of cases are caused by a virus. 1,2 The Avoidance of
Antibiotic Treatment in Adults With Acute Bronchitis measure evaluates whether adults were
treated appropriately by not receiving antibiotics, which are not indicated and may contribute to
antibiotic resistance.
• Acute bronchitis affects approximately
5 percent of U.S. adults annually and
continues to rank among the top 10
conditions for which patients seek treatment
in clinical settings. 1
• Antibiotics are prescribed in more than 60
percent of bronchitis cases; of those, 80
percent were unnecessary, according to the
Centers for Disease Control and Prevention
(CDC) guidelines. 1,2 Antibiotic treatment
is not usually appropriate for acute
bronchitis, with the exception of comorbid
diseases requiring antibiotics. 3
the Case for Improvement
• More than $1.1 billion is spent annually
on unnecessary antibiotics for respiratory
infections in adults. 4
• Treating drug-resistant pathogens poses
a significant burden on the system
through repeated health care visits and
greater risk of disease complications and
hospitalizations—which lead to increased
health care costs. 5,6
• Diminished effectiveness of antibiotics
against bacterial infections, particularly
for use in patients who may need them
to fight future, life-threatening bacterial
infections, poses a significant public health
concern. When resistance makes widelyused
antibiotics ineffective, an alternative
treatment may not be available, 7 or
physicians may use more potent antibiotics,
which are often more toxic and more
expensive. This can result in longer hospital
stays, more serious side effects and
increased financial burden on the system
and on patients. 8
HEdIs Measure definition
This measure assesses the percentage of
adults 18–64 years of age with a diagnosis of
acute bronchitis who were not dispensed an
antibiotic prescription on or three days after
an episode. A higher rate indicates better
performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
results
Antibiotic treatment is only infrequently
appropriate for acute bronchitis. Misuse
or overuse can be avoided by prescribing
treatment when necessary, as well as
informing patients and clinicians regarding
the appropriate use of antibiotics.
yEAR
trEatMEnt ratE
27
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 22.5 21.3 NA NA 23.5
2009 24.0 22.6 NA NA 25.6
2008 24.6 26.8 NA NA 25.8
2007 25.4 29.3 NA NA 25.9
2006 28.7 29.7 NA NA 28.0
S A f E T y A N D P o T E N T I A l W A S T E

S A f E T y A N D P o T E N T I A l W A S T E
28
back pain is one of America’s most common medical problems. An estimated 75 percent–85
percent of Americans will experience back pain at some point, 1 and approximately 25 percent
of Americans will experience at least one day of back pain during any three-month period. 2
Although imaging is used to diagnose the cause of low back pain, it is costly and ineffective. less
than 1 percent of radiographs identify a specific cause of low back pain. 3 The Use of Imaging
Studies for Low Back Pain measure assesses the number of patients with lower back pain who did
not get an x-ray, MRI or CT scan as part of their treatment.
• Although a variety of minor injuries and
conditions can lead to back pain, most
acute low back pain is benign and selflimiting.
Imaging studies are not required
for diagnosis. 8
• Studies have shown that patients treated
without imaging experience no difference
in health outcomes. 4,5 Abnormalities
discovered through imaging were as
common in individuals without back pain
as they were in individuals with low back
pain. 4
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
USE of IMAGING STUDIES foR loWER bACk PAIN
• Imaging for early, acute low back pain
can lead to surgery. Complications from
unnecessary surgery can prolong back
pain or lead to permanent disability. 5
the Case for Improvement
• on average, patients with low back pain
have higher overall medical costs. Patients
with back pain spend an average of
$7,211, while comparable patients without
back pain spend an average of $2,400
over a two-year period. Patients with low
back pain who opt for surgery incur an
average of $34,000 in direct medical costs. 8
• According to the Agency for Healthcare
Research and Quality (AHRQ), almost
18,000 Americans sought medical attention
for low back pain in 2008. Additionally,
medical care for these individuals cost
approximately $35 billion dollars, with
imaging driving much of the cost. 6,7

HEdIs Measure definition
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
The percentage of adults with a primary
diagnosis of low back pain who did not have
an imaging study (plain x-ray, MRI or CT
scan) within 28 days of the diagnosis.
results
With the use of costly imaging studies failing
to produce positive health outcomes for
patients with low back pain, x-ray, MRI and
CT scans should primarily be used for patients
with neurologic deficits or other serious
underlying conditions.
yEAR
IMagIng studIEs for
loW baCk PaIn
29
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 74.2 73.3 NA NA 75.5
2009 73.9 72.7 NA NA 76.1
2008 73.1 72.3 NA NA 75.7
2007 74.6 73.3 NA NA 77.3
2006 73.9 72.1 NA NA 78.3
2005 75.4 72.6 NA NA 79.0
S A f E T y A N D P o T E N T I A l W A S T E

S A f E T y A N D P o T E N T I A l W A S T E
30
RElATIVE RESoURCE USE
NCQa’s Relative Resource Use (RRU) measures indicate how intensively health plans use heath
care resources (e.g., doctor visits, hospital stays, surgery, drugs) compared with other plans
in the same region, adjusted for the population of members they serve. When combined with
NCQa heDiS quality measures, rru measures reveal value.
RRU measures help health care purchasers identify health plans that deliver high-quality care while
managing associated costs. The table below is a hypothetical example of RRU results for plans in
one region for patients with diabetes. Scores above 1.0 indicate higher-than-average use, while
scores below 1.0 indicate lower-than-average use. In this example, Plan D is highlighted because
it offers an appealing combination of above-average quality and below-average resource use.
Plan
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HyPotHEtICal dIabEtEs rru In a sInglE rEgIon
Quality
score
Combined
Medical
diabetes Medical resource use
Inpatient
Hospital
Evaluation &
Management
surgery &
Procedures
rx drugs
Plan A 1.06 1.14 1.32 1.00 0.89 1.14
Plan b 1.10 0.85 0.96 0.74 0.73 1.12
Plan C 1.10 0.80 0.84 0.79 0.71 1.16
Plan D 1.14 0.74 0.77 0.85 0.56 1.13
Plan E 0.97 0.73 0.79 0.76 0.54 1.19
NCQA collects RRU data for five conditions that account for more than 60 percent of all health
spending: asthma, cardiovascular disease, CoPD, diabetes and hypertension. overall, RRU measures
reveal that the amount of services used to treat people often has little correlation to the quality of care.
To allow fair comparison of plans, RRU measures feature risk adjustment and price
standardization of services. The goal of risk adjustment is to eliminate sources of variation that
neither health plans nor providers can control. factors used in risk adjustment include age,
gender and presence of other serious health conditions. Standardized prices are assigned to
each unit of service delivered to health plan members and reported by service category (e.g.,
inpatient hospital care, evaluation and management, surgery and other procedures, diagnostic
lab and imaging, prescription drugs) for each of the five conditions.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
looking at quality and resource use scores together, purchasers should be most interested in
plans that are high in quality and low in resource use. As depicted in the following scatterplots,
scores that place health plans in the upper left quadrant are generally considered most desirable
(above-average quality, below-average resource use). Health plans in the lower right quadrant
are less desirable (below-average quality, above-average resource use).
This report focuses on the three rru measures where discrepancies between plans’
resource use and resulting quality are most pronounced: hypertension, diabetes and certain
cardiovascular conditions. We do not show commercial rru scatterplots because they have
changed little since last year’s State of Health Care Quality Report and are available in NCQa’s
Quality Compass product. Conversely, we show Medicare and Medicaid results because we
did not do so in last year’s report, and because the data are not available in Quality Compass.
upcoming refinements to rru
• Updated Risk Adjustment Approach: NCQa moved to an improved risk adjustment
approach that was adapted from the Center for Medicare & Medicaid Service’s (CMS)
hierarchical Condition Category (hCC) case-mix adjustment approach. The revised risk
adjustment considers disease severity and number of comorbidities, in addition to other
factors that inform the cost of care delivered to health plan members.
• Measure Enhancement: NCQa expanded its measurement of specific procedures,
particularly for diabetes and cardiovascular care, to provide plans with actionable
information about the frequently performed services that significantly contribute to resource
use. examples of these procedures include cardiac catheterization; carotid artery stenosis
diagnostic tests; electron beam computed tomography and nuclear imaging stress tests
for coronary artery disease; and cardiac computed tomography screening. reporting risk
adjusted utilization of these services, alongside cost information, is expected to increase
meaning and actionability of measure results.
• Pharmacy Prescription Utilization: To provide more detail for the prescription drugs service
category, NCQa added generic and name-brand utilization rates to the five measures.
Compared with the previous format, the data now capture how well a plan manages its
pharmacy costs with respect to generic, brand-name and multisource drugs.
31
S A f E T y A N D P o T E N T I A l W A S T E

S A f E T y A N D P o T E N T I A l W A S T E
32
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Quality (Indexed Ratio)
Quality (Indexed Ratio)
1.5
1
0.5
MEdICarE HMos: dIabEtEs
0.5 1
RRU (Indexed Ratio)
1.5
1.5
1
0.5
MEdICarE PPos: dIabEtEs
0.5 1
RRU (Indexed Ratio)
1.5

Quality (Indexed Ratio)
Quality (Indexed Ratio)
1.5
1
0.5
1.5
1
0.5
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
MEdICarE HMos: CardIovasCular CondItIons
0.5 1 1.5
RRU (Indexed Ratio)
MEdICarE PPos: CardIovasCular CondItIons
0.5 1 1.5
RRU (Indexed Ratio)
33
S A f E T y A N D P o T E N T I A l W A S T E

S A f E T y A N D P o T E N T I A l W A S T E
34
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Quality (Indexed Ratio)
Quality (Indexed Ratio)
1.5
1
0.5
1.5
1
MEdICarE HMos: HyPErtEnsIon
0.5 1 1.5
RRU (Indexed Ratio)
MEdICarE PPos: HyPErtEnsIon
0.5
0.5 1 1.5
RRU (Indexed Ratio)

Quality (Indexed Ratio)
Quality (Indexed Ratio)
Quality (Indexed Ratio)
1.5
1
0.5
1.5
1
0.5
1.5
1
0.5
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
MEdICaId HMos: dIabEtEs
0.5 1 1.5
RRU (Indexed Ratio)
MEdICaId HMos: CardIovasCular CondItIons
0.5 1 1.5
RRU (Indexed Ratio)
MEdICaId HMos: HyPErtEnsIon
0.5 1 1.5
RRU (Indexed Ratio)
35
S A f E T y A N D P o T E N T I A l W A S T E

W E l l N E S S A N D P R E V E N T I o N
36
obesity is responsible for more deaths in the U.S. than AIDS, all cancers and all accidents
combined. 1 Individuals are identified as being overweight or obese if their weight range is greater
than is generally considered healthy for their height. 2 obesity is measured by body mass index
(bMI), which estimates body fat and gauges risk for high body-fat diseases. 3 The Adult Body
Mass Index Assessment measure evaluates the percentage of adults who have their bMI measured
regularly to assess their risk for overweight or obesity, and/or risk for related health complications.
• According to the Centers for Disease
Control and Prevention (CDC), more than
two-thirds of U.S. adults are overweight
or obese and more than one-third are
considered obese. 4
• overweight and obesity occur from
consuming too many calories and not
engaging in enough physical activity to
compensate. This can be the result of a
number of factors, including behavior,
environment, culture and socioeconomic
status. Genes and metabolism can also
affect weight. 5
• As few as 31 percent of U.S. adults report
that they participate in regular leisuretime
physical activity: three sessions per
week of vigorous physical activity lasting
20 minutes or more, or five sessions per
week of light-to-moderate physical activity
lasting 30 minutes or more. Approximately
40 percent report no leisure-time physical
activity. 4
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
ADUlT bMI ASSESSMENT
the Case for Improvement
• According to a 2009 study by the
CDC and RTI International, a research
organization, 6 the direct and indirect
cost of obesity is more than $147 billion
annually. obese patients spend 42 percent
more for their medical care than those in a
healthy weight range—an average $1,429
more per year. The study found that
Medicare, Medicaid and private insurers
increased spending due to obesity from 6.5
percent in 1998 to 9.1 percent in 2006.
This amounts to a $40 billion increase in
medical sending through 2006, including a
$7 billion increase in Medicare prescription
drug costs. 7
• obesity can cause a number of serious
medical conditions, including type 2
diabetes, heart disease and high blood
pressure, and increases the risk of strokes
and certain types of cancers. 8

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
• obese men are more likely to develop
cancer of the colon, rectum or prostate;
obese women are more likely to develop
cancer of the gallbladder, uterus, cervix or
ovaries. 8
HEdIs Measure definition
The percentage of adults 18–74 years of age
who had an outpatient visit and who had their
bMI documented during the measurement year
or the year prior to the measurement year.
results
Weight loss and physical activity are
recommended for people who are overweight
or obese. losing 5 percent–10 percent of
body weight will help lower an obese person’s
risk of developing diseases associated with
obesity. 4
yEAR
assEssMEnt ratE
37
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 40.7 11.6 50.4 36.6 42.2
2009 41.3 15.7 38.8 24.1 34.6
W E l l N E S S A N D P R E V E N T I o N

W E l l N E S S A N D P R E V E N T I o N
38
• flu especially affects the health of people
50–64 2 years of age. one third of all
Americans 50–64 have one or more
chronic medical conditions that puts
them at increased risk for serious flu
complications. 3
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
flU SHoTS foR ADUlTS
Each year, 5 percent–20 percent of Americans contract influenza (flu). More than 200,000
people are hospitalized from flu-related complications, which include pneumonia, dehydration
and deterioration of chronic health conditions, such as heart failure, diabetes and asthma. 1
The Flu Shots for Adults Ages 50–64 measure assesses whether adults received an influenza
vaccination (flu shot).
• flu shots are the most effective way to
prevent severe illness or death resulting
from influenza and its complications. 4
• Influenza vaccines may prevent 50
percent–60 percent of hospitalizations
and 68 percent of deaths from flu-related
complications for this age group. 5
the Case for Improvement
• In 2008, only 67 percent of adults between
50 and 64 reported receiving an influenza
vaccination. 6 over the course of an
average flu season, more than 15,000 lives
could be saved if 90 percent vaccination
coverage was achieved annually. 7
• A single flu epidemic can result in more
than $3 billion in direct hospitalization
costs alone. 8
• flu shots have been shown to be highly
cost-effective for adults 50–64. 9 The
vaccination is estimated to cost just $16.70
per person vaccinated, including direct and
indirect medical costs and costs associated
with potential side-effects. 10
HEdIs Measure definition
A rolling average represents the percentage of
commercial members 50–64 years of age who
received an influenza vaccination between
September 1 of the measurement year and
the date when the CAHPS 4.0H survey was
completed.

esults
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
flu shots for adults ages 50–64 could save
thousands of lives and result in dramatic cost
savings for the health care system.
yEAR
vaCCInatIon ratE
39
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 52.5 51.6 NA NA NA
2009 51.3 50.5 64.5 65.1 NA
2008 49.8 49.2 65.8 66.7 NA
2007 48.6 48.1 68.6 68.9 NA
2006 45.6 44.5 67.8 68.2 NA
2005 36.2 37.1 70.3 69.9 NA
2004 38.9 NA 74.8 NA NA
2003 47.9 NA 74.4 NA NA
2002 44.0 NA 72.5 NA NA
2001 30.3 NA 71.2 NA NA
W E l l N E S S A N D P R E V E N T I o N

W E l l N E S S A N D P R E V E N T I o N
40
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
bREAST CANCER SCREENING
breast cancer is one of the most common types of cancers, and accounts for a quarter of all new
cancer diagnoses among women in the U.S. 1 The Breast Cancer Screening measure assesses whether
women between 40 and 69 years of age received a mammogram screening for breast cancer.
• breast cancer is the second cause of cancer
deaths in women (after lung cancer). 2
• breast cancer deaths have decreased over
the years, thanks to early detection using
mammography. Screening every two years
decreases the risk of mortality by more
than 16 percent in women between 50 and
69, compared with no screening. 3
• About 70 percent–80 percent of breast
cancers occur in women who have no
family history of breast cancer. These
cancers occur because of genetic
abnormalities that happen as a result of
the aging process, 4 and there is a clear
connection between age and developing
breast cancer. 5,6
• Mammogram screening has demonstrated
reductions in breast cancer mortality
and there is a clear connection between
developing breast cancer and age. 5,6
the Case for Improvement
• breast cancer treatment costs in the U.S.
total nearly $7 billion a year, including $2
billion spent on late-stage treatment. 5 lowincome
women are less likely to have had
a mammogram within the past two years,
increasing their risk of late-stage diagnosis
and decreasing their chance of survival. 7
• Early detection of breast cancer by
mammography may lead to greater
range of treatment options that include
less-aggressive surgery and less-invasive
therapy. 7
• The five-year survival rate for women
who are diagnosed early is 98 percent,
compared with the late-diagnosed breast
cancer survival rate of only 23 percent. 2
HEdIs Measure definition
The percentage of women 40–69 years of age
who had at least one mammogram to screen
for breast cancer in the past two years.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
results
Early detection and better treatment have
resulted in increased survival rates for
women with breast cancer. If breast cancer
is diagnosed when it is in its earliest stages,
treatment may be more effective and less
expensive. 5
yEAR
sCrEEnIng ratE
41
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 70.8 67.0 68.5 65.8 51.3
2009 71.3 67.1 69.3 65.5 52.4
2008 70.2 66.0 68.0 65.2 50.8
2007 69.1 64.6 67.3 64.5 49.8
2006 68.9 63.5 69.5 68.6 49.1
2005 72.0 63.9 71.6 69.0 53.9
2004 73.4 NA 74.0 NA 54.1
2003 75.3 NA 74.0 NA 55.9
2002 74.9 NA 74.5 NA 56.0
2001 75.5 NA 75.3 NA 55.1
2000 74.5 NA NA NA NA
1999 73.4 NA NA NA NA
W E l l N E S S A N D P R E V E N T I o N

W E l l N E S S A N D P R E V E N T I o N
42
Cervical cancer is nearly 100 percent preventable, yet it is the second most common cancer
among women worldwide. 1,2 In the United States, about 12,000 women are diagnosed with
cervical cancer each year, resulting in more than 4,000 deaths. 3,4 The Cervical Cancer Screening
measure assesses whether women between 21 and 64 years of age received screening for
cervical cancer using a Pap test.
• for women in whom pre-cancerous lesions
were detected through Pap tests, the
likelihood of survival is nearly 100 percent
with appropriate evaluation, treatment and
follow up. 1,3
• In 2008, the prevalence of recent Pap
test use was lowest among older women,
women with no health insurance and recent
immigrants. 1
the Case for Improvement
• The total cost of treatment for cervical
cancer is $300 million–$400 million
annually. 2
• between 60 percent and 80 percent of
women with advanced cervical cancer
have not had a Pap test in the past five
years. 1
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CERVICAl CANCER SCREENING
• All women are at risk for cervical cancer
and women with the lowest levels of
education tend to have fewer screenings in
their lifetime. 4
• A woman who does not have regular Pap
tests significantly increases her chances of
developing cervical cancer. 3
HEdIs Measure definition
The percentage of women 21–64 years of age
who received one or more Pap test to screen
for cervical cancer in the past three years.
results
Cervical cancer incidence and mortality rates
have decreased 67 percent over the past
three decades. Most of the reduction can
be attributed to the Pap test, which detects
cervical cancer and precancerous lesions. 1

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
sCrEEnIng ratE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 77.0 74.5 NA NA 67.2
2009 77.3 74.6 NA NA 65.8
2008 80.7 74.0 NA NA 66.0
2007 81.7 73.5 NA NA 64.8
2006 81.0 72.6 NA NA 65.7
2005 81.8 74.6 NA NA 65.2
2004 80.9 NA NA NA 64.7
2003 81.8 NA NA NA 64.0
2002 80.5 NA NA NA 62.2
2001 80.0 NA NA NA 61.1
2000 78.1 NA NA NA NA
1999 71.8 NA NA NA NA
43
W E l l N E S S A N D P R E V E N T I o N

W E l l N E S S A N D P R E V E N T I o N
44
In 2010 an estimated 142,570 men and women were diagnosed with colon cancer, and
approximately 51,370 died from the disease, making it the second leading cause of cancer
death in the United States. 1,2 The Colorectal Cancer Screening measure assesses whether adults
50–75 years of age received screening for colorectal cancer, based on the recommendation of
the U.S. Preventive Services Task force. 3
• Symptoms are not common in colorectal
cancer until the disease has progressed
and chances of survival have decreased. 4
Treatment in the disease’s earliest stage is
highly successful, with a five-year survival
rate of 74 percent. 5
• Most colorectal cancers occur in people
without a family history of colorectal
cancer. 6 While screening is extremely
effective in detecting colorectal cancer, it
remains underutilized.
the Case for Improvement
• Approximately half of American adults do
not receive the necessary colorectal cancer
screening. 7 Screening rates for colorectal
cancer lag behind other cancer screening
rates. 8
• fecal occult blood tests, colonoscopy and
flexible sigmoidoscopy are shown to be
effective screening methods. 6 Colorectal
screen of individuals with no symptoms
can identify polyps whose removal can
prevent more than 90 percent of colorectal
cancers. 9
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
ColoRECTAl CANCER SCREENING
• Deaths associated with colorectal cancer
declined in 2010, continuing a 15-year
trend attributed to increased screening
and early detection. 3,10 between 2003
and 2007, 35 states saw decreases in the
number of new cases of colorectal cancer, 11
but regional variation exists.
• Screening for colorectal cancer is shown
to be cost effective for the health care
system. The cost of screening far outweighs
the costs of treating more progressive
colorectal cancer. 12
• Doctors’ recommendations have been
found to be a major predictor of whether
patients receive the supported screening. 13
HEdIs Measure definition
The percentage of adults 50–75 years of age
who had appropriate screening for colorectal
cancer with any of the following tests: fecal
occult blood test during the measurement
year; flexible sigmoidoscopy during the
measurement year or the four years prior to
the measurement year; or colonoscopy during

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
the measurement year or in any of the nine
years prior to the measurement year.
results
Colorectal cancer screening in asymptomatic
adults between 50 and 75 can catch
dangerous polyps before they become
cancerous, or can detect colorectal cancer
in its early stages, when treatment is most
effective.
yEAR
sCrEEnIng ratE
45
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 62.6 47.6 57.6 41.0 NA
2009 60.7 47.0 54.9 40.1 NA
2008 58.6 45.3 53.1 41.8 NA
2007 55.6 42.5 50.4 39.5 NA
2006 54.5 42.1 53.3 47.1 NA
2005 52.3 43.4 54.0 49.7 NA
2004 49.0 NA 52.6 NA NA
W E l l N E S S A N D P R E V E N T I o N

W E l l N E S S A N D P R E V E N T I o N
46
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
MEDICAl ASSISTANCE WITH SMokING
AND TobACCo USE CESSATIoN
Smoking is the second most common cause of death in the world, causing almost a half-million deaths
annually, 1 and it is by far the most directly preventable cause of death and disability in the United
States. 2,3 In 2009, almost 18 percent of adults in the U.S.—more than 40 million people—were
smokers. 2 The Medical Assistance With Smoking and Tobacco Use Cessation measure assesses whether
adults who use tobacco products receive counseling, medications and strategies to help them quit.
• Although consumption of cigarettes
continues to decline and the number of
people who are heavy smokers (i.e.,
smoke a pack each day) has dropped
significantly, 5 the consumption of cigars
and smokeless tobacco is on the rise. 6
• More than 70 percent of smokers want to
quit and more than 40 percent try to quit
each year. 7 less than 7 percent succeed in
kicking the habit. 7
the Case for Improvement
• Studies have shown that a physician’s
advice to quit is an important motivator
for smokers attempting to quit,8 but fewer
than half of smokers receive cessation
counseling. 9 Doctors and other health care
providers can improve a patient’s outcome
in as little as three minutes, according to
the Public Health Service Guidelines. 10
Research indicates that the more intense the
intervention, the higher the likelihood that
smokers will quit successfully. 8
• Annual smoking-related health care costs
are estimated at $96 billion. 9 When
productivity losses are considered, the total
economic burden of smoking is estimated
to be $193 billion per year. 9 In an
18-month period, smokers incur 18 percent
higher health care charges than people
who never smoked. 7
• Women and minorities receive advice
about quitting smoking less frequently than
men who smoke. 11,12
HEdIs Measure definition
This measure evaluates three facets of
providing medical assistance with smoking
and tobacco use cessations.
• Advising Smokers and Tobacco Users to Quit.
A rolling average represents the percentage
of adults 18 years of age and older who are
current smokers or tobacco users and who
received cessation advice from a physician
during the measurement year.
• Discussing Cessation Medication. A rolling
average represents the percentage of
adults 18 years of age and older who are
current smokers or tobacco users and who
discussed or were recommended cessation
medications by a physician during the
measurement year.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
• Discussing Cessation Strategies. A rolling
average represents the percentage of adults
18 years of age and older who are current
smokers or tobacco users who discussed or
were provided cessation methods or strategies
by a physician during the measurement year.
results
Care providers play an important role in
supporting smokers’ efforts to quit. Smoking
cessation practices are among the most
advantageous methods for reducing smokingrelated
deaths and health care costs. 2
yEAR
advIsIng sMokErs and
tobaCCo usErs to QuIt
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 76.7 71.7 NA NA 73.6
2009 NA NA 77.9 75.2 NA
2008 76.7 71.6 76.9 76.5 69.3
2007 75.8 71.0 75.8 75.4 69.4
2006 73.8 70.1 76.1 77.3 68.2
2005 71.2 66.9 75.5 77.3 65.6
2004 69.6 NA 64.7 NA 66.7
2003 68.6 NA 62.9 NA 65.8
2002 67.7 NA 61.6 NA 63.6
2001 65.7 NA 60.9 NA 63.9
2000 66.3 NA NA NA NA
yEAR
dIsCussIng CEssatIon
stratEgIEs
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 45.0 39.0 NA NA 38.5
2008 49.7 43.3 NA NA 40.8
2007 48.0 44.2 NA NA 39.2
2006 43.2 42.6 NA NA 36.7
2005 38.9 35.1 NA NA 33.9
2004 36.8 NA NA NA 32.7
2003 36.0 NA NA NA 32.3
yEAR
dIsCussIng CEssatIon
MEdICatIons
47
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 52.4 47.2 NA NA 42.7
2008 54.4 50.9 NA NA 40.6
2007 50.9 49.6 NA NA 38.7
2006 43.9 43.8 NA NA 35.1
2005 39.4 36.7 NA NA 31.8
2004 37.8 NA NA NA 31.3
2003 37.6 NA NA NA 31.5
W E l l N E S S A N D P R E V E N T I o N

C H R o N I C D I S E A S E M A N A G E M E N T
48
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
PERSISTENCE of bETA-bloCkER
TREATMENT AfTER A HEART ATTACk
Heart attacks occur when blood clots obscure the main blood vessel that feeds the heart. loss
of blood flow may permanently damage the heart tissue. 1 Each year, an estimated 785,000
Americans suffer a heart attack. of these, 470,000 have had at least one heart attack before,
and 150,000 are under the age of 65. 2,3 The Persistence of Beta-Blocker Treatment After a Heart
Attack measure reports the number of people who had a heart attack and received beta-blocker
treatment during the six months following their discharge from the hospital.
• beta-blocker therapy has been shown to
reduce mortality when used after a heart
attack. 4 These drugs can also reduce
patients’ risk for hospital readmission in the
first year. 5
• beta-blocker therapy restores blood flow,
which reduces damage to the heart muscle.
beta-blockers slow heart rate, lower blood
pressure and prevent irregular heartbeats
by blocking nervous impulses or stress
responses to the heart. 6,7
the Case for Improvement
• Despite beta-blockers’ effectiveness,
adherence to beta-blocker therapy is poor.
only 45 percent of patients consistently
took their medications in the first year after
discharge. 8 lack of adherence has been
shown to increase patients’ risk of dying. 9
• If beta-blocker adherence could be
increased to 100 percent in first-time
heart attack survivors for 20 years, an
estimated 62,000 heart attacks would be
prevented, 72,000 deaths from coronary
heart disease avoided, 447,000 life-years
gained and $18 million saved. 10,11
• Although the elderly benefit from betablocker
therapy, many patients are not
prescribed these medications. of all adults
who are good candidates for beta-blocker
medication, only 43.8 percent of nursing
home residents and 61.4 percent of
community-dwelling residents receive betablockers.
Research has shown that mortality
is significantly lower for nursing home
patients who receive beta-blockers. 12

HEdIs Measure definition
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
The percentage of adults 18 years of age
and older during the measurement year who
were hospitalized with a diagnosis of AMI
and discharged alive from July 1 of the year
prior to the measurement year to June 30
of the measurement year, and who received
persistent beta-blocker treatment for six
months after discharge.
results
The Persistence of Beta-Blocker Treatment After
Heart Attack measure provides insight into
the number of heart attack patients receiving
appropriate care with medications proven
effective in reducing cardiac-related mortality.
yEAR
trEatMEnt ratE
49
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 75.5 71.3 83.1 82.5 76.3
2009 74.4 69.6 82.6 78.9 76.6
2008 75.0 68.8 79.7 76.7 73.6
2007 71.9 62.9 75.5 70.4 62.0
2006 72.5 65.5 69.6 70.9 68.1
2005 70.2 64.3 65.4 58.5 69.8
C H R o N I C D I S E A S E M A N A G E M E N T

C H R o N I C D I S E A S E M A N A G E M E N T
50
Diabetes is the seventh leading cause of death in the United States. for people with diabetes, the
risk of death is twice that of people without diabetes. 1,2 Diabetes, especially when unmanaged,
may lead to blindness, heart disease and limb amputation. 1 It is also the leading cause of kidney
failure, accounting for 45 percent of new cases. 3 People with diabetes face tripled risk of stroke,
compared with people who have normal blood sugar levels. 4
Almost 26 million Americans are diabetic
and an additional 79 million adults are
prediabetic. 1 The number of diabetics is
increasing dramatically, due in large part
to the rising number of Americans who are
overweight or obese. 2
The Comprehensive Diabetes Care measure
assesses whether patients receive guidelinerecommended
care and achieve control levels
for their blood sugar, cholesterol and blood
pressure.
the Case for Improvement
• In 2007, diabetes was estimated to cost the
U.S. economy $174 billion. of this, $116
billion was attributed to the cost of medical
care. Another $58 billion was lost through
disability, missed work days and premature
mortality. 2
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CoMPREHENSIVE DIAbETES CARE
• between 1980 and 2006, the number of
hospitalizations for patients with diabetes
more than doubled. 5 Diabetes was the
primary diagnosis in almost 550,000
hospitalizations in 2009, when the average
medical charge was $12,849 for diabetes
without complications and $29,851 for
diabetes with complications. 6
• Improving blood sugar control has shown
to result in lower health care use and
better overall satisfaction with diabetes
treatment. 7,8 People who controlled their
diabetes also reported improved quality of
life and emotional well-being. 9
HEdIs Measure definition
The percentage of adults 18–75 years of age
with diabetes (type 1 and type 2) who had
each of the following:
• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control (>9.0%)
• HbA1c control (

• lDl-C screening
• lDl-C control (

C H R o N I C D I S E A S E M A N A G E M E N T
yEAR
Hba1C sCrEEnIng
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 89.9 85.2 90.4 90.6 82.0
2009 89.2 83.3 89.6 89.3 80.6
2008 89.0 79.5 88.3 85.7 80.5
2007 88.1 75.6 88.1 81.9 77.3
2006 87.5 72.1 87.2 83.3 78.0
2005 87.5 82.8 88.9 80.0 76.1
2004 86.5 NA 89.1 NA 75.9
2003 84.6 NA 87.9 NA 74.8
2002 82.6 NA 85.0 NA 73.0
2001 81.4 NA 85.7 NA 71.6
2000 78.4 NA NA NA NA
1999 75.0 NA NA NA NA
good glyCEMIC Control (Hba1C

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
ldl CHolEstErol sCrEEnIng
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 85.6 79.9 87.8 86.3 74.7
2009 85.0 78.6 87.3 85.5 74.2
2008 84.8 74.7 86.3 82.3 74.1
2007 83.9 72.7 85.7 80.0 70.8
2006 83.3 67.4 84.8 79.4 71.1
2005 92.3 87.0 93.3 87.1 80.6
2004 91.0 NA 93.5 NA 79.6
2003 88.4 NA 91.1 NA 75.9
2002 85.1 NA 87.9 NA 70.8
2001 81.4 NA 85.7 NA 66.5
2000 76.5 NA NA NA NA
1999 69.0 NA NA NA NA
yEAR
ldl CHolEstErol Control
(

C H R o N I C D I S E A S E M A N A G E M E N T
54
• Approximately 76.4 million (33.5 percent)
of people in the United States have high
2, 5
blood pressure.
• High blood pressure puts people at risk for
heart attacks and strokes. 3 over a lifetime,
people with hypertension have twice the
risk of stroke, compared with those without
hypertension. 4
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CoNTRollING HIGH blooD PRESSURE
High blood pressure, or hypertension, occurs when the force of blood against artery walls
increases, leading to greater risk of heart disease. High blood pressure may result when the
arteries narrow or when the amount of blood the heart pumps increases. 1 The Controlling High
Blood Pressure measure assesses whether adults with high blood pressure manage their condition
by taking steps to lower their blood pressure and keep their scores within the normal range.
• Although the risk of developing
hypertension increases with age, 9 nearly
one in five young adults between the ages
of 24 and 32 has high blood pressure. of
these, only half are aware that they have
the condition. 6
• A study conducted by The National High
blood Pressure Education Program in 2002
indicated that reducing blood pressure by
5 mm Hg decreased death from stroke by
14 percent, death from coronary heart
disease by 9 percent and death from all
causes by 7 percent. 9
the Case for Improvement
• In 2007, over 46 million ambulatory care
visits were attributed to hypertension. 7
Hypertension was listed as a primary or
secondary diagnosis in over 8.7 million
hospital admissions. 1 The associated direct
and indirect medical costs were estimated
to be $43.5 billion. 1
• Approximately 69 percent of people who
suffer a first heart attack, 77 percent of
people who have a stroke and 79 percent
of people with congestive heart failure have
high blood pressure. 1
• only half of people with hypertension
10, 11
control their high blood pressure.
• life expectancy for people with
hypertension is 5.1 years shorter for
men and 4.9 years shorter for women,
compared with individuals who have
normal blood pressure. 8

HEdIs Measure definition
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
The percentage of adults 18–85 years of
age who had a diagnosis of hypertension
and whose blood pressure was adequately
controlled (

C H R o N I C D I S E A S E M A N A G E M E N T
56
High cholesterol puts people at increased risk for heart disease when fatty deposits adhere to
artery walls and make it more difficult for blood to flow. Reduced blood flow limits the amount
of oxygen reaching the heart, which could lead to heart failure, and low blood circulation to
the brain could lead to a stroke. 1,2 An estimated 82 million American adults have some form
of cardiovascular disease. 3 Each year more than 600,000 die, making heart disease the
leading cause of death in the United States. 4 The Cholesterol Management for Patients with
Cardiovascular Conditions measure assesses whether adults who have cardiovascular conditions
are screened for high cholesterol.
• High cholesterol has no symptoms, making
screening vital to diagnosing and treating
this harbinger of heart disease before
serious damage occurs. 5
• Reducing lDl-C (“bad” cholesterol) levels
has been shown to lower the occurrence of
adverse cardiovascular events. 6
the Case for Improvement
• Researchers from the American Heart
Association predict that by 2030, more
than 40 percent of the U.S. population will
have some form of cardiovascular disease.
The estimated direct medical costs to treat
these individuals will triple during this time
frame, from $273 billion to $818 billion
annually. 7
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CHolESTERol MANAGEMENT foR PATIENTS
WITH CARDIoVASCUlAR CoNDITIoNS
• lowering the level of lDl cholesterol in
patients with coronary heart disease
reduces the risk that patients will suffer
another cardiac event or stroke. 8 lifestyle
changes, like physical activity, a low-fat
diet and drug therapy, such as statins, have
been found to be effective ways to lower
lDl cholesterol. 8,9
• If the American population decreased its
total cholesterol levels by 10 percent, new
cases of cardiovascular disease would drop
an estimated 30 percent. 3
HEdIs Measure definition
The percentage of adults 18–75 years of
age who were discharged alive for acute
myocardial infarction (AMI), coronary
artery bypass graft (CAbG) or percutaneous
coronary interventions (PCI) from January
1–November 1 of the year prior to the
measurement year, or who had a diagnosis
of ischemic vascular disease (IVD) during

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
the measurement year and the year prior to
the measurement year and had each of the
following during the measurement year:
• lDl-C screening
• lDl-C control (

C H R o N I C D I S E A S E M A N A G E M E N T
58
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
DISEASE MoDIfyING ANTI-RHEUMATIC DRUG
THERAPy IN RHEUMAToID ARTHRITIS
Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the immune system attacks
healthy joints. 1 It causes joint destruction, bone erosion and damage to muscles, kidneys and other
organs. 2 RA affects 1.5 million Americans. 3 The Disease Modifying Anti-Rheumatic Drug Therapy
(DMARD) in Rheumatoid Arthritis measure assesses whether RA patients receive medications that
slow the disease’s progression and help them maintain functional capacity longer.
• People with persistent RA are at greater risk
for premature death. 4 In particular, people
with RA die from heart-related problems at
higher rates than people without RA. 5
• Arthritis and other rheumatic conditions
are the most common causes of disability
in the United States. Approximately
850,000 adults reported being disabled by
RA—more than blindness, deafness, bone
fracture, cancer and diabetes combined. 6
• Although there is no cure for RA, DMARDs
may effectively protect joints and minimize
inflammation, slowing progression of the
disease and reducing pain. 7
the Case for Improvement
• Arthritis and related conditions, including
RA, cost the U.S. economy $128 billion
each year. Direct costs, like medical
expenses, are estimated at $81 billion,
and indirect costs, such as lost wages and
disability payments, are estimated at $47
billion. 8
• In 2009, RA was the principal diagnosis in
over 16,000 hospitalizations. on average,
each visit lasted 4 days and cost nearly
$36,000. 9
• Approximately 60 percent of people with
RA become too ill to work after 10 years of
the disease. 10
HEdIs Measure definition
The percentage of diagnosed adults with
rheumatoid arthritis who were dispensed
at least one ambulatory prescription for a
DMARD.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
results
RA is a debilitating disease affecting over one
million Americans. Although there is no cure
for RA, treatment with DMARDs can slow the
disease’s progression, reduce pain and lower
medical and disability costs.
yEAR
trEatMEnt ratE
59
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 87.7 87.0 72.8 77.8 70.1
2009 86.4 86.6 72.3 76.4 70.5
2008 85.7 81.5 70.4 75.1 69.4
2007 85.3 78.9 68.7 73.5 68.1
2006 84.8 82.3 68.2 69.7 67.6
C H R o N I C D I S E A S E M A N A G E M E N T

C H R o N I C D I S E A S E M A N A G E M E N T
60
• In 2009, approximately 24.6 million
Americans (17.5 million adults and 7.1
million children) reported having asthma. 2
• Treatment that aligns with clinical
guidelines reduces the severity of symptoms
and the occurrence of asthma-related
events (e.g., hospitalizations, emergency
department visits). 3
• According to the Asthma Regional Council,
two-thirds of adults and children who
display asthma symptoms are considered
“not well controlled” or “very poorly
controlled” as defined by clinical practice
guidelines. 4
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
USE of APPRoPRIATE MEDICATIoNS
foR PEoPlE WITH ASTHMA
Asthma, a long-term lung disease that affects the ability to breathe in both adults and children,
has become one of the most prevalent chronic diseases over the past 20 years. 1 The Use of
Appropriate Medications for People With Asthma measure assesses whether adults and children
diagnosed with persistent asthma receive appropriate therapeutic medications.
the Case for Improvement
• The financial burden of asthma is nearly
$56 billion annually. 5
• Asthma is a leading cause of lost
productivity and absenteeism. In 2008
there were 10.5 million missed work days
for adults and 14.2 million missed school
days for children 5–17 years of age. 2
• Adults and children with persistent asthma
are at increased risk of complications. 1
Among the four million individuals who
reported missing at least one work or
school day due to asthma attacks, at least
one in seven (13.6 percent) required
additional outpatient treatment. 6
MEasurE dEfInItIon
The percentage of adults 5–50 years of
age during the measurement year who
were identified as having persistent asthma
and who were appropriately prescribed
medication during the measurement year.
results
Adults and children with asthma can manage
their symptoms through use of long-term
control medications and environmental
changes to reduce exposure to irritants. 6

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
5–11 yEars
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 96.7 97.0 NA NA 91.8
2009 96.6 97.0 NA NA 91.8
yEAR
12–50 yEars
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 91.8 91.8 NA NA 85.8
2009 91.4 91.6 NA NA 86.0
yEAR
ovErall ratE
61
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 92.9 93.0 NA NA 88.4
2009 92.7 92.8 NA NA 88.6
2008 92.4 92.7 NA NA 88.7
2007 92.3 92.9 NA NA 86.9
2006 91.6 92.7 NA NA 87.1
2005 89.9 91.6 NA NA 85.7
2004 72.9 NA NA NA 64.5
2003 71.4 NA NA NA 64.1
2002 67.9 NA NA NA 62.5
2001 65.6 NA NA NA 60.1
2000 62.6 NA NA NA NA
1999 57.7 NA NA NA NA
C H R o N I C D I S E A S E M A N A G E M E N T

C H R o N I C D I S E A S E M A N A G E M E N T
62
USE of SPIRoMETRy TESTING IN THE
ASSESSMENT AND DIAGNoSIS of CoPD
Chronic obstructive pulmonary disease (CoPD), characterized by blocked airflow and
diminished capacity to breathe, is a major health problem in the U.S. The most significant
risk factor is long-term cigarette smoking. 1,2 other factors include old age and exposure to
occupational and environmental pollutants. The Use of Spirometry Testing in the Assessment and
Diagnosis of COPD measure evaluates whether adults with a new CoPD diagnosis received a
spirometry test, which helps in early diagnosis and enables appropriate treatment planning.
• CoPD ranks as the fourth leading cause of
death in the United States. 3
• According to the Global Initiative for
Chronic obstructive lung Disease
guidelines, the spirometry test is an
effective and objective screening tool. 4 It
measures how much and how fast one can
breathe air in and out to assess how well
oxygen is delivered to the lungs.
• Early detection of CoPD is crucial
for promoting smoking cessation and
instituting appropriate pharmacological
and nonpharmacological therapy before
patients reach more costly stages of the
disease. 3,4
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
the Case for Improvement
• In 2010, total annual costs were estimated
to exceed $50 billion—$29.5 billion of this
was for direct health care costs, including
hospitalizations, drugs and physician
office and emergency department visits. 1,6
of direct costs, 40–65-year-old patients
represented 67 percent of physician office
visits and 43 percent of hospitalizations.
• Disability and premature death from CoPD
cost an additional $14.1 billion in lost
income. 1
• In 2008, 13.1 million adults over 18 were
estimated to have CoPD, 1,5 but close to
24 million U.S. adults have evidence of
impaired lung function, which indicates
underdiagnosis 1,5

HEdIs Measure definition
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
This measure estimates the percentage of
adults 40 years of age and older with a new
diagnosis or newly active CoPD who received
spirometry testing to confirm the diagnosis.
results
Spirometry tests can improve health outcomes
through early detection; promoting smoking
cessation; administration of influenza and
pneumococcal vaccines; and permitting
earlier initiation of pharmacological and
nonpharmacological treatments. 7,8
yEAR
tEstIng ratE
63
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 41.7 40.2 33.9 35.3 31.3
2009 38.8 36.7 28.5 28.8 28.6
2008 37.6 36.4 27.7 26.5 29.3
2007 35.7 33.7 27.2 25.4 28.4
2006 36.1 33.7 26.2 30.2 27.3
C H R o N I C D I S E A S E M A N A G E M E N T

C H R o N I C D I S E A S E M A N A G E M E N T
64
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
PHARMACoTHERAPy MANAGEMENT
of CoPD ExACERbATIoN
Chronic obstructive pulmonary disease (CoPD) exacerbations are characterized by acute
worsening of clinical symptoms (e.g., breathlessness or sputum production). Exacerbations
may range from temporary decline in functional status to fatal events. 1,2 After an exacerbation,
patients’ symptoms and lung function can take several weeks to recover to baseline, and quality
of life declines drastically. 2 The Pharmacotherapy Management of COPD Exacerbation measure
evaluates whether patients received appropriate medical treatment after an event and assesses
effective outpatient management of the disease.
• CoPD exacerbations are responsible for
the majority of CoPD-related costs from
unscheduled physician and emergency
room visits and hospitalizations. 2
• Exacerbations have contributed to an
increase in CoPD-related mortality, from
21.4 to 43.3 deaths per 100,000 persons
in the U.S. in the last two decades. 1
• According to the Global Initiative for
Chronic obstructive lung Disease
guidelines, inhaled bronchodilators are
a cornerstone of treatment for CoPD
exacerbation. 3,4 Short-term corticosteroid
therapy may also be required. 5,6
the Case for Improvement
• CoPD exacerbations are estimated to
result in approximately 110,000 deaths
and more than 500,000 hospitalizations
annually. More than $18 billion is spent
on direct costs every year. 4 Hospital
admissions for CoPD exacerbations
average a 10-day length of stay, at a cost
of $10,000 per stay. 5,6
• Approximately one-third of patients
discharged from the emergency department
with acute exacerbations have recurrent
symptoms within 14 days, and 17 percent
relapse and require hospitalization—a
good indicator that patients are not getting
the care they require. 3
• benefits of appropriate medical treatment
include decreased duration of hospital
stays and less likelihood of treatment
failure. Patients also exhibit decreased
frequency of exacerbations and maintain
longer disease-free intervals. 5

HEdIs Measure definition
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
The percentage of adults 40 years and older
who experience an CoPD exacerbation event
and who were given appropriate medication
therapy to manage an exacerbation. As
identified by claims, a CoPD exacerbation
is an inpatient or ED visit with a primary
discharge diagnosis of CoPD.
results
CoPD medications aimed at controlling
symptoms have been shown to increase
exercise capacity, improve health status and
reduce exacerbations. 5,7 Decreasing the
frequency of an exacerbation has shown to
slow the progression of CoPD and should be
a critical goal of care management. 2,5
yEAR
bronCHodIlators
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 77.8 73.5 78.2 76.1 82.1
2009 78.0 75.0 76.2 74.9 80.7
2008 76.1 68.1 74.1 71.3 78.2
yEAR
65
systEMIC CortICostEroIds
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 69.8 66.2 66.6 69.6 65.3
2009 66.1 64.1 60.9 64.2 61.8
2008 67.0 58.2 60.0 60.8 61.7
C H R o N I C D I S E A S E M A N A G E M E N T

C H R o N I C D I S E A S E M A N A G E M E N T
66
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
ANNUAl MoNIToRING foR PATIENTS
oN PERSISTENT MEDICATIoNS
Adverse drug events trigger 700,000 emergency department (ED) visits a year. A quarter of
those visits come from adults 65 years and older. Approximately 120,000 hospital visits a
year are attributable to adverse drug events, and older adults are seven times more likely to be
hospitalized after an ED visit compared to the rest of the population. 1 The Annual Monitoring for
Patients on Persistent Medications measure assesses whether adults were properly monitored for
selected medications usually prescribed for long-term use.
• Adults over 65 consume more health care
than any other age group, and prescribing
medications to the elderly is the most
common clinical decision doctors make. 2
• Allergic reactions and unintentional overdoses
are two of the most common adverse drug
reactions that cause hospitalization. Rates
may improve with ongoing monitoring and
quality improvement. 3
the Case for Improvement
• Adverse drug events are responsible for $4
billion dollars of extra medical costs annually. 4
• Adverse drug events present a public
health concern as over-the-counter drugs
become more available and more drugs
are prescribed in an outpatient setting.
• In one study, patients brought to the
ED with adverse drug events caused by
outpatient medications were shown to
spend between three and eight more days
in the hospital in the six-month period post
ED visit, compared with patients admitted
to the ED for other reasons. 5 better methods
to identify and monitor adverse drug events
may reduce avoidable hospitalizations. 3,6
HEdIs Measure definition
This measure assesses the percentage of adults
18 years of age and older who received at least
180 treatment days of ambulatory medication
therapy for the following therapeutic agents
during the measurement year and at least one
therapeutic monitoring event for the therapeutic
agent in the measurement year.
• Angiotensin converting enzyme (ACE) inhibitors
or angiotensin receptor blockers (ARb)
• Digoxin
• Diuretics
• Anticonvulsants
A combined rate is also reported.
results
When patients do not adhere to a drug
regimen, they have high rates of inpatient and
outpatient health resource use. 7 Continued

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
monitoring of patients on persistent medications
would reduce the likelihood of hospitalization
and ED visits and increase adherence rates.
yEAR
aCE InHIbItors or arbs
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 81.6 78.4 90.7 90.8 86.0
2009 80.8 77.6 89.6 89.8 85.9
2008 79.4 76.4 86.7 88.8 84.8
2007 77.2 75.6 84.8 87.8 82.5
2006 74.8 66.3 82.7 83.9 79.9
yEAR
antIConvulsants
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 60.4 57.9 68.2 69.1 67.7
2009 62.0 59.2 69.7 68.5 68.7
2008 61.7 59.0 67.5 70.0 68.7
2007 59.6 56.3 65.1 66.0 65.9
2006 59.4 49.8 63.6 64.9 63.6
yEAR
dIgoxIn
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 84.6 79.1 93.1 92.7 89.7
2009 83.6 77.9 92.0 92.2 88.9
2008 81.9 76.6 90.4 91.1 88.5
2007 79.7 75.7 87.9 90.4 84.9
2006 77.3 64.2 86.2 87.1 83.0
yEAR
dIurEtICs
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 81.0 78.1 90.9 91.2 85.5
2009 80.4 77.2 89.8 90.3 85.4
2008 79.1 76.1 87.1 89.1 84.2
2007 76.8 75.2 84.8 87.6 81.3
2006 74.4 65.7 83.0 84.1 79.1
yEAR
CoMbInEd
67
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 80.9 77.8 90.2 90.6 83.9
2009 80.3 77.0 89.2 89.7 83.2
2008 78.9 75.8 86.3 88.6 82.6
2007 76.6 74.9 84.3 87.2 80.1
2006 74.3 65.6 82.2 83.6 77.7
C H R o N I C D I S E A S E M A N A G E M E N T

C H R o N I C D I S E A S E M A N A G E M E N T
68
Major depression is considered a serious medical illness; it affects approximately 5 percent–
8 percent of American adults. 1 Depression is the leading cause of disability in the United States. 1
Symptoms include persistent sadness, loss of energy, loss of appetite and inability to concentrate. 2
The Antidepressant Medication Management measure assesses short-term and long-term
medication adherence rates for adults newly diagnosed with depression.
• According to evidence-based guidelines,
medication management reduces the risk
of relapse and reoccurrence for patients
with depression. Without antidepressant
medication, 50 percent–80 percent of
patients have major depressive relapses
and reoccurrences. 3
• The need for antidepressant medication
increases as the severity of depression
intensifies. 2
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
ANTIDEPRESSANT MEDICATIoN MANAGEMENT
the Case for Improvement
• Major depression accounts for a variety
of indirect economic costs resulting from
personal developmental delays and
productivity losses. 4 Personal income
loss for people with depression reaches
an average of $10,400 annually, with a
lifetime total cost of $300,000. 5 Individuals
with depression take an average of 10
sick days a year. 6 Time missed from work
or school due to depression is higher than
many anxiety and emotional disorders.
• Inefficiencies in diagnosing and applying
evidence-based treatments for depression
add to loss of productivity and affect
mental and physical well-being. 7,8
• The risk of physical and functional
impairments because of missed work
or school can increase as well-being
deteriorates. Responsible, evidence-based
medication management may improve the
secondary impact of the disease. 9
HEdIs Measure definition
The percentage of adults 18 years of age
and older who were diagnosed with a new
episode of major depression and treated with
antidepressant medication, and who remained
on an antidepressant medication treatment.
Two rates are reported.
• Effective Acute Phase Treatment. The
percentage of newly diagnosed and treated
people who remained on an antidepressant
medication for at least 84 days (12 weeks).

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
• Effective Continuation Phase Treatment.
The percentage of newly diagnosed and
treated people who remained on an
antidepressant medication for at least 180
days (6 months).
results
Measurement of both rates will address
the incomplete prescribing and use of
antidepressants that contribute to negative
economic, clinical and public health
outcomes. 10 Improvements in antidepressant
medication adherence will reduce the burden
of relapse and reoccurrence. 11
yEAR
aCutE PHasE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 64.7 64.3 65.0 67.4 50.7
2009 62.9 63.2 63.7 63.4 49.6
2008 63.1 63.1 62.5 61.6 48.2
2007 62.9 63.8 61.2 61.0 42.8
2006 61.1 63.6 58.2 56.7 42.9
2005 61.3 65.6 55.0 49.2 45.1
2004 60.9 NA 56.4 NA 46.4
2003 60.7 NA 53.3 NA 46.2
2002 59.8 NA 52.1 NA 47.5
2001 56.9 NA 51.2 NA 45.5
2000 57.4 NA NA NA NA
1999 58.8 NA NA NA NA
yEAR
ContInuatIon PHasE
69
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 48.3 48.1 51.9 55.7 34.4
2009 46.2 46.4 50.6 51.0 33.0
2008 46.3 46.4 49.3 48.9 31.8
2007 46.1 47.6 48.7 48.7 27.4
2006 45.1 46.6 45.1 40.9 27.5
2005 45.0 48.4 41.1 31.1 29.7
2004 44.3 NA 42.4 NA 30.4
2003 44.1 NA 39.2 NA 29.3
2002 42.8 NA 37.7 NA 32.4
2001 40.1 NA 36.8 NA 30.0
2000 40.1 NA NA NA NA
1999 42.1 NA NA NA NA
C H R o N I C D I S E A S E M A N A G E M E N T

C H R o N I C D I S E A S E M A N A G E M E N T
70
In 2009, an estimated 21.8 million persons 12 or older were classified with substance
dependence or abuse. of these, 70 percent were dependent on or abused alcohol, 15 percent
abused or were dependent on both alcohol and illicit drugs and 16 percent were dependent on
or abused illicit drugs. 1,2 The Initiation and Engagement of Alcohol and Other Drug Dependence
Treatment measure monitors whether adolescents and adult members with an episode of alcohol
or drug dependence initiated and followed up on necessary treatment.
• The primary goals of drug abuse or
addiction treatment are abstinence, relapse
prevention and rehabilitation. less than
20 percent of people diagnosed with
substance abuse and less than 40 percent
of those with addiction problems seek
treatment. 3
• one in four deaths in the U.S. is attributed
to alcohol, tobacco or illicit drugs. 6
the Case for Improvement
• Total overall costs of substance abuse in
the U.S., including productivity, health and
crime-related costs, exceed $600 billion
annually. Every American adult pays
nearly $1,000 per year for the damages of
addiction. 4,5
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
INITIATIoN AND ENGAGEMENT of AlCoHol
AND oTHER DRUG DEPENDENCE TREATMENT
• The health burden of substance use
includes the harmful effects of acute
intoxication, substance use-associated
injury and violence and the consequences
of numerous medical and psychiatric
disorders associated with chronic alcohol
and other drug (AoD) use. 6
• Treatment is essential to stem the economic
and human costs associated AoD
dependence or addiction. Treatment
frequency and intensity of engagement is
important for successful outcomes. 3,7
HEdIs Measure definition
This measure asses the percentage of adolescent
and adults with a new episode of AoD
dependence who received the following care.
• Initiation of AOD Treatment. The
percentage of people who initiated
treatment through an inpatient AoD
admission, outpatient visit, intensive
outpatient encounter or partial
hospitalization within 14 days of the
diagnosis.
• Engagement of AOD Treatment. The
percentage of people with a diagnosis of
AoD use or dependence who initiated
treatment and had two or more additional
services within 30 days of the initiation visit.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
results
Research suggests that treatment reduces drug
use, improves health and job performance,
reduces involvement with the criminal justice
system, reduces family dysfunction and
improves quality of life. 3,7
yEAR
EngagEMEnt
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 15.6 16.0 3.7 4.8 14.2
2009 16.1 15.7 4.6 4.2 12.3
2008 16.2 16.2 4.3 9.4 12.4
2007 15.2 15.2 4.5 6.3 14.4
2006 13.8 16.0 4.5 7.0 11.7
2005 14.1 15.3 4.7 3.2 9.7
2004 15.5 NA 7.1 NA 11.9
yEAR
InItIatIon
71
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 42.7 40.8 44.6 57.4 42.9
2009 42.7 41.8 46.2 57.4 44.3
2008 42.4 42.6 45.9 49.1 44.5
2007 44.5 46.0 50.4 56.5 45.6
2006 43.2 49.0 50.3 50.0 43.3
2005 44.5 45.8 50.9 52.3 40.7
2004 45.9 NA 52.6 NA 45.7
C H R o N I C D I S E A S E M A N A G E M E N T

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
72
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
APPRoPRIATE TREATMENT foR CHIlDREN
WITH UPPER RESPIRAToRy INfECTIoN
Upper respiratory infections (URI) are self-regulating viral infections that cannot be treated
by antibiotics. 1 Despite this, clinical practice trends show that antibiotics are often prescribed,
leading to a trend in overuse and growing antimicrobial resistance among patients. 1 Also known
as the “common cold,” URIs target the lining of the throat and nose, resulting in fever, congestion,
coughing and other symptoms. 2 The Appropriate Treatment for Children With Upper Respiratory
Infection measure evaluates whether children were properly treated for URIs by not receiving
antibiotics unless deemed appropriate by a clinician.
• Approximately over 100 million antibiotic
prescriptions are written in the ambulatory
care setting every year. 3
• According to the Centers for Disease
Control and Prevention, antibiotics were
prescribed during 68 percent of URI visits.
of these visits, 80 percent did not require
the prescription of antibiotics as defined by
practice guidelines. 4
• In 2005, there were 1.17 billion visits
to ambulatory clinics and emergency
departments. 11 percent (130 million visits)
were for acute respiratory infections. 7
the Case for Improvement
• In the U.S., URIs are responsible for
nearly $17 billion in direct costs (e.g.,
physician services and treatment because
of complications) and $22.5 billion in
indirect costs (e.g., absenteeism and lost
productivity) every year. 6
• Studies have shown that up to 60 percent
of patients with colds or URIs seen in the
emergency department are prescribed
antibiotics, which have not demonstrated
improvement in clinical outcomes. 5
• overuse of antibiotics is a significant issue
in URI treatment. A survey conducted
in 2004 illustrated that among children
seen in a primary practice, outpatient
or emergency department setting, those
diagnosed with viral URIs experienced
even higher rates of antibiotic prescription,
even though antibiotics are ineffective for
treating viral infections. 8

HEdIs Measure definition
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
The percentage of children 3 months–18 years
of age who were diagnosed with a URI and
were not dispensed an antibiotic prescription.
results
Antibiotic treatment is only infrequently
appropriate for URIs. Misuse or overuse can
be avoided by prescribing treatment when
necessary, as well as educating patients
and clinicians about the use of antibiotics in
treating URIs. 8
yEAR
trEatMEnt ratE
73
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 85.1 83.7 NA NA 87.2
2009 84.1 82.5 NA NA 86.0
2008 83.9 83.3 NA NA 85.5
2007 83.5 83.0 NA NA 84.1
2006 82.8 82.1 NA NA 83.4
2005 82.9 81.9 NA NA 82.4
2004 82.7 NA NA NA 79.9
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
74
• The two most common methods of
screening children for lead poisoning are
venous blood sampling (inserting a needle
into a vein) and capillary blood sampling
(finger or heel stick). 4
• Children with elevated blood lead levels
have increased all-cause mortality. 5
the Case for Improvement
• Although lead-based paints were
banned for use in housing units in 1978,
approximately 24 million homes in the
United States contain lead paint and
elevated levels of lead-contaminated house
dust. More than 4 million of these homes
are inhabited by young children. 6
• The total annual costs of environmental
pollutants are estimated at $76.6 billion.
of this, $50.9 billion is attributable to lead
poisoning. 7
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
lEAD SCREENING IN CHIlDREN
lead poisoning is highly toxic and can cause cognitive impairment, behavioral disorders,
seizures and death. 1,2 Children are especially at risk for developing lead poisoning.
Approximately 250,000 children under the age of 5 have elevated blood lead levels (>10
micrograms of lead per deciliter of blood). 3 The Lead Screening in Children measure gauges the
number of children tested for lead poisoning before they turn 2.
• low-income children, non-Hispanic black
children and children living in housing
built before 1950 are disproportionately
affected by lead poisoning. for these
populations, blood lead levels have
remained consistently high, even though
they have declined for the overall
population by 84 percent since 1988. 8
HEdIs Measure definition
This measure assesses the percentage of
children 2 years of age who had one or more
capillary or venous lead blood test for lead
poisoning by their second birthday.
results
lead poisoning is a common medical
condition causing serious bodily harm in
children, one of the most vulnerable of
populations. Screening is an inexpensive
way to detect the presence of lead in a child’s
environment and reduce further exposure.
yEAR
sCrEEnIng ratE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA NA NA 66.2
2009 NA NA NA NA 66.4
2008 NA NA NA NA 66.7

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
AMbUlAToRy CARE: EMERGENCy DEPARTMENT VISITS
Although visits to the emergency department (ED) do not indicate poor quality of care,
unnecessary use of emergency care may signal a lack of access to more appropriate sources of
medical attention. 1 The Ambulatory Care: ED Visits measure assesses the number of people who
visited the ED during the measurement year. In 2007 there were nearly 120 million ED visits,
an increase of 23 percent from 1997. of these, more than 34 percent occurred during normal
business hours. 2
• Approximately 40 percent of ED visits are
not urgent. Many of these visits occur when
patients cannot be seen by their primary
care physician. 3
the Case for Improvement
• Avoidable use of urgent care contributes to
ED overcrowding, an increasingly common
problem in the United States. 4 More than
48 percent of EDs are at or over patient
capacity, 5 which can be a threat to patient
safety and public health. 6
• Increased ED wait time is frustrating for
patients, especially when they visit the ED
for routine care. Research has shown that
patients with urgent symptoms are more
satisfied with their emergency care than
patients with nonurgent symptoms. 7
75
• Time spent waiting is costly in terms of
productivity. More than 65 percent of
people visiting the ED spent over two hours
in the facility. Almost 9 percent left before
being seen by a physician. 2
HEdIs Measure definition
This measure summarizes utilization of
ambulatory care by calculating the number of
ED visits per measurement year.
results
When possible, unnecessary ED visits should
be avoided; they lead to ED overcrowding,
increased wait time and lower patient
satisfaction. Access to other sources of
ambulatory care can improve patient
outcomes and keep the quality of care high.
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
vIsIts PEr 1,000 MEMbEr MontHs
yEAR
76
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 187.4 174.0 450.3 379.0 62.0
2009 196.7 182.5 461.4 371.1 67.4
2008 194.5 181.3 459.1 395.7 60.2
2007 200.8 191.1 457.9 411.3 61.4
2006 200.5 188.7 403.9 375.2 56.6
2005 187.5 186.0 316.0 264.0 54.4
2004 177.5 NA 306.3 NA 48.5
2003 181.3 NA 292.3 NA 49.2
2002 182.6 NA 279.8 NA 49.4
2001 176.9 NA 276.1 NA 46.2
2000 164.3 NA NA NA NA
1999 150.3 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
PRENATAl AND PoSTPARTUM CARE &
fREQUENCy of oNGoING PRENATAl CARE
Among the 4.3 million deliveries in 2008, 94 percent listed some type of pregnancy
complication. 1,2 Each year, more than 500,000 pregnant women across the U.S. deliver babies
with potentially avoidable complications such as preterm birth, low birthweight and pre-eclampsia. 2
The Prenatal and Postpartum Care and Frequency of Ongoing Prenatal Care measures assess
whether women have access to timely and consistent prenatal and postpartum care.
• Diabetes, hypertension and postpartum
depression are the most commonly reported
health conditions among pregnant women. 3
• Prenatal care during the first trimester
helps to improve maternal health and
survival, and results in improved infant
survival by linking women who have highrisk
pregnancies to better obstetrical and
neonatal care. 3
• Postpartum care encompasses management
of the mother and the newborn infant
and is aimed at detecting early parenting
problems and performing physical exams
and postpartum depression screenings. 4
the Case for Improvement
• Hospital stays with pregnancy-related
complications tended to be longer
(2.7–2.9 days) than without complicating
conditions (1.9 days). Maternal stays with
complicating conditions were also about
50 percent more costly ($8,000) than
those without complications ($2,600). In
2008, maternal stays with pregnancy and
delivery-related complications accounted
77
for $17.4 billion, or nearly 5 percent of
total hospital costs in the U.S. 1
• Women who failed to receive prenatal care
were almost three times more likely to have
a low-birthweight infant than women who
had care, resulting in expected hospital
cost savings of more than $1,000 for
women who received prenatal care. 5
• Women who receive only the minimal
amount of prenatal care are at high risk
for pregnancy complication and negative
birth outcomes. 8,10 More than 11 percent
of pregnant women receive inadequate
prenatal care each year. 9
• Early, comprehensive and continuous
prenatal and postpartum care can promote
healthier pregnancies and reduce the
risk of costly, adverse birth outcomes and
postpartum depression. 6,7
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
78
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs Measure definition
This measure has two indicators related to
deliveries of live births between November 6
of the year prior to the measurement year and
November 5 of the measurement year.
• Timeliness of Prenatal Care: The percentage
of deliveries that received a prenatal care
visit in the first trimester or within 42 days
of enrollment in the health plan.
• Postpartum Care: The percentage of
deliveries that had a postpartum visit on or
between 21 and 56 days after delivery.
The Frequency of Ongoing Prenatal Care
measure assesses the percentage of Medicaid
deliveries between November 6 of the year
prior to the measurement year and November
5 of the measure year that received the
following number of expected prenatal visits:
•

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
PostPartuM vIsIt bEtWEEn 21
and 56 days aftEr dElIvEry
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 80.7 65.9 NA NA 64.4
2009 83.6 54.1 NA NA 64.1
2008 82.8 45.8 NA NA 62.6
2007 82.0 41.6 NA NA 58.6
2006 79.9 46.3 NA NA 59.1
2005 81.5 62.8 NA NA 57.2
2004 80.6 NA NA NA 56.5
2003 80.3 NA NA NA 55.3
2002 77.0 NA NA NA 52.1
2001 77.0 NA NA NA 53.0
frEQuEnCy of PrEnatal CarE
vIsIts—>80% of ExPECtEd vIsIts
yEAR
79
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA NA NA 61.1
2009 NA NA NA NA 61.6
2008 NA NA NA NA 58.7
2007 NA NA NA NA 59.6
2006 NA NA NA NA 58.6
2005 NA NA NA NA 55.8
2004 NA NA NA NA 51.5
2003 NA NA NA NA 48.2
2002 NA NA NA NA 41.0
2001 NA NA NA NA 39.2
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
80
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CHlAMyDIA SCREENING IN WoMEN
Chlamydia is the most commonly reported bacterial sexually transmitted disease in the United
States, occurring most often among adolescent and young adult females. 1,2 Chlamydia is
often known as a “silent” disease because most infected people are asymptomatic. 1 Untreated
chlamydia infections can lead to serious and irreversible complications, including pelvic
inflammatory disease (PID), infertility and increased risk of becoming infected with HIV. 1,3 The
Chlamydia Screening in Women measure looks at the percentage of non-pregnant, sexually
active women 24 years of age and younger who are screened annually for chlamydia, as
recommended by the U.S. Preventive Services Task force. 4
• Approximately 75 percent of chlamydia
infections in women and 95 percent in men
are asymptomatic, resulting in delayed
medical care and treatment. 5
• between 10 percent and 15 percent of
untreated chlamydia infections result in
PID, which can lead to ectopic pregnancy
and infertility. 1 As many as 15 percent of
women with PID will become infertile. 5
the Case for Improvement
• The estimated annual cost of chlamydia
infections is approximately $647 million.
The lifetime medical cost of chlamydia is
about $315 per case for females. If the
infection leads to PID, treatment can range
between $1,060 to $3,180 per case. 6
• Chlamydia is easily detected and treated,
but screening remains underutilized.
Challenges affecting annual screening
rates include lack of awareness, social
stigma, barriers to finding and treating sex
partners of infected women and difficulties
in measuring the public health impact. 2
• Multiple chlamydia infections increase a
woman’s risk of serious reproductive health
complications. 7
HEdIs Measure definition
The percentage of women 16–24 years of age
who were identified as sexually active and
who had at least one test for chlamydia during
the measurement year.
results
If recommended annual chlamydia screening
guidelines were followed, as many as 60,000
cases of PID, 8,000 cases of chronic pelvic
pain and 7,500 cases of infertility could be
prevented each year. 8

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
16–20 yEars
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 40.8 38.1 NA NA 54.6
2009 41.0 37.7 NA NA 54.4
2008 40.1 36.7 NA NA 52.7
2007 36.4 32.4 NA NA 48.6
2006 36.2 29.4 NA NA 50.5
2005 34.4 26.2 NA NA 49.2
2004 32.6 NA NA NA 45.9
2003 30.4 NA NA NA 44.3
2002 26.7 NA NA NA 40.8
2001 24.5 NA NA NA 39.6
2000 23.6 NA NA NA NA
1999 18.5 NA NA NA NA
yEAR
21–24 yEars
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 45.7 41.9 NA NA 62.3
2009 45.4 41.4 NA NA 61.6
2008 43.5 39.4 NA NA 59.4
2007 39.2 34.9 NA NA 54.0
2006 38.0 31.2 NA NA 55.0
2005 35.2 27.6 NA NA 52.5
2004 31.7 NA NA NA 49.0
2003 29.1 NA NA NA 46.0
2002 24.5 NA NA NA 41.5
2001 22.1 NA NA NA 41.1
2000 20.7 NA NA NA NA
1999 16.0 NA NA NA NA
yEAR
total ratE
81
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 43.1 40.0 NA NA 57.5
2009 43.1 39.5 NA NA 56.7
2008 41.7 38.0 NA NA 54.9
2007 38.1 33.8 NA NA 50.7
2006 37.3 30.4 NA NA 52.4
2005 34.9 26.9 NA NA 50.7
2004 32.2 NA NA NA 47.2
2003 29.7 NA NA NA 44.9
2002 25.4 NA NA NA 40.9
2001 23.1 NA NA NA 40.4
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
82
• Mental illness accounts for more burden
from disease than all forms of cancer
combined. 3
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
folloW-UP AfTER HoSPITAlIzATIoN
foR MENTAl IllNESS
Mental illness affects about 1 in 4 adults, and approximately 15 million adults in the United
States suffer from a serious mental illness. 1,2 less than half of adults with a serious mental illness
receive treatment or counseling. 2 The Follow-Up After Hospitalization for Mental Illness measure
assesses whether patients 6 years of age and older who were hospitalized for treatment of
selected mental health disorders were seen by a mental health provider.
• The World Health organization has
reported that 4 of the 10 leading causes of
disability in the U.S. and other developed
countries are mental disorders. by 2020,
it is expected that mental illness will be the
leading cause of disability in the world for
women and children. 4
• Half of first-time psychiatric patients were
readmitted within two years of hospital
discharge; appropriate follow-up care
is known to reduce the risk of repeat
hospitalization. 5,6
the Case for Improvement
• The economic burden of serious mental
illness is estimated at $317 billion dollars
and includes the cost of health services,
loss of earning and disability benefits. 7
• Suicide is the 11th leading cause of
death in the U.S., accounting for 30,000
deaths each year, and could be caused by
untreated depression. 8
• In 2008, 30 million adults received
treatment for mental health problems. 9 In
2005, more than 2 million patients were
discharged from a hospital with a mental
disorder. 10
HEdIs Measure definition
The percentage of discharges for members
6 years of age and older who were
hospitalized for treatment of selected mental
health disorders and who had an outpatient
visit, an intensive outpatient encounter or
partial hospitalization with a mental health
practitioner. The measure separately identifies
the percentage of members who received
follow-up within 7 and 30 days of discharge.
results
Proper follow-up treatment for psychiatric
hospitalization can lead to improved quality
of life for patients, families and society as a
whole.

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
WItHIn 7 days Post-dIsCHargE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 59.7 54.2 37.4 39.1 44.6
2009 58.7 52.6 37.3 40.6 42.9
2008 57.2 49.8 38.1 37.3 42.6
2007 55.6 41.9 37.0 33.3 42.5
2006 56.7 48.3 36.9 38.5 39.1
2005 55.8 49.9 39.2 47.1 39.2
2004 55.9 NA 40.1 NA 38.0
2003 54.4 NA 38.8 NA 37.7
2002 52.7 NA 38.7 NA 37.2
2001 51.3 NA 37.2 NA 33.2
2000 48.2 NA NA NA NA
1999 47.4 NA NA NA NA
WItHIn 30 days Post-dIsCHargE
yEAR
83
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 77.4 74.1 55.4 61.2 63.8
2009 76.8 72.1 54.8 60.5 60.2
2008 76.1 71.4 56.5 55.5 61.7
2007 74.0 63.4 54.4 50.2 61.0
2006 75.8 68.1 56.3 58.3 57.7
2005 75.9 70.7 59.4 60.1 56.8
2004 75.9 NA 60.7 NA 54.9
2003 74.4 NA 60.3 NA 56.4
2002 73.6 NA 60.6 NA 56.7
2001 73.2 NA 60.6 NA 52.2
2000 71.2 NA NA NA NA
1999 70.1 NA NA NA NA
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
84
over the last 10 years, the Centers for Disease Control and Prevention (CDC) have increased
efforts to prevent the misuse of antibiotics to treat respiratory infections, particularly pharyngitis.
Pharyngitis, or sore throat, is common in children and adolescents and can be caused by a
bacteria or virus. 1 The Appropriate Testing for Children With Pharyngitis measure evaluates
whether children are properly treated for pharyngitis after undergoing diagnostic testing, thereby
avoiding the build-up of antibiotic resistance.
• Pharyngitis affects a large number of
individuals and is responsible for 12
million primary care visits each year in the
U.S. 2
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
APPRoPRIATE TESTING foR CHIlDREN
WITH PHARyNGITIS
• The bacteria most commonly associated
with pharyngitis (Group A streptococcus)
is responsible for up to 30 percent of
pharyngitis cases in children. 3 In winter
and early spring, up to 15 percent of
school-age children may carry the bacteria
without displaying symptoms. 4
the Case for Improvement
• Pharyngitis has a significant financial
burden on children and adults alike,
costing an estimated $224 million–
$539 million and resulting in 1,300 deaths
every year. 5
• Pharyngitis often is overdiagnosed. While
there are differing opinions on performing
rapid antigen detection testing (RADT) and
throat cultures, clinical guidelines strongly
recommend performing a diagnostic test or
a throat culture before treatment. 6
• Infections resulting from pharyngitis can
have lifestyle and productivity effects. one
study found that both children and parents
missed a notable number of school and
work days because of pharyngitis-related
treatment and management. 7
HEdIs Measure definition
The percentage of children 2–18 years of
age who were diagnosed with pharyngitis
and dispensed an antibiotic, and who also
received a group A streptococcus test for
the episode. A higher rate represents better
performance (i.e., appropriate testing).
results
Antibiotic treatment is only infrequently
appropriate for pharyngitis. The availability
of RADT has made it easier to perform
diagnostics, thereby potentially reducing
antibiotic use and preventing the spread of
drug-resistant strains of pharyngitis. 8

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
tEstIng ratE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 77.6 76.6 NA NA 64.9
2009 77.4 75.5 NA NA 62.3
2008 75.6 74.1 NA NA 61.4
2007 74.7 73.5 NA NA 58.7
2006 72.7 69.4 NA NA 56.0
2005 69.7 64.5 NA NA 52.0
2004 72.6 NA NA NA 54.4
85
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
86
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
WEll-CHIlD VISITS IN THE fIRST 15 MoNTHS of lIfE AND
IN THE THIRD, foURTH, fIfTH AND SIxTH yEARS of lIfE
The beginning years of childhood are filled with rapid growth and development. Well-child visits
offer doctors the opportunity to evaluate children’s physical, emotional and social developmental
progress. 1,2 The Well-Child Visits measures assess the number of children that met with a primary
care practitioner during their most important developmental milestones.
• Primary care practitioners may detect
health problems and developmental
delays early and initiate interventions that
eliminate problems or lessen their effect
over the long term. 1,2
• Well-child visits facilitate communication
between children, care providers and
doctors. 3 Primary care practitioners can
promote healthy behaviors and provide
anticipatory guidance on a variety of
topics, including injury prevention, physical
activity and nutrition. 4
the Case for Improvement
• The number of children younger than 6
who received well-child visits increased
from 84 percent in 2000 to 87 percent
in 2008, 1 but almost one million children
under 6 received no preventive medical
care of any kind in 2007. 5
• Children with incomplete well-child care
during the first six months of life are 60
percent more likely to visit the emergency
department than children with complete
well-child care. 6
• Development delays occur in approximately
13 percent of American children and have
high costs to society. 7,8 over the course
of a lifetime, untreated developmental
delays and disabilities are estimated to cost
between $417,000 in direct medical costs
and indirect lost productivity per child. 9
HEdIs Measure definition
Well-Child Visits in the First 15 Months of Life:
The percentage of children who turned 15
months old during the measurement year and
had the following number of well-child visits
with a primary care physician during the first
15 months of life:
• No well-child visits
• one well-child visit
• Two well child visits
• Three well-child visits
• four well-child visits
• five well-child visits
• Six or more well-child visits.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
Well-Child Visits in the Third, Fourth, Fifth
and Sixth Years of Life: The percentage of
children 3–6 years of age who received one
or more well-child visits with a primary care
practitioner during the measurement year.
results
Primary care doctors are an important
resource for parents. Well-child visits facilitate
communication about health between care
givers and physicians. Screening for physical,
emotional, social and developmental progress
is vital to ensuring the health of children
during their most vulnerable years and well
into adulthood.
yEAR
agEs 3–6 yEars: onE or
MorE WEll-CHIld vIsIts
87
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 71.6 67.8 NA NA 71.9
2009 70.3 66.0 NA NA 71.6
2008 69.8 63.6 NA NA 69.7
2007 67.8 60.7 NA NA 65.3
2006 66.7 61.6 NA NA 66.8
2005 65.6 54.5 NA NA 63.6
2004 64.4 NA NA NA 62.4
2003 62.7 NA NA NA 60.7
2002 60.4 NA NA NA 58.2
2001 57.5 NA NA NA 56.0
2000 54.2 NA NA NA NA
1999 51.3 NA NA NA NA
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
88
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
ADolESCENT WEll-CARE VISITS
Adolescence is a time marked by transition. As children become adults, they face new physical,
emotional and social challenges that may affect their health. 1 because of changing patterns
of illness and death among youth over the last two decades, increased screening and health
counseling have become especially important. 2,3 The Adolescent Well-Care Visits measure
assesses the number of adolescents who received preventive care.
• Risk taking behaviors, such as substance
use, drunk driving, risky sexual activity and
smoking, often begin in adolescence. These
behaviors put youth at increased risk for
sexually transmitted diseases, unintended
pregnancy, injury or death. 2,3 In 2009,
almost 20 percent of high school students
smoked tobacco. More than 6 percent used
cocaine and 24 percent reported binge
drinking (i.e., had five or more alcoholic
drinks within a couple of hours). 4
• Many chronic diseases seen in adults begin
in childhood, when eating habits and
physical activity levels are often established. 3
With obesity among adolescents in the
U.S. on the rise, this is especially troubling.
obesity can lead to type 2 diabetes, heart
disease and certain cancers. 5
• Adolescent well-care visits are an
effective way for doctors to present health
promotion advice that is timely and
relevant to adolescents’ development and
well-being. The average preventive visit
lasts about 20 minutes; during this time,
doctors can provide counseling or initiate
health interventions. 6
the Case for Improvement
• Adolescents are the least likely to have
access to health care, and use less primary
care, than any age group. 3 The proportion
of children who receive well-care visits
declines with age. only 70 percent of
10–14-year-olds and 67 percent of
15–17-year-olds received preventive health
care in 2008. 2 for those who did have a
well-child visit, only 10 percent received all
recommended preventive services. 7
• In 2007, nearly 13,299 deaths from
unintentional injury (such as from a car
accident) were reported among adolescents
between the ages of 15 and 19. 8 The total
lifetime medical costs for adolescents who
survive is estimated to be $25 billion. 9

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
• Each year, preventable adolescent deaths
cost an estimated $33.5 billion in direct
medical costs, and lifetime indirect and
direct costs are more than $700 billion. 10
for those that survive, the total lifetime
medical costs for these individuals is
estimated to be $25 billion. 9
HEdIs Measure definition
The percentage of enrolled adolescents and
young adults 12–21 years of age who had at
least one comprehensive well-care visit with
a primary care practitioner or an ob/GyN
practitioner during the measurement year.
results
While most adolescents are healthy, changes
in their physical and social circumstances put
them at increased risk for serious and longterm
health effects of risky behaviors. yearly
well-care visits offer primary care providers
the opportunity to provide the screening and
health counseling services adolescents need to
stay healthy.
yEAR
89
at lEast onE CoMPrEHEnsIvE
WEll-CarE vIsIt
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 42.7 39.2 NA NA 48.1
2009 42.5 38.3 NA NA 47.7
2008 42.9 36.2 NA NA 45.9
2007 41.8 34.7 NA NA 42.1
2006 40.3 34.6 NA NA 43.6
2005 38.8 29.3 NA NA 40.7
2004 38.2 NA NA NA 40.0
2003 37.1 NA NA NA 37.5
2002 35.8 NA NA NA 37.1
2001 33.1 NA NA NA 32.6
2000 30.9 NA NA NA NA
1999 28.9 NA NA NA NA
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
90
• In 2007, more than five million children
0–17 years of age had no usual source
of care; the same number had one or
more unmet medical need during the year.
Almost six million children were without a
doctor or nurse who knew their medical
history. 4
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CHIlDREN AND ADolESCENTS’ ACCESS
To PRIMARy CARE PRACTITIoNERS
Children and adolescents need access to primary care practitioners (PCP) to ensure their optimal
health and well-being. 1 PCPs play an important role in preventing illness and death in the
young. 2 The Children and Adolescents’ Access to Primary Care Practitioners measure assesses
whether children and adolescents were able to obtain medical attention from a PCP, such as a
family doctor, internist, pediatrician or general practitioner.
• Although the primary care workforce
increased by 35 percent between 1996
and 2006, almost one million children
live in areas with no PCP. Children and
adolescents living in rural areas are
affected disproportionately. 5
the Case for Improvement
• fewer than half of children and
adolescents in the United States receive the
recommended amount of preventive care. 3
• Accessible primary care reduces hospital
use and maintains quality of care. 6 Access
to primary care is an effective way to
reduce expensive hospitalizations and curb
rising health care costs. 7
• for adolescents, inaccessible care can put
them at risk for developing chronic disease,
substance-use disorders and risk-taking
sexual behaviors. 8-10
HEdIs Measure definition
The percentage of children and young adults
12 months to 19 years of age who had a
visit with a PCP. The measure reports on four
separate percentages:
• Children 12–24 months who had a visit
with a PCP during the measurement year
• Children 25 months–6 years who had a
visit with a PCP during the measure year
• Children 7–11 years who had a visit with
a PCP during the measure year or the year
prior to the measurement year
• Adolescents 12–19 years who had a visit
with a PCP during the measurement year or
the year prior to the measurement year.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
results
Improving access to PCPs may reduce
unnecessary medical costs and advance health
outcomes for children and adolescents by
enabling them to receive preventive services,
screening and timely treatment from clinicians
who know their medical histories and serve as
a medical home.
yEAR
CHIldrEn 12–24 MontHs
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 97.5 96.9 NA NA 96.1
2009 97.5 96.2 NA NA 95.2
2008 96.7 95.4 NA NA 95.0
2007 96.9 93.7 NA NA 93.4
2006 97.0 94.2 NA NA 94.1
2005 97.0 95.0 NA NA 92.6
2004 96.8 NA NA NA 92.3
2003 96.3 NA NA NA 92.4
2002 95.7 NA NA NA 91.1
2001 95.2 NA NA NA 90.7
2000 92.5 NA NA NA NA
1999 91.2 NA NA NA NA
yEAR
91
CHIldrEn 25 MontHs–6 yEars
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 91.2 89.1 NA NA 88.3
2009 91.6 89.1 NA NA 88.3
2008 89.7 87.4 NA NA 87.2
2007 89.4 86.3 NA NA 84.3
2006 89.3 86.3 NA NA 84.9
2005 89.3 85.7 NA NA 83.1
2004 88.1 NA NA NA 81.9
2003 88.5 NA NA NA 82.1
2002 87.2 NA NA NA 80.0
2001 85.7 NA NA NA 79.3
2000 82.4 NA NA NA NA
1999 81.3 NA NA NA NA
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
yEAR
92
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CHIldrEn 7–11 yEars
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 91.6 89.4 NA NA 90.2
2009 91.4 89.0 NA NA 90.3
2008 89.9 87.4 NA NA 87.8
2007 89.5 86.8 NA NA 85.9
2006 89.2 85.7 NA NA 85.9
2005 88.6 83.4 NA NA 83.4
2004 88.5 NA NA NA 82.5
2003 88.5 NA NA NA 82.1
2002 87.4 NA NA NA 80.3
2001 85.8 NA NA NA 79.3
2000 83.6 NA NA NA NA
1999 82.6 NA NA NA NA
yEAR
adolEsCEnts 12–19 yEars
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 89.2 86.8 NA NA 88.1
2009 89.0 86.1 NA NA 87.9
2008 87.3 84.2 NA NA 85.3
2007 86.9 83.4 NA NA 82.7
2006 86.6 82.3 NA NA 83.2
2005 86.1 79.8 NA NA 80.9
2004 85.5 NA NA NA 79.3
2003 85.8 NA NA NA 79.6

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
folloW-UP CARE foR CHIlDREN
PRESCRIbED ADHD MEDICATIoN
Attention deficit/hyperactivity disorder (ADHD) typically begins in childhood and often persists
into adulthood. 1 The disorder is characterized by inattention and impulsiveness, which can result
in academic underachievement, family issues and behavioral problems. 2,3 The Follow-Up Care
for Children Prescribed ADHD Medication measure assesses two rates of follow-up care for
children between 6 and 12 years of age who are prescribed ADHD medication.
• ADHD is one of the most common mental
disorders in children. Almost 4 percent of
children in the United States between the ages
of 4 and 10 are medicated for ADHD. 1,4,5
• Data from the National Health Interview
Survey suggest that roughly half of children
between 6 and 11 who are diagnosed with
ADHD may also have a learning disorder. 3
The combination of attention problems
caused by ADHD and the learning disorder
can make it hard for a child to succeed
in school. boys are twice as likely to have
ADHD than girls. 1,3
the Case for Improvement
• The annual cost of illness for ADHD in the
U.S. is estimated to be more than $42 billion. 6
• ADHD may culminate in significant health
care-related costs, including frequent
unintentional injuries, co-occurring
psychiatric conditions and productivity loss. 7
• Combining behavioral therapy with
medication has been shown to improve
behavior and could lead to a decrease in
medication dependence. 8
93
HEdIs Measure definition
The following two rates of this measure assess
follow-up care for children prescribed an
ADHD medication:
• Initiation Phase: The percentage of children
between 6 and 12 years of age diagnosed
with ADHD who had one follow-up
visit with a practitioner with prescribing
authority within 30 days of their first
prescription of ADHD medication.
• Continuation and Maintenance Phase:
The percentage of children between 6
and 12 years of age with a prescription
for ADHD medication who remained on
the medication for at least 210 days and
had at least two follow-up visits with a
practitioner in the 9 months subsequent to
the Initiation Phase.
results
Medications used to treat ADHD have known
side effects and, like all medications, need to
be closely monitored by a practitioner with
prescribing authority.
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
yEAR
94
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
InItIatIon
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 38.8 38.1 NA NA 38.1
2009 36.6 35.4 NA NA 36.6
2008 35.8 34.1 NA NA 34.4
2007 33.7 31.8 NA NA 33.5
2006 33.0 30.6 NA NA 31.8
yEAR
ContInuatIon
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 43.4 43.3 NA NA 43.9
2009 41.7 39.0 NA NA 41.7
2008 40.2 37.1 NA NA 39.5
2007 38.7 34.2 NA NA 38.9
2006 38.1 30.0 NA NA 34.0

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
CHIlDHooD IMMUNIzATIoN STATUS
Immunizing a child not only protects the child’s health but also the health of the community,
especially for those who are not immunized. 1 Infants and toddlers are particularly vulnerable
to infectious diseases because their immune systems have not built up the necessary defenses to
fight infection. 2,3 The Childhood Immunization Status measure looks at the percentage of children
2 years of age who receive all immunizations recommended by the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention (CDC). 4
• Most childhood vaccines are between
90 percent and 99 percent effective in
preventing diseases. 5
• Statistics show dramatic declines in
vaccine-preventable diseases in the U.S.
when compared with the pre-vaccine
era. Cases of diphtheria, polio and
smallpox declined by 100 percent; cases
of bacterial meningitis, measles, mumps,
rubella, congenital rubella syndrome and
tetanus, by 98 percent–99 percent; cases
of hepatitis A, by 91 percent; cases of
whooping cough, by 93 percent; cases
of chickenpox, by 89 percent; cases of
hepatitis b, by 83 percent; and cases of
pneumonia, by 74 percent. 6
the Case for Improvement
• Vaccination of each U.S. child according
to the current childhood immunization
schedule prevents approximately 42,000
deaths and 20 million cases of disease and
saves nearly $14 billion in direct costs and
$69 billion in societal costs each year. 8,9
95
• The perception among some parents that
vaccines are unsafe for their children was
heightened in recent years by several
factors, including the number of vaccines in
the recommended childhood immunization
schedule, the presence of conflicting
vaccine-safety information and scientifically
refuted—yet widely publicized—theories that
link vaccines to chronic health problems or
developmental disabilities such as autism. 10
• According to the CDC’s National
Immunization Survey, nearly 40 percent of
parents of toddlers delay or refuse at least
one recommended immunization for their
children each year. 11
HEdIs Measure definition
The percentage of children 2 years of
age who had four diphtheria, tetanus and
acellular pertussis (DTaP); three polio (IPV);
one measles, mumps and rubella (MMR);
three H influenza type b (Hib); three hepatitis
b (Hepb); one chickenpox (VzV); four
pneumococcal conjugate (PCV); two hepatitis
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
96
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
A (HepA); two or three rotavirus (RV); and
two influenza (flu) vaccines by their second
birthday. This measure calculates a rate for
each vaccine and nine separate combination
rates; including a comprehensive rate.
results
Immunizations are a safe and important way
parents protect their children’s health. 2 The
diseases childhood vaccines are meant to
prevent are most likely to occur when children
are very young and the risk of complications
is highest. Without these recommended
vaccines, a child must contract a disease
in order to become immune to the germ or
virus that causes it, which can be extremely
dangerous for younger children whose
immune systems may not be strong enough to
fight off infections. It is because of childhood
immunizations that the majority of many
once-common diseases are now at their lowest
levels in history. 12
yEAR
dtaP/dt
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 86.3 64.7 NA NA 80.2
2009 85.4 59.9 NA NA 79.6
2008 87.2 47.7 NA NA 78.6
2007 86.9 42.4 NA NA 77.8
2006 87.2 39.2 NA NA 79.3
2005 86.1 62.8 NA NA 76.9
2004 85.9 NA NA NA 75.6
2003 84.3 NA NA NA 72.6
2002 80.1 NA NA NA 69.4
2001 81.5 NA NA NA 71.2
2000 80.4 NA NA NA NA
1999 78.7 NA NA NA NA

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
HEPatItIs b
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 90.2 58.7 NA NA 90.1
2009 90.1 53.7 NA NA 89.1
2008 91.8 38.7 NA NA 88.3
2007 91.3 35.8 NA NA 87.2
2006 91.0 31.1 NA NA 88.4
2005 90.0 57.7 NA NA 85.4
2004 87.2 NA NA NA 81.9
2003 85.8 NA NA NA 79.5
2002 81.9 NA NA NA 76.2
2001 79.9 NA NA NA 75.4
2000 77.9 NA NA NA NA
1999 75.5 NA NA NA NA
yEAR
HIb
97
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 94.3 75.5 NA NA 90.3
2009 94.8 74.8 NA NA 93.7
2008 94.8 66.3 NA NA 93.4
2007 93.1 53.6 NA NA 87.7
2006 93.4 49.2 NA NA 89.1
2005 92.9 72.6 NA NA 86.8
2004 87.7 NA NA NA 79.1
2003 86.1 NA NA NA 77.7
2002 83.2 NA NA NA 73.8
2001 83.4 NA NA NA 74.9
2000 82.7 NA NA NA NA
1999 80.7 NA NA NA NA
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
yEAR
98
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
IPv
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 91.8 71.1 NA NA 90.8
2009 91.1 65.3 NA NA 89.0
2008 92.1 52.6 NA NA 87.9
2007 91.5 47.5 NA NA 87.3
2006 91.4 43.0 NA NA 87.9
2005 90.3 66.7 NA NA 84.7
2004 90.1 NA NA NA 84.8
2003 88.7 NA NA NA 83.1
2002 86.0 NA NA NA 80.3
2001 85.4 NA NA NA 79.1
2000 84.2 NA NA NA NA
1999 82.6 NA NA NA NA
yEAR
MMr
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 90.8 82.7 NA NA 90.6
2009 90.6 80.5 NA NA 91.2
2008 93.5 76.4 NA NA 90.9
2007 93.5 76.3 NA NA 90.4
2006 93.6 75.0 NA NA 91.1
2005 93.0 86.2 NA NA 89.6
2004 92.3 NA NA NA 88.1
2003 91.5 NA NA NA 87.4
2002 90.1 NA NA NA 84.4
2001 89.4 NA NA NA 83.7
2000 88.4 NA NA NA NA
1999 87.0 NA NA NA NA
PnEuMoCoCCal ConjugatE (PCv)
yEAR
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 85.6 65.6 NA NA 79.4
2009 84.6 60.1 NA NA 77.6
2008 84.8 47.8 NA NA 75.6
2007 83.6 42.3 NA NA 73.8
2006 72.8 37.1 NA NA 68.3

yEAR
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
vZv
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 90.8 82.2 NA NA 90.0
2009 90.6 79.7 NA NA 90.6
2008 92.0 74.8 NA NA 89.7
2007 91.9 74.4 NA NA 88.7
2006 90.9 72.0 NA NA 88.9
2005 89.9 82.0 NA NA 86.6
2004 87.5 NA NA NA 84.7
2003 85.7 NA NA NA 81.8
2002 82.0 NA NA NA 76.4
2001 75.3 NA NA NA 73.6
2000 70.5 NA NA NA NA
1999 63.8 NA NA NA NA
CoMbInatIon 2 (dtaP, IPv, MMr,
HIb, HEPatItIs b and vZv)
yEAR
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 78.5 48.5 NA NA 74.1
2009 77.7 43.1 NA NA 74.3
2008 81.2 30.6 NA NA 73.7
2007 80.8 30.1 NA NA 72.1
2006 79.8 24.5 NA NA 73.4
2005 77.7 54.8 NA NA 70.5
2004 72.5 NA NA NA 63.1
2003 69.8 NA NA NA 58.5
2002 62.5 NA NA NA 53.2
2001 57.6 NA NA NA 52.5
2000 53.5 NA NA NA NA
1999 47.5 NA NA NA NA
CoMbInatIon 3 (dtaP, IPv, MMr,
HIb, HEPatItIs b, vZv and PCv)
yEAR
99
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 75.1 46.1 NA NA 69.9
2009 73.4 40.4 NA NA 69.4
2008 76.6 28.5 NA NA 67.6
2007 75.5 27.6 NA NA 65.4
2006 65.7 22.4 NA NA 60.9
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
yEAR
HEPatItIs a
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 35.4 28.6 NA NA 36.5
yEAR
rotavIrus
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 63.5 51.9 NA NA 57.6
yEAR
InfluEnZa
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 57.1 51.1 NA NA 43.6
CoMbInatIon 10 (dtaP, IPv, MMr,
HIb, HEPatItIs a, HEPatItIs b, vZv,
PCv, rotavIrus and InfluEnZa)
yEAR
100
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 18.5 10.4 NA NA 15.2
IMMunIZatIons for
adolEsCEnts: MEnIngoCoCCal
yEAR
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 55.2 43.8 NA NA 56.3
yEAR
IMMunIZatIons for
adolEsCEnts: tdaP/td
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 69.5 55.3 NA NA 67.8
yEAR
IMMunIZatIons for
adolEsCEnts: CoMbInatIon 1
(MEnIngoCoCCal, tdaP/td)
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 51.6 39.4 NA NA 52.2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
IMMUNIzATIoNS foR ADolESCENTS
Adolescence is considered the healthiest period of one’s life. This is, in large part, thanks to
childhood immunizations. Recommended adolescent immunizations can help maintain wellbeing
and provide protection against vaccine-preventable diseases that extend into adulthood. 1
The Immunizations for Adolescents measure assesses the percentage of adolescents who were
vaccinated against four vaccine-preventable diseases: meningococcal meningitis, tetanus,
diphtheria and pertussis (whooping cough).
• Protection against some childhood
vaccinated diseases can wear off as
children get older, requiring booster shots
to maintain immunity. 2 for example,
Tdap is the booster shot for the tetanus,
diphtheria and pertussis vaccine received
in childhood. 3
• Prior to vaccines, the U.S. averaged
approximately 500–600 cases of tetanus,
100,000–200,000 cases of diphtheria and
175,000 cases of pertussis each year. 3
Today, because of vaccines, the number of
tetanus cases has declined by 98 percent,
diphtheria cases by 100 percent and
pertussis cases by 93 percent. 4
the Case for Improvement
• Vaccine-preventable diseases not only
have a direct impact on the infected and
their families, but also carry a high price
tag for society as a whole. Direct medical
costs and indirect societal costs exceed $10
billion per year. 5
101
• Despite what is understood about
the effectiveness of recommended
immunizations in protecting against
serious, sometimes fatal diseases,
adolescent immunization rates are low. 5
• Reasons frequently cited for low adolescent
immunization rates include lack of
regular preventive care visits that provide
an opportunity for vaccination; lack of
awareness of the need for immunizations;
inaccurate risk assessments by parents and
adolescents about vaccine-preventable
diseases; and financial barriers. 1,6,7
HEdIs Measure definition
The percentage of adolescents 13 years of
age who had one dose of meningococcal
vaccine and one tetanus, diphtheria toxoids
and acellular pertussis vaccine (Tdap) or one
tetanus, diphtheria toxoids vaccine (Td) by
their 13th birthday. The measure calculates a
rate for each vaccine and one combination
rate.
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
results
Today, fewer infections are seen, thanks to
vaccines, but that does not mean the viruses
and bacteria that cause the infections do not
still exist. Infectious diseases and death are still
common among the unimmunized. Americans
should continue to be immunized, to prevent
future cases of illness. 5
IMMunIZatIons for
adolEsCEnts—MEnIngoCoCCal
yEAR
102
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 55.2 43.8 NA NA 56.3
yEAR
IMMunIZatIons for
adolEsCEnts—tdaP/td
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 69.5 55.3 NA NA 67.8
IMMunIZatIons for
adolEsCEnts—CoMbInatIon 1
(MEnIngoCoCCal, tdaP/td)
yEAR
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 51.6 39.4 NA NA 52.2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
WEIGHT ASSESSMENT AND CoUNSElING foR NUTRITIoN
AND PHySICAl ACTIVITy foR CHIlDREN/ADolESCENTS
The prevalence of overweight and obesity among young people in the U.S. has increased
dramatically in the past few decades; it has more than doubled in children and tripled in
adolescents. 1 Childhood obesity has become a health crisis that affects children’s healthy growth
and development and increases their risks for serious health problems later in life. 2 The Weight
Assessment and Counseling for Nutrition and Physical Activity in Children/Adolescents measure
evaluates the percentage of children and adolescents who are regularly screened for weight
problems and have received counseling about healthy eating and physical activity.
• An estimated 17 percent (12.5 million) of
all children and adolescents in the U.S. are
overweight or obese. 2,3
• overweight and obesity occurs when more
calories are consumed than the body can
burn during physical activity. 4
• Childhood overweight and obesity is
determined by measuring body mass index
(bMI). A child with a bMI at or above the
85th percentile but lower than the 95th
percentile for children of the same sex and
age is classified as overweight. A child
with a bMI at or above the 95th percentile
for children of the same age and sex is
classified as obese. 5
the Case for Improvement
• According to a 2009 study, the cost of
hospitalizations related to childhood
obesity rose from $125.9 million in 2001
to $237.6 million in 2005. America spends
as much as $147 billion annually on the
103
direct and indirect costs of obesity—9.1
percent of medical spending. 6,7
• obese children are more likely to have high
blood pressure and high cholesterol, risk
factors for cardiovascular disease; increased
risk of impaired glucose tolerance, insulin
resistance and type 2 diabetes; breathing
problems, including sleep apnea and
asthma; joint problems and musculoskeletal
discomfort; fatty liver disease; gallstones;
and gastroesophageal reflux. 7
• obese children and adolescents are
at greater risk of having social and
psychological problems, including
discrimination and poor self-esteem, which
can continue into adulthood. 7
HEdIs Measure definition
The percentage of children 3–17 years of age
who had an outpatient visit with a primary
care physician or an ob/GyN and who had
evidence of bMI percentile documentation and
counseling for nutrition and physical activity
M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S

M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A D o l E S C E N T S
during the measurement year. because bMI
norms for youths vary with age and gender,
this measure evaluates whether bMI percentile
is assessed rather than an absolute bMI value.
results
If children are overweight or obese, obesity
in adulthood is likely to be more severe. Adult
obesity is associated with a number of serious
health conditions, including heart disease,
diabetes and some cancers. 8 It is important for
parents and care providers to monitor a child’s
weight status. Children need guidance on
maintaining healthy eating and exercising habits.
yEAR
bMI PErCEntIlE (ovErall)
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 35.2 10.9 NA NA 37.3
2009 35.4 17.4 NA NA 30.3
yEAR
104
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
CounsElIng for
nutrItIon (ovErall)
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 37.4 11.8 NA NA 45.6
2009 41.0 20.3 NA NA 41.9
yEAR
CounsElIng for PHysICal
aCtIvIty (ovErall)
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 35.3 10.5 NA NA 36.7
2009 36.5 17.6 NA NA 32.5
frEQuEnCy of PrEnatal CarE
vIsIts—

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
fAll RISk MANAGEMENT
falls among older adults are a growing national concern because of the financial and societal
costs associated with falls and the expanding body of evidence that falls can be reduced. 1,2 The Fall
Risk Management measure assesses whether adults over 65 years of age who are at risk of falling
discussed their problem with their practitioner and received an appropriate intervention, if necessary.
• Among adults 65 and older, falls are the
leading cause of injury and death—each
year one in every three adults experiences
a fall. 2 falls are also the most common
cause of nonfatal injuries and hospital
admissions for trauma. 3 The chances of
falling and of being seriously injured in a
fall increase with age. 2,3
• Most falls result in fractures. 3,4
the Case for Improvement
• Direct medical costs of falls total more than
$19.3 billion—$349 million for fatal falls
and $19 billion for nonfatal fall injuries. 6,7
This translates to $26 billion in dollars. 7
Hospitalizations and visits to the emergency
department make up more than 80 percent
of the costs. 7
• In 2009, 2.2 million adults were treated
in emergency departments for nonfatal
fall injuries; more than 581,000 of these
patients were hospitalized. 5
105
• Many older adults who fall develop a fear
of falling that may cause them to limit
their activities, leading to reduced mobility
and loss of physical fitness, which in turn
increases their actual risk of falling. 3
HEdIs Measure definition
The two components of this survey measure
assess different facets of fall risk management.
• The percentage of Medicare adults 75
years of age and older, or adults 65–74
years of age with balance or walking
problems or a fall in the past 12 months,
who were seen by a practitioner in the
past 12 months and who discussed falls
or problems with balance or walking with
their current practitioner.
• The percentage of Medicare adults 65
years of age and older who had a fall or
had problems with balance or walking in
the past 12 months, who were seen by a
practitioner in the past 12 months and who
received fall risk intervention from their
current practitioner.
M E A S U R E S T A R G E T E D A T o l D E R A D U l T S

M E A S U R E S T A R G E T E D A T o l D E R A D U l T S
results
A discussion between provider and patient
regarding falls identifies risk factors related
to vision, muscle strength and reflexes—
important information for developing an
appropriate intervention plan. 2
yEAR
106
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
dIsCussIon
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 32.8 31.1 NA
2009 NA NA 31.1 30.3 NA
2008 NA NA 31.3 30.7 NA
2007 NA NA 29.4 28.1 NA
2006 NA NA 27.5 26.9 NA
yEAR
ManagEMEnt
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 60.1 55.3 NA
2009 NA NA 57.7 54.7 NA
2008 NA NA 57.8 54.6 NA
2007 NA NA 55.8 53.4 NA
2006 NA NA 56.0 54.2 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
MEDICATIoN IN THE ElDERly
The elderly are twice as likely as younger adults to have an adverse drug reaction and are
seven times more likely to be hospitalized as the result of an adverse drug event. 1 The Use
of High-Risk Medications in the Elderly measure assesses how often elderly individuals are
exposed to potentially harmful drugs. 2-4 The Potentially Harmful Drug-Disease Interactions in the
Elderly measure assesses how often patients with a specific diagnosis are prescribed high-risk
medications that are considered potentially dangerous.
• In a 2002–2005 study of 384 American
hospitals, 49 percent of patients received
at least one potentially inappropriate
medication; among patients 65 years of
age and older, 13 percent were given a
potentially harmful medication. 5
• In a study that measured potentially
inappropriate medication use in the elderly,
40 percent of the population filled at least
one prescription for such medications and
13 percent filled two or more. 6
the Case for Improvement
• Exposure to high-risk medications increases
health care costs, including medication
costs, an estimated $7.2 billion annually. 7
• The use of high-risk medications increases
the risk for hospitalization, death and
adverse health outcomes. 6,8
• Mobility problems from dementia are
exacerbated by the use of high-risk
medications, and patients exposed to these
107
medications are more likely to be admitted
to long-term care facilities. 9
• Prescribing harmful drugs to the elderly
population puts them at risk for further
complications, which include falls,
fractures and longer duration of illnesses.
Data from a multidisciplinary falls clinic
and a cooperative adverse drug event
surveillance project show that patients
on five or more medications are twice as
likely to have impaired balance and are
at higher risk for further inappropriate
medication use. 1,10
HEdIs Measure definition
The measures assess two different dimensions
of medication management in the Medicare
population 65 years of age and older.
Potentially Harmful Drug-Disease
Interactions in the Elderly
The percentage of adults 65 and older who
have evidence of an underlying disease,
condition or health concern and who were
dispensed an ambulatory prescription for a
M E A S U R E S T A R G E T E D A T o l D E R A D U l T S

M E A S U R E S T A R G E T E D A T o l D E R A D U l T S
contraindicated medication, concurrent with or
after the diagnosis.
Use of High-Risk Medications in the Elderly
The percentage of adults 65 and older who
received at least one high-risk medication
and the percentage of adults 65 and older
who received at least two different high-risk
medications. A combined rate is reported.
results
Currently, close to a quarter of all Medicare
patients are prescribed one potentially harmful
medication. Although some drugs are harmful
regardless of a patient’s current health, some
drugs prescribed for patients with a specific
disease are associated with poor physical
and cognitive performance, including balance
disorders and an increased likelihood of falls. 9,11
yEAR
108
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
PotEntIally HarMful drugdIsEasE
IntEraCtIons In tHE
EldErly: ovErall ratE*
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 23.3 21.8 NA
2009 NA NA 23.2 21.8 NA
2008 NA NA 23.0 21.7 NA
2007 NA NA 21.8 21.5 NA
yEAR
usE of HIgH-rIsk MEdICatIons
In tHE EldErly: at lEast
onE MEdICatIon*
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 22.1 21.9 NA
2009 NA NA 23.0 22.3 NA
2008 NA NA 23.4 22.1 NA
2007 NA NA 23.2 22.1 NA
2006 NA NA 23.1 23.1 NA
yEAR
usE of HIgH-rIsk MEdICatIons
In tHE EldErly: at lEast
tWo MEdICatIons*
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 5.1 5.1 NA
2009 NA NA 5.7 5.3 NA
2008 NA NA 6.0 5.4 NA
2007 NA NA 6.0 5.3 NA
2006 NA NA 5.9 6.5 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
MANAGEMENT of URINARy INCoNTINENCE
IN olDER ADUlTS
Urinary incontinence (UI) is involuntary loss of urine. 1,2 It is largely underestimated because
fewer than half of affected patients report it to their providers, partly because it is believed to
be an inevitable part of aging. 3 In the older population, UI is the result of several factors that
include comorbid conditions, multiple medications and functional and cognitive impairment. 1 The
Management of Urinary Incontinence in Older Adults measure assesses whether adults over the
age of 65 were asked about UI symptoms and received appropriate treatment.
• UI prevalence increases with age and is
a major cause of admittance to nursing
homes. It is more common in older
women—its prevalence in older men is
approximately one-third that of women. 1
• Many studies report that females with UI
seek help in very low percentages (ranging
from 14 percent–38 percent). Another
study found that 74 percent of women with
UI symptoms waited for one year before
seeking help, and 46 percent waited for
three years. 4,5
the Case for Improvement
• The estimated total annual cost of UI
is about $32 billion, or approximately
$3,565 per individual with UI. The largest
components are management costs and
expenses associated with nursing home
admissions attributable to UI. 7
• Given a rapidly aging population, the
incidence and prevalence of UI continues to
be a major problem. Among homebound
elderly, the incidence of UI is 15 percent–
33 percent. 5,6
• UI further puts older adults at risk for falls,
fractions and functional impairment. It is
associated with poor self-rated health,
impaired quality of life, social isolation,
depressive symptoms and dependence on
caregivers. 8
109
HEdIs Measure definition
This patient survey measure assesses the
diagnosis and management of UI in older adults.
• Discussing UI. The percentage of Medicare
adults 65 and older who reported having a
problem with urine leakage in the past six
months and discussed their problem with
their current practitioner.
• Receiving UI Treatment. The percentage
of Medicare adults 65 and older who
reported having a urine leakage problem
in the past six months and received
treatment for their current urine leakage
problem.
M E A S U R E S T A R G E T E D A T o l D E R A D U l T S

M E A S U R E S T A R G E T E D A T o l D E R A D U l T S
results
Routinely asking older patients about their
symptoms, combined with appropriate
treatment, is associated with minimal adverse
outcomes, satisfactory results for many
patients and possible prevention of the need
for medical or surgical intervention. 9
yEAR
110
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
dIsCussIon
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 58.2 57.9 NA
2009 NA NA 57.1 58.2 NA
2008 NA NA 57.3 58.0 NA
2007 NA NA 57.8 57.7 NA
2006 NA NA 56.8 57.3 NA
2005 NA NA 56.0 55.8 NA
yEAR
trEatMEnt
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 36.0 36.3 NA
2009 NA NA 35.5 37.4 NA
2008 NA NA 35.4 36.3 NA
2007 NA NA 35.4 35.6 NA
2006 NA NA 35.3 36.8 NA
2005 NA NA 33.3 34.8 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
PHySICAl ACTIVITy IN olDER ADUlTS
Physical activity in older adults is an important part of managing chronic diseases like diabetes,
obesity and high blood pressure. Physical activity helps older adults maintain their ability to live
independently and reduces the risk of falling and fracturing bones. 1,2 The Physical Activity in
Older Adults measure assesses whether older adults have either discussed or received advice
from their physician about exercise.
• lack of physical activity is one of the major
causes of obesity. About 14 percent of
all deaths in the U.S. can be attributed to
insufficient physical activity and inadequate
nutrition. 3
• Physical inactivity increases with age.
Data from the Centers for Disease Control
and Prevention reveal that 28 percent–34
percent of adults 65–74 are inactive and
engage in little or no physical activity, and
35 percent–44 percent of adults 75 or
older are not as active as they should be. 4
• Regular exercise and increased aerobic
fitness are associated with a decrease in
all-cause mortality and morbidity in older
adults. 1 Research proves that older adults
have more to gain from physical activity
than younger adults. 1,2
the Case for Improvement
• The medical costs for inactive adults are
substantially higher than for active adults,
and the cost of inactivity increases with
age. If inactive older adults increased their
physical activity to 90 minutes per week,
$2,200 per person could be saved in
health care costs every year. 3,5
• The number of older Americans is
expected to double in the next two
decades. Approximately 95 percent of
health care spending for older adults is
attributed to chronic conditions. lack of
physical activity among older adults is
an independent risk factor for a range of
chronic diseases. 3,5 80 percent of older
adults have at least one chronic condition;
50 percent have at least two.
• Regular physical activity for older adults
has beneficial health effects on a variety of
health outcomes, including decreased risk
of early death, heart disease and diabetes;
weight loss; fall prevention; reduced
depression; and improved cognitive
function. 6,7
111
HEdIs Measure definition
This survey-based measure assesses the
percentage of Medicare adults age 65 and
older who had a doctor’s visit in the past 12
months and who:
M E A S U R E S T A R G E T E D A T o l D E R A D U l T S

M E A S U R E S T A R G E T E D A T o l D E R A D U l T S
• Spoke with a with a doctor or other health
provider about their level of exercise or
physical activity
• Received advice to start, increase or
maintain their level of exercise or physical
activity.
results
Strong evidence suggests that physical activity
reduces the risk of developing chronic diseases
and should be a high priority for preventing
and treating disease and disability in older
adults. 7
112
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
yEAR
advICE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 47.9 47.6 NA
2009 NA NA 46.9 47.8 NA
2008 NA NA 47.0 47.1 NA
2007 NA NA 46.1 46.7 NA
2006 NA NA 45.2 48.8 NA
2005 NA NA 43.7 46.3 NA
yEAR
dIsCussIon
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 52.3 53.9 NA
2009 NA NA 51.3 54.4 NA
2008 NA NA 51.5 54.0 NA
2007 NA NA 51.1 53.0 NA
2006 NA NA 50.3 53.6 NA
2005 NA NA 50.6 53.7 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
GlAUCoMA SCREENING IN olDER ADUlTS
Glaucoma represents a family of diseases commonly associated with optic nerve damage and
changes in the visual field (narrowing of the eyes’ usual scope of vision). Disease development
is gradual, starting with “blind spots” and progressing up to complete blindness, with little or no
warning signs or symptoms. 1 The Glaucoma Screening in Older Adults measure assesses whether
older adults received an eye exam to check for this condition.
• Elevated eye pressure and older age are
key risk factors. With an aging population,
the prevalence and incidence of glaucoma
continue to rise. 2,3
• Untreated glaucoma is the second leading
cause of irreversible blindness in the U.S. 1,2
• Among African Americans, glaucoma is
the leading cause of blindness—African
Americans are six to eight times more likely
than Caucasians to have glaucoma. 3,4
the Case for Improvement
• Managed care organizations spend
approximately $1 billion ($2,000 per
patient) annually to treat glaucoma.
Treatment costs increase significantly as the
disease progresses. 6
• At least 4.2 million people in the United
States have glaucoma, but only half of
them know that they have it. Another 5–10
million have elevated eye pressure and are
at risk of developing glaucoma. 5
113
• Glaucoma-associated visual impairment
affects the quality of life and the ability to
function independently, hampering basic
daily activities. Vision loss among the elderly
has been shown to result in social isolation,
family stress and a greater tendency to
experience other health conditions. 2,3
HEdIs Measure definition
The percentage of Medicare adults 65
years and older without a prior diagnosis
of glaucoma or glaucoma suspect, who
received a glaucoma eye exam by an eyecare
professional for the early identification of
glaucomatous conditions.
M E A S U R E S T A R G E T E D A T o l D E R A D U l T S

M E A S U R E S T A R G E T E D A T o l D E R A D U l T S
114
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
results
Glaucoma’s asymptomatic progression points
to the importance of early detection and
treatment, which can prevent, slow or stop
vision loss. 6
yEAR
sCrEEnIng ratE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 63.8 65.1 NA
2009 NA NA 62.3 63.7 NA
2008 NA NA 59.8 62.2 NA
2007 NA NA 59.5 62.6 NA
2006 NA NA 62.2 63.3 NA
2005 NA NA 61.5 64.5 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
oSTEoPoRoSIS TESTING IN olDER WoMEN
osteoporosis is a disease characterized by low bone mass and structural deterioration of bone
tissue, leading to bone fragility and an increased susceptibility to fractures. It mostly affects
elderly women. Disease development is gradual, progressing without symptoms until a lowenergy
fall or minor activity fractures a bone. 1 The Osteoporosis Testing in Older Women
measure assesses whether women over the age of 65 reported receiving a bone density test.
• According to the National osteoporosis
foundation, about 12 million Americans
have osteoporosis and approximately 52.4
million over the age of 50 have low bone
density—which puts them at increased
risk for developing the disease. About 80
percent of those affected are women. 2
• one in two women and one in four men
over 50 will have an osteoporosis-related
fracture in their lifetime, most commonly of
the hip, wrist or spine. 1,2
the Case for Improvement
• In 2008, the annual direct medical costs
of osteoporosis and fractures ranged from
$17 billion to $22 billion. by 2025, annual
fractures and costs are expected to rise by
almost 50 percent. The most rapid growth
is estimated for people 65–74 years of
age. 3,4
115
• osteoporosis is responsible for more than
1.5 million fractures each year, and results
in 500,000 hospital admissions, 800,000
emergency room visits, 2.6 million
physician visits and 180,000 nursing home
admissions annually. 4,5
• Despite being a covered service under
Medicare with no out-of-pocket costs, bone
density tests are underutilized by elderly,
at-risk populations. In 2005 only an
estimated 30 percent of Medicare women
enrollees received a bone density test. 5
HEdIs Measure definition
This survey based measure assesses the
percentage of Medicare women 65 years
of age and older who report ever having
received a bone density test to check for
osteoporosis.
M E A S U R E S T A R G E T E D A T o l D E R A D U l T S

M E A S U R E S T A R G E T E D A T o l D E R A D U l T S
results
116
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
bone density screenings are an important
strategy for reducing the rate of fractures
among women over the age of 65. 6,7
yEAR
tEstIng
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 68.5 73.4 NA
2009 NA NA 68.0 72.8 NA
2008 NA NA 66.7 72.0 NA
2007 NA NA 65.7 70.3 NA
2006 NA NA 64.4 71.3 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E
oSTEoPoRoSIS MANAGEMENT IN
WoMEN WHo HAD A fRACTURE
osteoporosis is a weakening of the bones that puts patients at risk for bone fracture. 1 fragility
fractures, like those caused by osteoporosis, are associated with chronic pain, skeletal deformities,
loss of independence and increased mortality. 6 by 2012, over 12 million Americans over the age
of 50 are expected to have osteoporosis. 4 The Osteoporosis Management in Women Who Had a
Fracture measure assesses whether women suffering from bone fractures received a bone density
test to determine if bone fragility was the underlying cause of the fracture.
• Women are more likely to develop
osteoporosis than men. Women lose bone
density with age, 2 and a woman over
50 has a 50 percent chance of having
an osteoporosis-related fracture in her
lifetime. 3 once a woman has a fracture,
she is at four times greater risk for another
fracture. 3
• A bone mineral density test is the most
effective method for determining bone
health, and can identify osteoporosis,
determine risk for fractures and assess
response to osteoporosis treatment. 3
The U.S. Preventive Services Task force
recommends that osteoporosis screening
begin at 65 for most women. Women at
increased risk for osteoporotic fractures
should begin screening at age 60. 4
the Case for Improvement
• More than 300,000 hip fractures occur
each year due to osteoporosis. of these,
42,000 people die as a result. 7
117
• osteoporosis is underdiagnosed and
undertreated. only one-third of patients
with fragility fractures receive appropriate
testing and treatment for osteoporosis. 6
osteoporosis is asymptomatic in the early
stages of the disease, so most people are
not aware that they have the condition. 6
A fracture may be an indicator of the
presence of osteoporosis. 3,5
• osteoporosis treatment costs $17 billion
annually. 7 Direct medical costs are
predicted to increase to $25.3 billion
annually by 2025. 8 Each year, fragility
fractures are estimated to result in 500,000
hospitalizations, 800,000 emergency
department visits, 2.6 million doctors’ visits
and 180,000 nursing home placements. 9
M E A S U R E S T A R G E T E D A T o l D E R A D U l T S

M E A S U R E S T A R G E T E D A T o l D E R A D U l T S
118
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs Measure definition
The percentage of women 67 years of age
and older who suffered a fracture and who
had either a bone mineral density test or
prescription for a drug to treat or prevent
osteoporosis in the six months after the
fracture.
results
osteoporosis may lead to painful bone
fractures that limit mobility and put patients
at risk for other adverse health conditions.
osteoporosis therapy has the potential to
reduce the risk of fracture by nearly 50
percent. 10 Screening and treatment can
significantly improve health outcomes by
preventing fractures.
yEAR
trEatMEnt ratE
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 NA NA 20.7 18.5 NA
2009 NA NA 20.7 18.1 NA
2008 NA NA 20.7 18.0 NA
2007 NA NA 20.4 17.8 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • C A H P S
CoNSUMER AND PATIENT ENGAGEMENT AND ExPERIENCE
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a public/
private initiative to develop standardized surveys of patients’ experiences with ambulatory and
facility-level care in commercial and Medicaid plans. Surveys were developed with the Agency
for Healthcare Research and Quality (AHRQ). CAHPS data address areas such as patient ease
of obtaining information from a health plan; timeliness of service; and speed and accuracy of
claim processing.
CAHPS results offer an indication of how well health care organizations meet member expectations.
rating of Health Plan
Respondents were asked to give their health plan an overall rating, with 0 equaling “worst health
plan possible” and 10 equaling “best health plan possible.” The tables below represent the
percentage of respondents who rated their health plans either 9 or 10.
yEAR
ratIng of HEaltH Plan:
ratIng of 9 or 10
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 40.3 33.7 NA NA 54.7
2009 38.3 32.4 59.0 52.2 52.5
2008 39.1 34.2 60.7 53.4 55.3
2007 37.1 31.8 61.1 52.9 53.3
2006 38.0 35.9 61.7 53.9 52.4
2005 39.8 43.1 61.3 54.2 54.0
2004 38.4 NA 57.5 NA 52.3
2003 36.7 NA 53.3 NA 51.7
2002 36.0 NA 60.5 NA 51.5
2001 37.4 NA 62.4 NA 69.1
2000 34.7 NA NA NA NA
1999 32.6 NA NA NA NA
119
C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E

C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E
120
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
rating of Health Care
Respondents were asked to give their health care an overall rating, with 0 equaling “worst health
plan possible” and 10 equaling “best health plan possible.” The tables below represent the
percentage of respondents who rated their health plans either 9 or 10.
yEAR
ratIng of HEaltH CarE:
ratIng of 9 or 10
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 50.7 48.1 NA NA 48.8
2009 48.7 46.6 56.2 57.4 47.0
2008 48.7 46.7 56.2 56.4 48.1
2007 47.2 45.8 55.9 55.0 46.8
2006 47.0 48.3 62.0 62.7 46.2
2005 53.4 55.6 69.1 72.2 54.1
2004 52.1 NA 68.7 NA 53.5
2003 51.5 NA 67.5 NA 52.8
2002 49.4 NA 67.8 NA 53.0
2001 47.5 NA 68.8 NA 71.3
2000 45.6 NA NA NA NA
1999 44.1 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • C A H P S
getting needed Care
The Getting Needed Care composite measures members’ perception of how easy it was to get
care from their doctor and from specialists in the last 12 months. Members were asked how often
they were able to:
• See a specialist when they needed one
• obtain the care, tests or treatment they believed were necessary.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
yEAR
gEttIng nEEdEd CarE: alWays
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 53.9 53.9 NA NA 50.1
2009 52.9 52.7 63.6 64.4 48.5
2008 52.6 52.6 62.4 61.9 49.4
2007 50.4 49.5 62.0 63.4 48.7
2006 50.1 51.2 62.6 64.6 46.7
2005 80.1 84.7 95.9 97.0 73.4
2004 79.3 NA 95.7 NA 73.8
2003 78.4 NA 94.9 NA 72.1
2002 76.9 NA 94.8 NA 72.3
2001 76.7 NA 94.9 NA 75.4
2000 75.4 NA NA NA NA
121
C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E

C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E
122
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
getting Care Quickly
The Getting Care Quickly composite measures members’ perception of how quickly they received
care when it was sought in the last 12 months. Members were asked how often they were able to:
• Receive needed care right away
• Get an appointment for health care at a doctor’s office or clinic as soon as they thought care
was needed.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
yEAR
gEttIng CarE QuICkly: alWays
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 58.2 57.7 NA NA 56.2
2009 57.8 57.4 64.0 64.7 54.7
2008 57.6 56.2 63.7 64.6 55.7
2007 56.0 55.6 63.5 65.0 55.6
2006 56.8 57.5 65.4 67.0 53.4
2005 46.5 46.2 58.7 60.2 44.5
2004 45.5 NA 58.5 NA 44.2
2003 45.0 NA 57.2 NA 42.6
2002 43.9 NA 55.8 NA 44.1
2001 44.8 NA 60.0 NA 46.5
2000 45.8 NA NA NA NA

How Well doctors Communicate
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • C A H P S
The How Well Doctors Communicate composite measures members’ perception of the quality of
communication with their personal doctor in the last 12 months. Members were asked how often
their doctor:
• Explained things in a way that was easy to understand
• listened carefully to them
• Showed respect for what they had to say
• Spent enough time with them.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
yEAR
HoW WEll doCtors
CoMMunICatE: alWays
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 73.5 73.5 NA NA 69.1
2009 72.0 71.7 74.7 74.8 67.5
2008 71.1 70.7 75.3 74.8 68.0
2007 70.2 70.1 74.6 75.7 67.7
2006 70.3 71.5 75.0 76.2 66.7
2005 61.3 58.8 69.5 71.6 61.5
2004 60.2 NA 69.0 NA 60.8
2003 59.4 NA 68.6 NA 59.1
2002 57.7 NA 68.0 NA 59.9
2001 57.1 NA 68.5 NA 60.4
2000 58.4 NA NA NA NA
123
C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E

C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E
124
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
rating of Personal doctor
Respondents were asked to give their personal doctor an overall rating, with 0 equaling “worst
personal doctor possible” and 10 equaling “best personal doctor possible.” The tables below
represent the percentage of respondents who rated their personal doctor either 9 or 10.
yEAR
ratIng of PErsonal doCtor:
ratIng of 9 or 10
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 65.0 62.8 NA NA 61.1
2009 63.2 61.2 73.3 73.9 60.1
2008 63.3 61.9 73.6 73.3 61.1
2007 62.1 61.7 73.6 73.8 60.4
2006 62.3 63.2 73.8 75.0 60.3
2005 52.8 54.0 67.8 70.9 59.2
2004 51.7 NA 67.5 NA 58.4
2003 51.9 NA 66.4 NA 58.9
2002 49.7 NA 65.2 NA 58.0
2001 50.5 NA 65.8 NA 76.5
2000 48.3 NA NA NA NA
1999 47.0 NA NA NA NA

ating of specialist
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • C A H P S
Respondents were asked to give their specialist an overall rating, with 0 equaling “worst
specialist possible” and 10 equaling “best specialist possible.” The tables below represent the
percentage of respondents who rated their specialist either 9 or 10.
yEAR
ratIng of sPECIalIst:
ratIng of 9 or 10
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 64.1 61.9 NA NA 61.3
2009 61.8 60.4 69.3 70.8 60.5
2008 62.3 60.5 68.9 69.9 60.7
2007 61.7 60.5 69.2 70.2 60.8
2006 60.7 62.4 70.7 73.0 59.3
2005 57.2 59.1 67.7 71.7 60.2
2004 56.2 NA 67.5 NA 59.2
2003 55.8 NA 67.7 NA 58.3
2002 54.4 NA 67.7 NA 57.8
2001 54.6 NA 68.5 NA 75.3
2000 53.7 NA NA NA NA
1999 51.8 NA NA NA NA
125
C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E

C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E
126
Customer service
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
The Customer Service composite measures members’ perception of the usefulness and quality of
customer service they experienced in the last 12 months (for those who tried to get information
or help from their plan’s customer service). Members were asked how often their health plan’s
customer service:
• Gave them the information or help they needed
• Treated them with courtesy and respect.
Responses were “Never,” “Sometimes,” “Usually” and “Always.” The rates displayed represent
the average percentage of health plan members nationwide who responded “Always.”
yEAR
CustoMEr sErvICE: alWays
CoMMERCIAl MEDICARE MEDICAID
HMo PPo HMo PPo HMo
2010 59.4 55.5 NA NA 59.5
2009 57.9 54.5 66.4 NA 57.9
2008 57.2 53.5 66.6 64.3 59.0
2007 55.4 50.7 66.5 62.5 57.3
2006 54.2 53.9 NA NA 49.7
2005 71.2 69.7 91.5 87.7 68.6
2004 71.0 NA 94.8 NA 69.8
2003 70.8 NA 94.5 NA 69.7
2002 70.4 NA 94.3 NA 67.4
2001 67.2 NA 94.8 NA 67.5
2000 66.6 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • M E T H o D o l o G y o V E R V I E W
METHoDoloGy oVERVIEW
general Methods
Data in this report are from HEDIS year 2011, which is measure year 2010 (January 1–
December 31, 2010). Unless otherwise noted, all references to “years” in charts and tables are
to measure years, not HEDIS years.
because The State of Health Care Quality Report focuses on health plan performance, summary
tables are not weighted for the size of eligible populations. Most tables and appendices provide
mean rates separately for each measure, or for each indicator in a measure.
In most tables and appendices, rate means are provided side-by-side for commercial, Medicare
and Medicaid product lines. Results for HMo and PPo plans are shown in separate tables. HMo
plans include HMos, HMo/PoS combined, HMo/PPo/PoS combined, HMo/PPo combined
and PoS. only plans with the sole designation of PPo are shown as PPos in tables.
Some reporting periods are limited. for example, PPos have reported substantial HEDIS data
only since measure year 2005; Medicare and Medicaid performance data are reported only as
far back as measure year 2001.
best states
Identification of high-performing state cohorts is based on the state means of five measures:
Diabetes (nine indicators), Hypertension (one indicator), Persistence of Beta-Blockers After a
Heart Attack (one indicator) and Cholesterol Management for Patients With Cardiovascular
Conditions (two indicators).
The unweighted average of all indicators across all plans in a state is calculated for each state.
No distinction is made among plans with respect to product line or reporting type. The
composite means are ranked in descending order. The top 10 states compose the “best” cohort.
In the Diabetes quality composite, the Poor Glycemic Control Indicator is inverted before
calculating the composite so that higher performance is indicated by a higher rate.
Composite Measure Means by region
Analysis provides mean rates for several composite measures by U.S. Census region. The
Childhood and Adolescent Immunizations summary rate comprises the rates for vaccinations
127

128
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
appropriate to each age group. Childhood vaccinations included in the composite are DTaP/
DT, hepatitis A, hepatitis b, HIb, IPV, MMR, pneumococcal conjugate and chicken pox vaccines,
rotavirus, influenza and combinations. Adolescent vaccinations included in the composite are
meningococcal, Tdap/Td and combinations.
Consumer Experience is a summary of the following indicators: Getting Needed Care, Getting
Care Quickly, How Well Doctors Communicate, Claims Processing, Customer Service, Rating of
Personal Doctor, Rating of Specialist, Rating of All Health Care and Rating of Plan.
All rating summaries reflect ratings of 9 or 10 and all composites correspond to responses of
“Always.” The Diabetes composite summarizes the mean for the following indicators: blood
Pressure Control (9%), lDl Cholesterol Screening, lDl Cholesterol Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • M E T H o D o l o G y o V E R V I E W
Each of the five RRU measures summarizes a health plan’s utilization of several service
categories:
• Inpatient facility
• Evaluation and Management (E&M—Inpatient and outpatient)
• Procedure and Surgery (Inpatient and outpatient)
• Ambulatory Pharmacy Services.
NCQA calculates two observed-to-expected (o/E) ratios for each health plan, one for quality
and one for resource use. An o/E ratio is a plan’s actual quality level or resource use (the
“observed”), divided by an estimate of the quality level or resource use the plan would have if its
population was the same as the average population of all other plans submitting data to NCQA
(the “expected”).
To enable comparison within plan types (HMo or PPo), NCQA indexes o/E ratios by dividing
each plan’s ratio by the national average o/E for all HMos or PPos.
for the resource use index, shown as the horizontal axis on RRU scatter plots, a ratio of 1.00
represents the average resource utilization for all HMos or PPos nationally. A ratio greater than
1.00 represents higher-than-expected use; a ratio less than 1.00 represents lower-than-expected use.
for the quality index, otherwise known as the Effectiveness of Care ratio and shown as the
vertical axis on RRU scatter plots, a ratio greater than 1.00 represents better-than-expected
performance; a ratio less than 1.00 represents lower-than-expected performance. for example,
a PPo with a ratio of 1.12 for quality and 1.15 for resource use delivered quality that was
12 percent better than the average PPo serving similar patients, and used 15 percent more
resources than the PPo average.
Descriptive statistics are provided for composites with up to 10 indicators. With the exception of
the CoPD quality RRU composite, the summary statistics for composite measures are the simple,
unweighted average of all measures and indicators in the composite. Since 2 of the 3 CoPD
indicators describe the same dimension of care (Pharmacotherapy Management), each indicator
receives a weight of one-half.
129

130
APPENDIx 1: HEDIS EffECTIVENESS of CARE
MEASURES: 2010 NATIoNAl HMo AVERAGES
HEdIs EffECtIvEnEss of CarE MEasurEs
natIonal HMo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE MEDICAID
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Imaging Studies for low back Pain 74.2 NA 75.5
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 22.5 NA 23.5
Ambulatory Care—ED Visits per 1,000 Member Months 187.4 450.3 62.0
Wellness and Prevention
Adult bMI Assessment 40.7 50.4 42.2
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
76.7 NA 73.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
45.0 NA 38.5
52.4 NA 42.7
flu Shots for Adults 52.5 NA NA
Prenatal and Postpartum Care—Timeliness of Prenatal Care 91.0 NA 83.7
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 80.7 NA 64.4
breast Cancer Screening 70.8 68.5 51.3
Cervical Cancer Screening 77.0 NA 67.2
Colorectal Cancer Screening 62.6 57.6 NA
Chlamydia Screening in Women—16–20 years 40.8 NA 54.6
Chlamydia Screening in Women—21–24 years 45.7 NA 62.3
Chlamydia Screening in Women—Total Rate 43.1 NA 57.5
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 75.5 83.1 76.3
Comprehensive Diabetes Care—blood Pressure Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
natIonal HMo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE MEDICAID
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Control (

132
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
natIonal HMo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE MEDICAID
Childhood Immunization Status—Influenza 57.1 NA 43.6
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
18.5 NA 15.2
Immunizations for Adolescents—Meningococcal 55.2 NA 56.3
Immunizations for Adolescents—Tdap/Td 69.5 NA 67.8
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 51.6 NA 52.2
follow-Up Care for Children Prescribed ADHD Medication—Initiation 38.8 NA 38.1
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.4 NA 43.9
lead Screening in Children NA NA 66.2
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
35.2 NA 37.3
37.4 NA 45.6
35.3 NA 36.7
frequency of Prenatal Care Visits—80% of Expected Visits NA NA 61.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 1.6 NA 2.2
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.1 NA 2.2
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 1.3 NA 3.3
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 2.2 NA 5.7
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 4.9 NA 10.1
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 12.8 NA 16.1
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 76.3 NA 60.2
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 71.6 NA 71.9
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 42.7 NA 48.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 12–24 Months 97.5 NA 96.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 25 Months–6 years 91.2 NA 88.3
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 91.6 NA 90.2
Children and Adolescents’ Access to Primary Care Practitioners—Adolescents 12–19 years 89.2 NA 88.1

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
natIonal HMo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE MEDICAID
Measures targeted toward older adults
fall Risk Management—Discussion NA 32.8 NA
fall Risk Management—Management NA 60.1 NA
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—
falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
NA 11.6 NA
NA 28.7 NA
NA 17.1 NA
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* NA 23.3 NA
Use of High-Risk Medications in the Elderly—At least one Medication* NA 22.1 NA
Use of High-Risk Medications in the Elderly—At least Two Medications* NA 5.1 NA
Management of Urinary Incontinence—Discussion NA 58.2 NA
Management of Urinary Incontinence—Treatment NA 36.0 NA
Physical Activity in older Adults—Advice NA 47.9 NA
Physical Activity in older Adults—Discussion NA 52.3 NA
osteoporosis Testing in older Women NA 68.5 NA
osteoporosis Management in Women Who Had a fracture NA 20.7 NA
Glaucoma Screening in older Adults NA 63.8 NA
*Lower rates signify better performance.
133

134
APPENDIx 2: HEDIS EffECTIVENESS of CARE
MEASURES: 2010 NATIoNAl PPo AVERAGES
HEdIs EffECtIvEnEss of CarE MEasurEs
natIonal PPo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Imaging Studies for low back Pain 73.3 NA
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 21.3 NA
Ambulatory Care—ED Visits per 1,000 Member Months 174 379
Wellness and Prevention
Adult bMI Assessment 11.6 36.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
71.7 NA
Medical Assistance With Smoking and Tobacco Use Cessation—Discussing Cessation Strategies 39.0 NA
Medical Assistance With Smoking and Tobacco Use Cessation—Discussing Cessation Medications 47.2 NA
flu Shots for Adults 51.6 NA
Prenatal and Postpartum Care—Timeliness of Prenatal Care 75.7 NA
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 65.9 NA
breast Cancer Screening 67.0 65.8
Cervical Cancer Screening 74.5 NA
Colorectal Cancer Screening 47.6 41.0
Chlamydia Screening in Women—16–20 years 38.1 NA
Chlamydia Screening in Women—21–24 years 41.9 NA
Chlamydia Screening in Women—Total Rate 40.0 NA
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 71.3 82.5
Comprehensive Diabetes Care—blood Pressure Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
natIonal PPo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE
Use of Spirometry Testing in the Assessment and Diagnosis of CoPD 40.2 35.3
Pharmacotherapy Management of CoPD—bronchodilators 73.5 76.1
Pharmacotherapy Management of CoPD—Systemic Corticosteroids 66.2 69.6
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARbs 78.4 90.8
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants 57.9 69.1
Annual Monitoring for Patients on Persistent Medications—Digoxin 79.1 92.7
Annual Monitoring for Patients on Persistent Medications—Diuretics 78.1 91.2
Annual Monitoring for Patients on Persistent Medications—Combined 77.8 90.6
Antidepressant Medication Management—Acute Phase 64.3 67.4
Antidepressant Medication Management—Continuation Phase 48.1 55.7
follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge 54.2 39.1
follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge 74.1 61.2
Alcohol and other Drug Dependence Treatment—Engagement 16.0 4.8
Alcohol and other Drug Dependence Treatment—Initiation 40.8 57.4
Measures targeted toward Children and adolescents
Appropriate Testing for Children With Pharyngitis 76.6 NA
Appropriate Testing for Children With Upper Respiratory Infection 83.7 NA
Childhood Immunization Status—DTaP/DT 64.7 NA
Childhood Immunization Status—Hepatitis b 58.7 NA
Childhood Immunization Status—Hib 75.5 NA
Childhood Immunization Status—IPV 71.1 NA
Childhood Immunization Status—MMR 82.7 NA
Childhood Immunization Status—Pneumococcal Conjugate (PCV) 65.6 NA
Childhood Immunization Status—VzV 82.2 NA
Childhood Immunization Status—Combination 2 (DTaP, IPV, MMR, Hib, Hepatitis b and VzV) 48.5 NA
Childhood Immunization Status—Combination 3 (DTaP, IPV, MMR, Hib, Hepatitis b, VzV and PCV) 46.1 NA
Childhood Immunization Status—Hepatitis A 28.6 NA
Childhood Immunization Status—Rotavirus 51.9 NA
Childhood Immunization Status—Influenza 51.1 NA
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR, Hib,
Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
10.4 NA
Immunizations for Adolescents—Meningococcal 43.8 NA
Immunizations for Adolescents—Tdap/Td 55.3 NA
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 39.4 NA
follow-Up Care for Children Prescribed ADHD Medication—Initiation 38.1 NA
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.3 NA
135

136
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
natIonal PPo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
10.9 NA
11.8 NA
10.5 NA
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 2.9 NA
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.5 NA
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 1.7 NA
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 2.7 NA
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 5.3 NA
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 13.0 NA
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 72.8 NA
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 67.8 NA
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 39.2 NA
Children and Adolescents’ Access to Primary Care Practitioners—Children 12–24 Months 96.9 NA
Children and Adolescents’ Access to Primary Care Practitioners—Children 25 Months–6 years 89.1 NA
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 89.4 NA
Children and Adolescents’ Access to Primary Care Practitioners—Adolescents 12–19 years 86.8 NA
Measures targeted toward older adults
fall Risk Management—Discussion NA 31.1
fall Risk Management—Management NA 55.3
Potentially Harmful Drug-Disease Interactions in the Elderly—Chronic Renal failure
and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—Dementia and Tricyclic
Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—falls and Tricyclic Antidepressants,
Antipsychotics and Sleep Agents*
NA 11.7
NA 27.3
NA 16.3
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* NA 21.8
Use of High-Risk Medications in the Elderly—At least one Medication* NA 21.9
Use of High-Risk Medications in the Elderly—At least Two Medications* NA 5.1
Management of Urinary Incontinence—Discussion NA 57.9
Management of Urinary Incontinence—Treatment NA 36.3
Physical Activity in older Adults—Advice NA 47.6
Physical Activity in older Adults—Discussion NA 53.9
osteoporosis Testing in older Women NA 73.4
osteoporosis Management in Women Who Had a fracture NA 18.5
Glaucoma Screening in older Adults NA 65.1
*Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 3A: CAHPS MEMbER SATISfACTIoN
MEASURES: 2010 NATIoNAl HMo AVERAGES
CaHPs MEMbEr satIsfaCtIon MEasurEs
natIonal HMo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE MEDICAID
Consumer and Patient Engagement and Experience
Rating of Health Plan—Rating of 8, 9 or 10 64.2 NA 72.4
Rating of Health Plan—Rating of 9 or 10 40.3 NA 54.7
Rating of Health Care—Rating of 8, 9 or 10 76.6 NA 68.9
Rating of Health Care—Rating of 9 or 10 50.7 NA 48.8
Getting Needed Care—Usually or Always 86.2 NA 76.0
Getting Needed Care—Always 53.9 NA 50.1
Getting Care Quickly—Usually or Always 86.5 NA 80.6
Getting Care Quickly—Always 58.2 NA 56.2
How Well Doctors Communicate—Usually or Always 93.9 NA 87.8
How Well Doctors Communicate—Always 73.5 NA 69.1
Rating of Personal Doctor—Rating of 8, 9 or 10 83.2 NA 76.4
Rating of Personal Doctor—Rating of 9 or 10 65.0 NA 61.1
Rating of Specialist—Rating of 8, 9 or 10 82.3 NA 76.9
Rating of Specialist—Rating of 9 or 10 64.1 NA 61.3
Customer Service—Usually or Always 84.5 NA 79.7
Customer Service—Always 59.4 NA 59.5
Claims Processing—Usually or Always 88.6 NA NA
Claims Processing—Always 55.5 NA NA
137

138
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
APPENDIx 3b: CAHPS MEMbER SATISfACTIoN
MEASURES: 2010 NATIoNAl PPo AVERAGES
CaHPs MEMbEr satIsfaCtIon MEasurEs
natIonal PPo avEragEs—2010
MEASURE CoMMERCIAl MEDICARE
Consumer and Patient Engagement and Experience
Rating of Health Plan—Rating of 8, 9 or 10 58.6 NA
Rating of Health Plan—Rating of 9 or 10 33.7 NA
Rating of Health Care—Rating of 8, 9 or 10 75.6 NA
Rating of Health Care—Rating of 9 or 10 48.1 NA
Getting Needed Care—Usually or Always 86.6 NA
Getting Needed Care—Always 53.9 NA
Getting Care Quickly—Usually or Always 87.1 NA
Getting Care Quickly—Always 57.7 NA
How Well Doctors Communicate—Usually or Always 94.6 NA
How Well Doctors Communicate—Always 73.5 NA
Rating of Personal Doctor—Rating of 8, 9 or 10 82.8 NA
Rating of Personal Doctor—Rating of 9 or 10 62.8 NA
Rating of Specialist—Rating of 8, 9 or 10 81.6 NA
Rating of Specialist—Rating of 9 or 10 61.9 NA
Customer Service—Usually or Always 83.0 NA
Customer Service—Always 55.5 NA
Claims Processing—Usually or Always 87.8 NA
Claims Processing—Always 50.7 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 4A: ACCREDITED VS. NoNACCREDITED
PlANS: 2010 CoMMERCIAl HMo AVERAGES
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: CoMMErCIal HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
safety and Potential Waste
Imaging Studies for low back Pain 74.5 73.2 1.2
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 22.3 23.3 -0.9
Ambulatory Care—ED Visits per 1,000 Member Months 188.6 183.2 5.4
Wellness and Prevention
Adult bMI Assessment 41.4 38.1 3.2
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
76.8 76.1 0.7
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
45.1 44.6 0.5
52.4 52.2 0.3
flu Shots for Adults 52.1 54.1 -2.0
Prenatal and Postpartum Care—Timeliness of Prenatal Care 92.1 86.6 5.5
Prenatal and Postpartum Care—Postpartum Visit
between 21 and 56 Days After Delivery
81.5 77.6 3.9
breast Cancer Screening 71.2 69.5 1.7
Cervical Cancer Screening 77.7 74.5 3.2
Colorectal Cancer Screening 63.7 58.8 4.9
Chlamydia Screening in Women—16–20 years 42.1 36.4 5.6
Chlamydia Screening in Women—21–24 years 46.9 41.4 5.5
Chlamydia Screening in Women—Total Rate 44.4 39.0 5.4
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 75.5 75.5 0.0
Comprehensive Diabetes Care—blood Pressure Control (

140
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: CoMMErCIal HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Cholesterol Screening
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: CoMMErCIal HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, Hib, Hepatitis b, VzV and PCV)
76.5 69.4 7.1
Childhood Immunization Status—Hepatitis A 35.0 37.0 -2.1
Childhood Immunization Status—Rotavirus 63.8 62.1 1.7
Childhood Immunization Status—Influenza 58.1 53.5 4.6
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
18.9 17.3 1.6
Immunizations for Adolescents—Meningococcal 55.9 52.2 3.7
Immunizations for Adolescents—Tdap/Td 69.6 69.0 0.7
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 52.3 49.1 3.2
follow-Up Care for Children Prescribed ADHD Medication—Initiation 39.3 36.5 2.9
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.8 41.0 2.8
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
35.7 33.6 2.0
38.1 34.9 3.1
35.9 33.1 2.8
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 1.6 1.6 0.0
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.1 1.0 0.1
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 1.2 1.7 -0.4
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 2.1 2.6 -0.4
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 4.6 5.8 -1.2
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 12.3 14.7 -2.5
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 77.3 72.7 4.6
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 72.9 66.7 6.3
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 44.2 37.4 6.8
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 years
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
141
97.5 97.7 -0.2
91.4 90.4 1.1
91.9 90.5 1.5
89.5 88.1 1.4

142
APPENDIx 4b: ACCREDITED VS. NoNACCREDITED
PlANS: 2010 CoMMERCIAl PPo AVERAGES
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: CoMMErCIal PPo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Imaging Studies for low back Pain 73.0 73.9 -1.0
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 21.3 21.2 0.1
Ambulatory Care—ED Visits per 1,000 Member Months 180.8 159.9 20.9
Wellness and Prevention
Adult bMI Assessment 11.5 12.0 -0.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
71.7 71.6 0.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
39.0 38.9 0.0
47.3 46.9 0.4
flu Shots for Adults 51.8 51.2 0.6
Prenatal and Postpartum Care—Timeliness of Prenatal Care 72.5 82.2 -9.7
Prenatal and Postpartum Care—Postpartum Visit
between 21 and 56 Days After Delivery
63.9 70.0 -6.1
breast Cancer Screening 67.5 66.1 1.3
Cervical Cancer Screening 74.8 74.0 0.8
Colorectal Cancer Screening 49.1 44.2 4.9
Chlamydia Screening in Women—16–20 years 38.1 38.1 0.0
Chlamydia Screening in Women—21–24 years 41.7 42.4 -0.7
Chlamydia Screening in Women—Total Rate 39.9 40.2 -0.2
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 71.5 70.9 0.6
Comprehensive Diabetes Care—blood Pressure Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: CoMMErCIal PPo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Control (

144
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: CoMMErCIal PPo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
Childhood Immunization Status—Hepatitis A 28.1 29.6 -1.4
Childhood Immunization Status—Rotavirus 49.9 55.9 -6.0
Childhood Immunization Status—Influenza 50.3 52.7 -2.4
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
9.5 12.0 -2.5
Immunizations for Adolescents—Meningococcal 43.7 43.8 -0.1
Immunizations for Adolescents—Tdap/Td 55.3 55.1 0.2
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 39.5 39.2 0.3
follow-Up Care for Children Prescribed ADHD Medication—Initiation 37.7 39.1 -1.4
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.5 42.7 0.8
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
10.9 11.2 -0.4
11.6 12.4 -0.8
10.4 10.9 -0.5
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 2.3 4.4 -2.1
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.3 2.0 -0.7
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 1.6 2.0 -0.4
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 2.6 3.0 -0.4
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 5.3 5.3 -0.1
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 13.3 12.2 1.1
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 73.6 71.0 2.6
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 68.2 66.9 1.3
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 39.5 38.6 1.0
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 years
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
97.3 96.2 1.0
89.6 88.0 1.5
90.0 88.3 1.7
87.2 85.9 1.3

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 5: ACCREDITED VS. NoNACCREDITED
PlANS: 2010 MEDICAID HMo AVERAGES
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: MEdICaId HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
safety and Potential Waste
Imaging Studies for low back Pain 74.9 76.0 -1.1
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 22.4 24.5 -2.2
Ambulatory Care—ED Visits per 1,000 Member Months 64.1 60.1 4.0
Wellness and Prevention
Adult bMI Assessment 45.6 38.1 7.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
74.3
72.7 1.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
39.5
37.1 2.4
44.0 40.8 3.2
Prenatal and Postpartum Care—Timeliness of Prenatal Care 85.2 82.4 2.8
Prenatal and Postpartum Care—Postpartum Visit
between 21 and 56 Days After Delivery
65.2 63.7 1.4
breast Cancer Screening 52.0 50.8 1.2
Cervical Cancer Screening 69.1 65.8 3.3
Chlamydia Screening in Women—16–20 years 55.1 54.2 1.0
Chlamydia Screening in Women—21–24 years 63.5 61.2 2.3
Chlamydia Screening in Women—Total Rate 58.2 56.8 1.4
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 77.4 74.1 3.3
Comprehensive Diabetes Care—blood Pressure Control (

146
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: MEdICaId HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 71.1 68.4 2.7
Use of Appropriate Medications for People With Asthma—5–11 years 91.7 91.9 -0.2
Use of Appropriate Medications for People With Asthma—12–50 years 85.8 85.8 0.0
Use of Appropriate Medications for People With Asthma—overall Rate 88.4 88.4 0.0
Use of Spirometry Testing in the Assessment and Diagnosis of CoPD 30.4 32.9 -2.4
Pharmacotherapy Management of CoPD—bronchodilators 82.3 81.7 0.6
Pharmacotherapy Management of CoPD—Systemic Corticosteroids 65.7 64.8 0.9
Annual Monitoring for Patients on Persistent Medications—
ACE Inhibitors or ARbs
86.3 85.7 0.6
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants 67.9 67.5 0.4
Annual Monitoring for Patients on Persistent Medications—Digoxin 89.0 91.0 -2.1
Annual Monitoring for Patients on Persistent Medications—Diuretics 86.0 84.9 1.0
Annual Monitoring for Patients on Persistent Medications—Combined 83.9 83.8 0.1
Antidepressant Medication Management—Acute Phase 50.4 50.9 -0.5
Antidepressant Medication Management—Continuation Phase 33.5 35.1 -1.5
follow-Up After Hospitalization for Mental Illness—
Within 7 Days Post-Discharge
follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
48.2 41.8 6.4
66.8 61.4 5.4
Alcohol and other Drug Dependence Treatment—Engagement 15.6 13.1 2.5
Alcohol and other Drug Dependence Treatment—Initiation 47.2 39.5 7.7
Measures targeted toward Children and adolescents
Appropriate Testing for Children With Pharyngitis 63.9 65.9 -2.0
Appropriate Testing for Children With Upper Respiratory Infection 86.3 88.0 -1.7
Childhood Immunization Status—DTaP/DT 81.3 79.3 1.9
Childhood Immunization Status—Hepatitis b 91.0 89.3 1.7
Childhood Immunization Status—Hib 91.3 89.4 1.9
Childhood Immunization Status—IPV 91.6 90.2 1.5
Childhood Immunization Status—MMR 91.5 89.9 1.6
Childhood Immunization Status—Pneumococcal Conjugate (PCV) 80.9 78.1 2.8
Childhood Immunization Status—VzV 91.1 89.2 1.9
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, Hib, Hepatitis b and VzV)
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, Hib, Hepatitis b, VzV and PCV)
75.8 72.6 3.2
71.6 68.5 3.1
Childhood Immunization Status—Hepatitis A 37.9 35.1 2.7
Childhood Immunization Status—Rotavirus 59.8 55.6 4.2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: MEdICaId HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
Childhood Immunization Status—Influenza 45.0 42.2 2.7
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
16.6 13.9 2.7
Immunizations for Adolescents—Meningococcal 57.4 55.1 2.3
Immunizations for Adolescents—Tdap/Td 68.7 66.9 1.8
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 53.4 50.9 2.5
follow-Up Care for Children Prescribed ADHD Medication—Initiation 38.0 38.2 -0.1
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.1 45.0 -1.9
lead Screening in Children 69.0 63.4 5.6
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
37.4 37.1 0.3
47.4 43.9 3.4
37.5 35.9 1.6
frequency of Prenatal Care Visits—80% of Expected Visits 63.5 58.5 5.0
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 1.8 2.5 -0.7
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.9 2.4 -0.5
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 3.0 3.7 -0.7
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 5.3 6.1 -0.8
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 9.1 10.9 -1.8
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 14.8 17.2 -2.5
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 63.9 57.1 6.8
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 73.7 70.6 3.1
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 50.8 46.1 4.8
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 years
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
147
96.5 95.7 0.9
89.0 87.6 1.4
90.5 89.9 0.6
88.3 88.0 0.2

148
APPENDIx 6A: ACCREDITED VS. NoNACCREDITED
PlANS: 2010 MEDICARE HMo AVERAGES
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: MEdICarE HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Ambulatory Care—ED Visits per 1,000 Member Months 362.5 501 -138.5
Wellness and Prevention
Adult bMI Assessment 56.0 47.1 9.0
breast Cancer Screening 72.1 66.3 5.7
Colorectal Cancer Screening
Chronic disease Management
64.9 53.3 11.6
Persistence of beta-blocker Treatment After a Heart Attack 83.9 82.2 1.7
Comprehensive Diabetes Care—blood Pressure Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: MEdICarE HMo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
63.8 49.4 14.4
Alcohol and other Drug Dependence Treatment—Engagement 4.2 3.4 0.8
Alcohol and other Drug Dependence Treatment—Initiation 48.8 41.9 6.9
Measures targeted toward older adults
fall Risk Management—Discussion 28.8 35.2 -6.3
fall Risk Management—Management 58.0 61.3 -3.4
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—
falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
9.0 14.0 -4.9
24.2 31.6 -7.4
15.5 18.3 -2.8
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* 19.9 25.3 -5.4
Use of High-Risk Medications in the Elderly—At least one Medication* 18.6 24.1 -5.5
Use of High-Risk Medications in the Elderly—At least Two Medications* 3.7 5.9 -2.2
Management of Urinary Incontinence—Discussion 57.3 58.8 -1.5
Management of Urinary Incontinence—Treatment 35.8 36.1 -0.2
Physical Activity in older Adults—Advice 47.3 48.3 -1.0
Physical Activity in older Adults—Discussion 53.3 51.8 1.6
osteoporosis Testing in older Women 73.0 65.9 7.1
osteoporosis Management in Women Who Had a fracture 23.5 18.5 5.0
Glaucoma Screening in older Adults 67.0 61.9 5.1
* Lower rates signify better performance.
149

150
APPENDIx 6b: ACCREDITED VS. NoNACCREDITED
PlANS: 2010 MEDICARE PPo AVERAGES
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: MEdICarE PPo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Ambulatory Care—ED Visits per 1,000 Member Months 382.8 377.9 4.9
Wellness and Prevention
Adult bMI Assessment 42.1 34.9 7.1
breast Cancer Screening 66.7 65.5 1.2
Colorectal Cancer Screening
Chronic disease Management
45.3 39.8 5.5
Persistence of beta-blocker Treatment After a Heart Attack 82.0 82.7 -0.7
Comprehensive Diabetes Care—blood Pressure Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
aCCrEdItEd vs. nonaCCrEdItEd Plans: MEdICarE PPo avEragEs—2010
MEASURE ACCREDITED NoNACCREDITED DIffERENCE
follow-Up After Hospitalization for Mental Illness—
Within 30 Days Post-Discharge
63.1 60.7 2.4
Alcohol and other Drug Dependence Treatment—Engagement 4.4 4.9 -0.4
Alcohol and other Drug Dependence Treatment—Initiation 50.3 59.4 -9.1
Measures Targeted Toward older Adults
fall Risk Management—Discussion 30.1 31.3 -1.3
fall Risk Management—Management 55.8 55.2 0.6
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—falls
and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
9.5 12.5 -2.9
24.0 28.5 -4.5
14.0 17.1 -3.1
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* 19.1 22.7 -3.6
Use of High-Risk Medications in the Elderly—At least one Medication* 19.7 22.5 -2.8
Use of High-Risk Medications in the Elderly—At least Two Medications* 4.3 5.3 -1.0
Management of Urinary Incontinence—Discussion 57.1 58.1 -1.0
Management of Urinary Incontinence—Treatment 37.1 36.1 1.0
Physical Activity in older Adults—Advice 48.5 47.3 1.1
Physical Activity in older Adults—Discussion 55.6 53.4 2.2
osteoporosis Testing in older Women 75.0 73.0 2.0
osteoporosis Management in Women Who Had a fracture 19.5 18.1 1.4
Glaucoma Screening in older Adults 65.2 65.1 0.2
*Lower rates signify better performance.
151

152
APPENDIx 7A: PUblICly REPoRTING VS. NoNPUblICly
REPoRTING PlANS: 2010 CoMMERCIAl HMoS
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
CoMMErCIal HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Imaging Studies for low back Pain 74.4 72.7 1.7
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 22.4 24.1 -1.7
Ambulatory Care—ED Visits per 1,000 Member Months 186.9 192.3 -5.4
Wellness and Prevention
Adult bMI Assessment 40.8 38.5 2.3
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
76.8 75.2 1.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
45.2 43.0 2.3
52.5 51.0 1.5
flu Shots for Adults 52.3 54.4 -2.1
Prenatal and Postpartum Care—Timeliness of Prenatal Care 91.8 83.3 8.5
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 81.6 72.7 9.0
breast Cancer Screening 71.1 68.6 2.5
Cervical Cancer Screening 77.3 73.6 3.8
Colorectal Cancer Screening 63.1 58.7 4.4
Chlamydia Screening in Women—16–20 years 41.3 36.6 4.7
Chlamydia Screening in Women—21–24 years 46.2 41.4 4.8
Chlamydia Screening in Women—Total Rate 43.6 39.1 4.5
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 75.6 75.0 0.6
Comprehensive Diabetes Care—blood Pressure Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
CoMMErCIal HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Control (

154
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
CoMMErCIal HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Childhood Immunization Status—Rotavirus 63.8 60.9 2.9
Childhood Immunization Status—Influenza 58.0 49.4 8.7
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
18.7 16.7 2.0
Immunizations for Adolescents—Meningococcal 55.2 54.2 1.0
Immunizations for Adolescents—Tdap/Td 69.6 67.7 2.0
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 51.7 51.2 0.4
follow-Up Care for Children Prescribed ADHD Medication—Initiation 39.1 34.3 4.8
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.7 37.6 6.2
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
35.5 32.3 3.2
37.6 35.1 2.4
35.6 31.9 3.6
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 1.6 1.8 -0.2
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.1 0.6 0.5
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 1.3 1.8 -0.5
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 2.2 2.4 -0.2
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 4.8 5.7 -1.0
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 12.5 15.9 -3.5
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 76.8 71.7 5.2
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 72.4 64.5 7.8
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 43.5 35.7 7.8
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
97.5 97.1 0.5
91.4 89.3 2.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 91.9 89.3 2.6
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
89.5 86.9 2.6

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 7b: PUblICly REPoRTING VS. NoNPUblICly
REPoRTING PlANS: 2010 CoMMERCIAl PPoS
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
CoMMErCIal PPo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
safety and Potential Waste
Imaging Studies for low back Pain 73.2 77.8 -4.6
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 21.3 19.5 1.8
Ambulatory Care—ED Visits per 1,000 Member Months 175.1 131.7 43.3
Wellness and Prevention
Adult bMI Assessment 11.4 16.1 -4.6
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
71.7 71.7 0.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
39.0 35.2 3.8
47.3 41.6 5.7
flu Shots for Adults 51.7 47.3 4.4
Prenatal and Postpartum Care—Timeliness of Prenatal Care 76.1 62.0 14.1
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 65.9 68.1 -2.2
breast Cancer Screening 67.1 63.9 3.2
Cervical Cancer Screening 74.5 73.1 1.5
Colorectal Cancer Screening 47.8 39.0 8.8
Chlamydia Screening in Women—16–20 years 38.3 31.1 7.2
Chlamydia Screening in Women—21–24 years 42.1 34.1 8.0
Chlamydia Screening in Women—Total Rate 40.2 32.8 7.4
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 71.3 69.5 1.8
Comprehensive Diabetes Care—blood Pressure Control (

156
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
CoMMErCIal PPo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Cholesterol Screening
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
CoMMErCIal PPo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, Hib, Hepatitis b, VzV and PCV)
46.1 44.9 1.2
Childhood Immunization Status—Hepatitis A 28.6 30.2 -1.6
Childhood Immunization Status—Rotavirus 52.3 38.5 13.7
Childhood Immunization Status—Influenza 51.3 42.7 8.6
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
10.3 12.3 -1.9
Immunizations for Adolescents—Meningococcal 44.1 32.5 11.6
Immunizations for Adolescents—Tdap/Td 55.5 46.5 9.0
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 39.7 29.6 10.1
follow-Up Care for Children Prescribed ADHD Medication—Initiation 38.0 41.2 -3.2
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.2 47.5 -4.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
10.8 15.5 -4.7
11.8 10.5 1.3
10.5 12.4 -1.9
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 2.9 6.3 -3.5
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.5 1.8 -0.2
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 1.7 2.8 -1.1
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 2.6 6.1 -3.5
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 5.2 9.1 -3.9
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 13.0 14.0 -1.1
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 73.1 59.9 13.2
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 68.1 56.8 11.3
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 39.5 28.2 11.3
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
97.0 92.4 4.7
89.2 82.6 6.7
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 89.6 82.5 7.1
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
* Lower rates signify better performance.
157
86.9 83.2 3.7

158
APPENDIx 8: PUblICly REPoRTING VS. NoNPUblICly
REPoRTING PlANS: 2010 MEDICAID HMoS
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
MEdICaId HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
Imaging Studies for low back Pain 75.1 76.4 -1.3
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 23.1 24.4 -1.3
Ambulatory Care—ED Visits per 1,000 Member Months 62.2 61.4 0.8
Wellness and Prevention
Adult bMI Assessment 45.5 34.1 11.4
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
74.0 72.7 1.3
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
39.1 36.9 2.2
43.7 40.0 3.7
Prenatal and Postpartum Care—Timeliness of Prenatal Care 85.2 80.4 4.8
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 65.2 62.5 2.7
breast Cancer Screening 51.2 51.6 -0.4
Cervical Cancer Screening 67.6 66.3 1.3
Chlamydia Screening in Women—16–20 years 55.1 53.8 1.2
Chlamydia Screening in Women—21–24 years 62.3 62.2 0.1
Chlamydia Screening in Women—Total Rate 57.7 57.0 0.8
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 77.6 69.9 7.7
Comprehensive Diabetes Care—blood Pressure Control (

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
MEdICaId HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 70.6 68.7 1.9
Use of Appropriate Medications for People With Asthma—5–11 years 91.8 91.8 0.0
Use of Appropriate Medications for People With Asthma—12–50 years 85.8 85.9 -0.2
Use of Appropriate Medications for People With Asthma—overall Rate 88.5 88.1 0.4
Use of Spirometry Testing in the Assessment and Diagnosis of CoPD 30.4 34.2 -3.8
Pharmacotherapy Management of CoPD—bronchodilators 82.5 81.1 1.4
Pharmacotherapy Management of CoPD—Systemic Corticosteroids 65.4 65.2 0.2
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARbs 86.3 85.5 0.8
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants 68.4 66.1 2.4
Annual Monitoring for Patients on Persistent Medications—Digoxin 89.3 91.1 -1.8
Annual Monitoring for Patients on Persistent Medications—Diuretics 85.9 84.6 1.2
Annual Monitoring for Patients on Persistent Medications—Combined 84.0 83.6 0.4
Antidepressant Medication Management—Acute Phase 50.0 52.0 -1.9
Antidepressant Medication Management—Continuation Phase 33.5 36.0 -2.5
follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge 45.9 42.0 3.9
follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge 65.2 61.1 4.1
Alcohol and other Drug Dependence Treatment—Engagement 14.8 13.3 1.4
Alcohol and other Drug Dependence Treatment—Initiation 44.5 40.5 4.1
Measures targeted toward Children and adolescents
Appropriate Testing for Children With Pharyngitis 64.3 66.1 -1.8
Appropriate Testing for Children With Upper Respiratory Infection 86.9 87.8 -0.9
Childhood Immunization Status—DTaP/DT 80.4 79.7 0.7
Childhood Immunization Status—Hepatitis b 90.9 88.1 2.8
Childhood Immunization Status—Hib 90.7 89.1 1.7
Childhood Immunization Status—IPV 91.3 89.7 1.6
Childhood Immunization Status—MMR 91.2 89.4 1.8
Childhood Immunization Status—Pneumococcal Conjugate (PCV) 80.0 77.7 2.3
Childhood Immunization Status—VzV 90.6 88.8 1.7
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, Hib, Hepatitis b and VzV)
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, Hib, Hepatitis b, VzV and PCV)
74.8 72.5 2.3
70.7 67.9 2.8
Childhood Immunization Status—Hepatitis A 37.4 34.1 3.3
Childhood Immunization Status—Rotavirus 58.7 55.0 3.7
Childhood Immunization Status—Influenza 43.9 42.6 1.3
159

160
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
MEdICaId HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
16.0 13.3 2.8
Immunizations for Adolescents—Meningococcal 56.9 54.9 2.1
Immunizations for Adolescents—Tdap/Td 67.5 68.5 -1.0
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 52.9 50.6 2.3
follow-Up Care for Children Prescribed ADHD Medication—Initiation 38.8 36.7 2.1
follow-Up Care for Children Prescribed ADHD Medication—Continuation 45.0 41.3 3.7
lead Screening in Children 66.7 65.1 1.7
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
38.8 33.6 5.2
48.2 39.1 9.1
38.2 32.8 5.5
frequency of Prenatal Care Visits—80% of Expected Visits 64.2 53.3 10.9
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 2.1 2.3 -0.2
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 2.1 2.3 -0.2
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 3.3 3.5 -0.2
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 5.7 5.8 -0.2
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 9.7 10.8 -1.2
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 15.5 17.3 -1.8
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 61.4 57.5 4.0
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 72.2 71.2 0.9
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 48.9 46.2 2.7
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
96.0 96.2 -0.2
88.1 88.6 -0.5
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 90.2 90.2 0.0
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
88.1 88.2 -0.1

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 9A: PUblICly REPoRTING VS. NoNPUblICly
REPoRTING PlANS: 2010 MEDICARE HMoS
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
MEdICarE HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months 412.5 611.4 -198.8
Wellness and Prevention
Adult bMI Assessment 53.4 37.6 15.8
breast Cancer Screening 69.8 62.8 7.0
Colorectal Cancer Screening
Chronic disease Management
59.6 49.0 10.6
Persistence of beta-blocker Treatment After a Heart Attack 83.2 82.4 0.8
Comprehensive Diabetes Care—blood Pressure Control (

162
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
MEdICarE HMo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Alcohol and other Drug Dependence Treatment—Engagement 3.8 3.5 0.3
Alcohol and other Drug Dependence Treatment—Initiation 45.4 41.1 4.3
Measures targeted toward older adults
fall Risk Management—Discussion 31.3 38.9 -7.6
fall Risk Management—Management 59.1 64.3 -5.2
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—
falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
10.6 18.4 -7.8
27.5 33.9 -6.4
16.6 19.5 -2.9
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* 22.2 27.7 -5.4
Use of High-Risk Medications in the Elderly—At least one Medication* 21.2 26.1 -4.9
Use of High-Risk Medications in the Elderly—At least Two Medications* 4.8 6.7 -2.0
Management of Urinary Incontinence—Discussion 57.8 60.3 -2.5
Management of Urinary Incontinence—Treatment 36.0 36.0 -0.1
Physical Activity in older Adults—Advice 47.8 48.6 -0.9
Physical Activity in older Adults—Discussion 52.8 50.6 2.2
osteoporosis Testing in older Women 69.8 63.2 6.6
osteoporosis Management in Women Who Had a fracture 21.6 15.9 5.7
Glaucoma Screening in older Adults 65.0 58.5 6.5
*Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 9b: PUblICly REPoRTING VS. NoNPUblICly
REPoRTING PlANS: 2010 MEDICARE PPoS
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
MEdICarE PPo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months 372.3 428.3 -56.0
Wellness and Prevention
Adult bMI Assessment 37.7 27.2 10.6
breast Cancer Screening 65.8 65.7 0.0
Colorectal Cancer Screening
Chronic disease Management
41.3 38.9 2.4
Persistence of beta-blocker Treatment After a Heart Attack 83.2 78.7 4.5
Comprehensive Diabetes Care—blood Pressure Control (

164
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
PublICly rEPortIng vs. nonPublICly rEPortIng Plans:
MEdICarE PPo avEragEs—2010
MEASURE PUblIC NoNPUblIC DIffERENCE
Alcohol and other Drug Dependence Treatment—Engagement 4.6 6.2 -1.6
Alcohol and other Drug Dependence Treatment—Initiation 57.8 53.3 4.5
Measures targeted toward older adults
fall Risk Management—Discussion 31.0 31.6 -0.6
fall Risk Management—Management 55.5 54.2 1.3
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—
falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
10.8 19.1 -8.3
27.0 29.9 -2.9
16.1 18.0 -1.9
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* 21.4 25.6 -4.2
Use of High-Risk Medications in the Elderly—At least one Medication* 21.8 22.1 -0.2
Use of High-Risk Medications in the Elderly—At least Two Medications* 5.0 5.3 -0.3
Management of Urinary Incontinence—Discussion 58.1 56.3 1.8
Management of Urinary Incontinence—Treatment 36.6 34.3 2.3
Physical Activity in older Adults—Advice 47.5 48.7 -1.3
Physical Activity in older Adults—Discussion 54.1 52.0 2.1
osteoporosis Testing in older Women 73.5 73.2 0.2
osteoporosis Management in Women Who Had a fracture 18.7 16.7 2.0
Glaucoma Screening in older Adults 65.0 66.2 -1.3
*Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 10: HMoS VS. PPoS, CoMMERCIAl PlANS
HEdIs EffECtIvEnEss of CarE MEasurEs
HMos vs. PPos: CoMMErCIal avEragEs—2010
MEASURE HMo PPo DIffERENCE
safety and Potential Waste
Imaging Studies for low back Pain 74.2 73.3 -0.9
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 22.5 21.3 -1.2
Ambulatory Care—ED Visits per 1,000 Member Months 187.4 174 -13.4
Wellness and Prevention
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
76.7 71.7 -5.0
45.0 39.0 -6.0
52.4 47.2 -5.1
flu Shots for Adults 52.5 51.6 -0.9
breast Cancer Screening 70.8 67.0 -3.8
Cervical Cancer Screening 77.0 74.5 -2.4
Chlamydia Screening in Women—16–20 years 40.8 38.1 -2.7
Chlamydia Screening in Women—21–24 years 45.7 41.9 -3.8
Chlamydia Screening in Women—Total Rate 43.1 40.0 -3.1
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 75.5 71.3 -4.2
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 87.7 87.0 -0.7
Use of Appropriate Medications for People With Asthma—5–11 years 96.7 97.0 0.4
Use of Appropriate Medications for People With Asthma—12–50 years 91.8 91.8 0.0
Use of Appropriate Medications for People With Asthma—overall Rate 92.9 93.0 0.2
Use of Spirometry Testing in the Assessment and Diagnosis of CoPD 41.7 40.2 -1.5
Pharmacotherapy Management of CoPD—bronchodilators 77.8 73.5 -4.3
Pharmacotherapy Management of CoPD—Systemic Corticosteroids 69.8 66.2 -3.7
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARbs 81.6 78.4 -3.2
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants 60.4 57.9 -2.5
Annual Monitoring for Patients on Persistent Medications—Digoxin 84.6 79.1 -5.5
Annual Monitoring for Patients on Persistent Medications—Diuretics 81.0 78.1 -2.9
Annual Monitoring for Patients on Persistent Medications—Combined 80.9 77.8 -3.1
Antidepressant Medication Management—Acute Phase 64.7 64.3 -0.4
Antidepressant Medication Management—Continuation Phase 48.3 48.1 -0.3
follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge 59.7 54.2 -5.6
follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge 77.4 74.1 -3.2
Alcohol and other Drug Dependence Treatment—Engagement 15.6 16.0 0.3
165

166
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
HMos vs. PPos: CoMMErCIal avEragEs—2010
MEASURE HMo PPo DIffERENCE
Alcohol and other Drug Dependence Treatment—Initiation 42.7 40.8 -1.9
Measures targeted toward Children and adolescents
Appropriate Testing for Children With Pharyngitis 77.6 76.6 -0.9
Appropriate Testing for Children With Upper Respiratory Infection 85.1 83.7 -1.4
follow-Up Care for Children Prescribed ADHD Medication—Initiation 38.8 38.1 -0.7
follow-Up Care for Children Prescribed ADHD Medication—Continuation 43.4 43.3 -0.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 1.6 2.9 1.4
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 1.1 1.5 0.5
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 1.3 1.7 0.4
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 2.2 2.7 0.5
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 4.9 5.3 0.4
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 12.8 13.0 0.2
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 76.3 72.8 -3.6
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 71.6 67.8 -3.8
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 42.7 39.2 -3.5
Children and Adolescents’ Access to Primary Care Practitioners—Children 12–24 Months 97.5 96.9 -0.6
Children and Adolescents’ Access to Primary Care Practitioners—Children 25 Months–6 years 91.2 89.1 -2.1
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 91.6 89.4 -2.2
Children and Adolescents’ Access to Primary Care Practitioners—Adolescents 12–19 years 89.2 86.8 -2.4
*Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 11: HMoS VS. PPoS, MEDICARE PlANS
HEdIs EffECtIvEnEss of CarE MEasurEs
HMos vs. PPos: MEdICarE avEragEs—2010
MEASURE HMo PPo DIffERENCE
safety and Potential Waste
Ambulatory Care—ED Visits per 1,000 Member Months 450.3 379 -71.2
Wellness and Prevention
breast Cancer Screening 68.5 65.8 -2.7
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 83.1 82.5 -0.6
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 72.8 77.8 5.1
Use of Spirometry Testing in the Assessment and Diagnosis of CoPD 33.9 35.3 1.4
Pharmacotherapy Management of CoPD—bronchodilators 78.2 76.1 -2.2
Pharmacotherapy Management of CoPD—Systemic Corticosteroids 66.6 69.6 3.0
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARbs 90.7 90.8 0.1
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants 68.2 69.1 0.9
Annual Monitoring for Patients on Persistent Medications—Digoxin 93.1 92.7 -0.5
Annual Monitoring for Patients on Persistent Medications—Diuretics 90.9 91.2 0.4
Annual Monitoring for Patients on Persistent Medications—Combined 90.2 90.6 0.5
Antidepressant Medication Management—Acute Phase 65.0 67.4 2.4
Antidepressant Medication Management—Continuation Phase 51.9 55.7 3.8
follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge 37.4 39.1 1.6
follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge 55.4 61.2 5.8
Alcohol and other Drug Dependence Treatment—Engagement 3.7 4.8 1.0
Alcohol and other Drug Dependence Treatment—Initiation 44.6 57.4 12.8
Measures targeted toward older adults
fall Risk Management—Discussion 32.8 31.1 -1.8
fall Risk Management—Management 60.1 55.3 -4.8
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—
falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
11.6 11.7 0.1
28.7 27.3 -1.4
17.1 16.3 -0.9
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* 23.3 21.8 -1.4
Use of High-Risk Medications in the Elderly—At least one Medication* 22.1 21.9 -0.2
Use of High-Risk Medications in the Elderly—At least Two Medications* 5.1 5.1 -0.1
Management of Urinary Incontinence—Discussion 58.2 57.9 -0.4
Management of Urinary Incontinence—Treatment 36.0 36.3 0.4
Physical Activity in older Adults—Advice 47.9 47.6 -0.3
167

168
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
HMos vs. PPos: MEdICarE avEragEs—2010
MEASURE HMo PPo DIffERENCE
Physical Activity in older Adults—Discussion 52.3 53.9 1.5
osteoporosis Testing in older Women 68.5 73.4 4.9
osteoporosis Management in Women Who Had a fracture 20.7 18.5 -2.2
Glaucoma Screening in older Adults 63.8 65.1 1.3
*Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 12: HMoS VS. PPoS, CoMMERCIAl PlANS
CaHPs MEMbEr satIsfaCtIon MEasurEs
HMos vs. PPos: CoMMErCIal avEragEs—2010
MEASURE HMo PPo DIffERENCE
Consumer and Patient Engagement and Experience
Rating of Health Plan—Rating of 8, 9 or 10 64.2 58.6 -5.6
Rating of Health Plan—Rating of 9 or 10 40.3 33.7 -6.6
Rating of Health Care—Rating of 8, 9 or 10 76.6 75.6 -1.0
Rating of Health Care—Rating of 9 or 10 50.7 48.1 -2.6
Getting Needed Care—Usually or Always 86.2 86.6 0.4
Getting Needed Care—Always 53.9 53.9 0.0
Getting Care Quickly—Usually or Always 86.5 87.1 0.7
Getting Care Quickly—Always 58.2 57.7 -0.5
How Well Doctors Communicate—Usually or Always 93.9 94.6 0.7
How Well Doctors Communicate—Always 73.5 73.5 0.0
Rating of Personal Doctor—Rating of 8, 9 or 10 83.2 82.8 -0.4
Rating of Personal Doctor—Rating of 9 or 10 65.0 62.8 -2.2
Rating of Specialist—Rating of 8, 9 or 10 82.3 81.6 -0.7
Rating of Specialist—Rating of 9 or 10 64.1 61.9 -2.2
Customer Service—Usually or Always 84.5 83.0 -1.4
Customer Service—Always 59.4 55.5 -3.9
Claims Processing—Usually or Always 88.6 87.8 -0.8
Claims Processing—Always 55.5 50.7 -4.7
169

170
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
APPENDIx 13: HMoS VS. PPoS, MEDICARE PlANS
CaHPs MEMbEr satIsfaCtIon MEasurEs
HMos vs. PPos: MEdICarE avEragEs—2010
MEASURE HMo PPo DIffERENCE
Consumer and Patient Engagement and Experience
Information not available for the October 2011 pre-publication edition of this report. Information will appear in the November 2011 final edition.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 14A: VARIATIoN IN PlAN PERfoRMANCE: THE 90TH
PERCENTIlE VS. THE 10TH PERCENTIlE: CoMMERCIAl HMoS
MEASURE
safety and Potential Waste
HEdIs EffECtIvEnEss of CarE MEasurEs
CoMMErCIal HMo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Imaging Studies for low back Pain 82.0 66.4 15.6
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 31.6 15.0 16.6
Ambulatory Care—ED Visits per 1,000 Member Months 231.8 139.9 91.8
Wellness and Prevention
Adult bMI Assessment 76.9 1.2 75.7
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
85.2 67.2 18.0
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
59.0 33.6 25.4
63.2 42.6 20.5
flu Shots for Adults 62.4 43.9 18.6
Prenatal and Postpartum Care—Timeliness of Prenatal Care 97.8 81.3 16.5
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 90.7 66.7 24.0
breast Cancer Screening 79.5 63.3 16.2
Cervical Cancer Screening 83.2 71.0 12.2
Colorectal Cancer Screening 74.2 48.9 25.3
Chlamydia Screening in Women—16–20 years 53.9 29.3 24.5
Chlamydia Screening in Women—21–24 years 61.4 32.6 28.9
Chlamydia Screening in Women—Total Rate 56.7 30.6 26.1
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 87.5 64.1 23.4
Comprehensive Diabetes Care—blood Pressure Control (

172
MEASURE
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
CoMMErCIal HMo statIstICs—2010
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Cholesterol Screening
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Control (

MEASURE
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
CoMMErCIal HMo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Childhood Immunization Status—Hepatitis A 54.6 20.0 34.6
Childhood Immunization Status—Rotavirus 78.8 47.0 31.8
Childhood Immunization Status—Influenza 70.1 41.8 28.2
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
30.9 8.3 22.6
Immunizations for Adolescents—Meningococcal 77.7 35.9 41.7
Immunizations for Adolescents—Tdap/Td 91.9 46.1 45.8
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 75.2 30.6 44.6
follow-Up Care for Children Prescribed ADHD Medication—Initiation 49.0 30.7 18.4
follow-Up Care for Children Prescribed ADHD Medication—Continuation 55.6 31.3 24.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
75.9 0.2 75.7
74.1 0.2 73.9
70.1 0.0 70.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 3.6 0.0 3.6
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 2.0 0.0 2.0
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 2.5 0.0 2.5
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 3.9 0.4 3.5
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 8.3 1.9 6.4
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 21.7 5.9 15.9
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 89.6 61.1 28.6
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 84.5 56.9 27.7
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 60.2 28.5 31.7
Children and Adolescents' Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
Children and Adolescents’ Access to Primary Care Practitioners—
Children 7–11 years
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
173
99.4 95.4 4.0
95.7 86.2 9.4
96.7 86.8 9.9
95.1 83.5 11.6

174
APPENDIx 14b: VARIATIoN IN PlAN PERfoRMANCE: THE 90TH
PERCENTIlE VS. THE 10TH PERCENTIlE: CoMMERCIAl PPoS
MEASURE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
CoMMErCIal PPo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Imaging Studies for low back Pain 80.6 65.4 15.2
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 27.1 15.9 11.2
Ambulatory Care—ED Visits per 1,000 Member Months 208.8 133.3 75.6
Wellness and Prevention
Adult bMI Assessment 47.3 0.8 46.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
79.8 65.3 14.5
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
47.0 32.6 14.4
55.6 38.8 16.7
flu Shots for Adults 57.9 45.3 12.6
Prenatal and Postpartum Care—Timeliness of Prenatal Care 96.0 41.6 54.4
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 87.1 36.2 50.9
breast Cancer Screening 72.5 62.2 10.3
Cervical Cancer Screening 79.0 69.2 9.8
Colorectal Cancer Screening 55.3 41.1 14.2
Chlamydia Screening in Women—16–20 years 48.2 29.5 18.7
Chlamydia Screening in Women—21–24 years 55.2 30.6 24.6
Chlamydia Screening in Women—Total Rate 51.0 29.9 21.0
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 79.9 62.3 17.6
Comprehensive Diabetes Care—blood Pressure Control (

MEASURE
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
CoMMErCIal PPo statIstICs—2010
Cholesterol Management for Patients With Cardiovascular Conditions—
lDl Control (

176
MEASURE
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
CoMMErCIal PPo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Childhood Immunization Status—Rotavirus 70.6 33.6 37.0
Childhood Immunization Status—Influenza 65.2 35.4 29.8
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
19.9 3.3 16.5
Immunizations for Adolescents—Meningococcal 63.7 26.6 37.1
Immunizations for Adolescents—Tdap/Td 77.0 37.6 39.4
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 58.4 24.5 33.8
follow-Up Care for Children Prescribed ADHD Medication—Initiation 44.9 31.7 13.2
follow-Up Care for Children Prescribed ADHD Medication—Continuation 52.7 34.4 18.3
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
46.3 0.1 46.2
54.3 0.2 54.0
48.2 0.0 48.2
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 5.3 0.9 4.3
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 2.6 0.5 2.0
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 2.8 0.7 2.1
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 4.3 1.3 3.0
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 7.5 2.7 4.9
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 18.1 7.8 10.3
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 82.7 60.1 22.6
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 82.5 51.9 30.6
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 57.7 24.4 33.2
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
98.7 94.8 3.9
94.3 83.1 11.2
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 95.4 81.6 13.8
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
93.7 80.4 13.3

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
APPENDIx 15: VARIATIoN IN PlAN PERfoRMANCE: THE 90TH
PERCENTIlE VS. THE 10TH PERCENTIlE: MEDICAID HMoS
MEASURE
safety and Potential Waste
HEdIs EffECtIvEnEss of CarE MEasurEs
MEdICaId HMo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Imaging Studies for low back Pain 82.3 67.0 15.2
Avoidance of Antibiotic Treatment in Adults With Acute bronchitis 31.6 15.1 16.5
Ambulatory Care—ED Visits per 1,000 Member Months 76.6 44.4 32.2
Wellness and Prevention
Adult bMI Assessment 70.5 3.2 67.2
Medical Assistance With Smoking and Tobacco Use Cessation—
Advising Smokers and Tobacco Users to Quit
80.8 64.7 16.1
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Strategies
Medical Assistance With Smoking and Tobacco Use Cessation—
Discussing Cessation Medications
48.5 30.0 18.4
55.0 30.2 24.7
Prenatal and Postpartum Care—Timeliness of Prenatal Care 93.3 71.4 21.9
Prenatal and Postpartum Care—Postpartum Visit between 21 and 56 Days After Delivery 75.2 53.7 21.5
breast Cancer Screening 62.9 38.7 24.3
Cervical Cancer Screening 78.7 53.0 25.6
Chlamydia Screening in Women—16–20 years 66.7 42.9 23.8
Chlamydia Screening in Women—21–24 years 72.2 50.5 21.6
Chlamydia Screening in Women—Total Rate 69.1 46.0 23.0
Chronic disease Management
Persistence of beta-blocker Treatment After a Heart Attack 88.6 61.0 27.5
Comprehensive Diabetes Care—blood Pressure Control (

178
MEASURE
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
MEdICaId HMo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 83.2 53.3 29.8
Use of Appropriate Medications for People With Asthma—5–11 years 96.0 87.5 8.5
Use of Appropriate Medications for People With Asthma—12–50 years 91.3 79.8 11.4
Use of Appropriate Medications for People With Asthma—overall Rate 93.2 83.6 9.6
Use of Spirometry Testing in the Assessment and Diagnosis of CoPD 47.2 19.1 28.0
Pharmacotherapy Management of CoPD—bronchodilators 89.3 71.1 18.2
Pharmacotherapy Management of CoPD—Systemic Corticosteroids 76.8 46.5 30.3
Annual Monitoring for Patients on Persistent Medications—ACE Inhibitors or ARbs 90.6 79.9 10.7
Annual Monitoring for Patients on Persistent Medications—Anticonvulsants 76.6 57.6 19.0
Annual Monitoring for Patients on Persistent Medications—Digoxin 95.5 80.4 15.1
Annual Monitoring for Patients on Persistent Medications—Diuretics 90.7 79.3 11.3
Annual Monitoring for Patients on Persistent Medications—Combined 88.1 78.3 9.9
Antidepressant Medication Management—Acute Phase 59.9 43.0 16.9
Antidepressant Medication Management—Continuation Phase 44.2 25.7 18.5
follow-Up After Hospitalization for Mental Illness—Within 7 Days Post-Discharge 68.3 23.0 45.3
follow-Up After Hospitalization for Mental Illness—Within 30 Days Post-Discharge 82.6 36.0 46.6
Alcohol and other Drug Dependence Treatment—Engagement 25.9 2.0 23.9
Alcohol and other Drug Dependence Treatment—Initiation 60.7 30.0 30.7
Measures targeted toward Children and adolescents
Appropriate Testing for Children With Pharyngitis 83.0 45.1 37.9
Appropriate Testing for Children With Upper Respiratory Infection 94.8 79.2 15.6
Childhood Immunization Status—DTaP/DT 88.5 70.8 17.7
Childhood Immunization Status—Hepatitis b 95.9 82.9 13.0
Childhood Immunization Status—Hib 96.1 84.3 11.8
Childhood Immunization Status—IPV 95.9 85.6 10.2
Childhood Immunization Status—MMR 95.4 86.1 9.3
Childhood Immunization Status—Pneumococcal Conjugate (PCV) 88.8 68.8 20.0
Childhood Immunization Status—VzV 95.1 85.4 9.7
Childhood Immunization Status—Combination 2
(DTaP, IPV, MMR, Hib, Hepatitis b and VzV)
Childhood Immunization Status—Combination 3
(DTaP, IPV, MMR, Hib, Hepatitis b, VzV and PCV)
85.8 62.3 23.6
82.6 56.8 25.8
Childhood Immunization Status—Hepatitis A 48.7 24.3 24.4
Childhood Immunization Status—Rotavirus 72.2 43.6 28.7
Childhood Immunization Status—Influenza 60.3 22.0 38.3

MEASURE
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
MEdICaId HMo statIstICs—2010
Childhood Immunization Status—Combination 10 (DTaP, IPV, MMR,
Hib, Hepatitis A, Hepatitis b, VzV, PCV, Rotavirus and Influenza)
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
23.6 6.3 17.3
Immunizations for Adolescents—Meningococcal 79.7 38.0 41.7
Immunizations for Adolescents—Tdap/Td 87.8 45.3 42.5
Immunizations for Adolescents—Combination 1 (Meningococcal, Tdap/Td) 75.5 33.8 41.7
follow-Up Care for Children Prescribed ADHD Medication—Initiation 50.7 24.9 25.8
follow-Up Care for Children Prescribed ADHD Medication—Continuation 62.5 23.0 39.5
lead Screening in Children 87.6 34.6 53.0
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—bMI Percentile (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Nutrition (overall)
Weight Assessment and Counseling for Nutrition and Physical Activity
in Children and Adolescents—Counseling for Physical Activity (overall)
69.8 0.7 69.1
72.0 0.7 71.3
60.6 0.0 60.5
frequency of Prenatal Care Visits—80% of Expected Visits 81.8 34.7 47.1
Well-Child Visits: Ages 0–15 Months—No Well-Child Visits 4.4 0.5 3.9
Well-Child Visits: Ages 0–15 Months—one Well-Child Visit 4.1 0.7 3.4
Well-Child Visits: Ages 0–15 Months—Two Well-Child Visits 6.1 1.1 5.0
Well-Child Visits: Ages 0–15 Months—Three Well-Child Visits 9.3 2.7 6.6
Well-Child Visits: Ages 0–15 Months—four Well-Child Visits 15.6 5.3 10.3
Well-Child Visits: Ages 0–15 Months—five Well-Child Visits 21.9 8.3 13.6
Well-Child Visits: Ages 0–15 Months—Six or More Well-Child Visits 77.1 41.9 35.2
Well-Child Visits: Ages 3–6 years—one or More Well-Child Visits 82.9 60.9 22.0
Adolescent Well-Care Visits—At least one Comprehensive Well-Care Visit 64.1 35.0 29.1
Children and Adolescents’ Access to Primary Care Practitioners—
Children 12–24 Months
Children and Adolescents’ Access to Primary Care Practitioners—
Children 25 Months–6 years
98.6 92.6 6.0
92.7 82.0 10.7
Children and Adolescents’ Access to Primary Care Practitioners—Children 7–11 years 94.7 85.2 9.5
Children and Adolescents’ Access to Primary Care Practitioners—
Adolescents 12–19 years
*Lower rates signify better performance.
179
93.4 81.1 12.4

180
APPENDIx 16A: VARIATIoN IN PlAN PERfoRMANCE: THE
90TH PERCENTIlE VS. THE 10TH PERCENTIlE: MEDICARE HMoS
MEASURE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
MEdICarE HMo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Ambulatory Care—ED Visits per 1,000 Member Months 782.1 248.3 533.8
Wellness and Prevention
Adult bMI Assessment 80.2 16.8 63.4
breast Cancer Screening 80.9 55.5 25.4
Colorectal Cancer Screening
Chronic disease Management
75.6 40.0 35.5
Persistence of beta-blocker Treatment After a Heart Attack 91.6 72.4 19.2
Comprehensive Diabetes Care—blood Pressure Control (

MEASURE
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
MEdICarE HMo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Alcohol and other Drug Dependence Treatment—Engagement 7.9 0.4 7.5
Alcohol and other Drug Dependence Treatment—Initiation 63.3 25.0 38.3
Measures targeted toward older adults
fall Risk Management—Discussion 44.4 25.8 18.7
fall Risk Management—Management 69.8 51.6 18.2
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—
falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
5.0 23.0 -18.0
18.8 41.3 -22.5
11.9 23.4 -11.5
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* 15.8 32.4 -16.6
Use of High-Risk Medications in the Elderly—At least one Medication* 13.2 33.1 -19.8
Use of High-Risk Medications in the Elderly—At least Two Medications* 1.6 9.8 -8.1
Management of Urinary Incontinence—Discussion 64.3 50.9 13.4
Management of Urinary Incontinence—Treatment 41.1 30.7 10.3
Physical Activity in older Adults—Advice 54.5 41.7 12.8
Physical Activity in older Adults—Discussion 60.3 44.7 15.6
osteoporosis Testing in older Women 80.6 54.4 26.2
osteoporosis Management in Women Who Had a fracture 29.8 12.0 17.9
Glaucoma Screening in older Adults 77.9 48.0 29.9
*Lower rates signify better performance.
181

182
APPENDIx 16b: VARIATIoN IN PlAN PERfoRMANCE: THE
90TH PERCENTIlE VS. THE 10TH PERCENTIlE: MEDICARE PPoS
MEASURE
safety and Potential Waste
N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E
HEdIs EffECtIvEnEss of CarE MEasurEs
MEdICarE PPo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Ambulatory Care—ED Visits per 1,000 Member Months 506.7 266.8 239.9
Wellness and Prevention
Adult bMI Assessment 64.0 2.8 61.2
breast Cancer Screening 77.5 54.1 23.4
Colorectal Cancer Screening
Chronic disease Management
53.4 31.1 22.3
Persistence of beta-blocker Treatment After a Heart Attack 89.9 72.1 17.8
Comprehensive Diabetes Care—blood Pressure Control (

MEASURE
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A P P E N D I C E S
HEdIs EffECtIvEnEss of CarE MEasurEs
MEdICarE PPo statIstICs—2010
90TH
PERCENTIlE
10TH
PERCENTIlE DIffERENCE
Alcohol and other Drug Dependence Treatment—Engagement 8.7 1.3 7.4
Alcohol and other Drug Dependence Treatment—Initiation 80.7 35.5 45.2
Measures targeted toward older adults
fall Risk Management—Discussion 39.9 25.2 14.6
fall Risk Management—Management 65.9 46.6 19.3
Potentially Harmful Drug-Disease Interactions in the Elderly—
Chronic Renal failure and NSAIDS or Cox-2 Selective NSAIDS*
Potentially Harmful Drug-Disease Interactions in the Elderly—
Dementia and Tricyclic Antidepressants or Anticholinergic Agents*
Potentially Harmful Drug-Disease Interactions in the Elderly—
falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents*
4.3 20.0 -15.7
17.7 38.3 -20.5
10.5 22.2 -11.7
Potentially Harmful Drug-Disease Interactions in the Elderly—overall Rate* 15.0 29.8 -14.8
Use of High-Risk Medications in the Elderly—At least one Medication* 14.9 30.4 -15.5
Use of High-Risk Medications in the Elderly—At least Two Medications* 1.9 8.4 -6.5
Management of Urinary Incontinence—Discussion 65.6 51.5 14.1
Management of Urinary Incontinence—Treatment 42.1 31.1 10.9
Physical Activity in older Adults—Advice 52.7 41.6 11.1
Physical Activity in older Adults—Discussion 59.6 47.1 12.5
osteoporosis Testing in older Women 82.8 62.0 20.8
osteoporosis Management in Women Who Had a fracture 25.7 10.3 15.5
Glaucoma Screening in older Adults 76.1 53.8 22.3
*Lower rates signify better performance.
183

184
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usE of aPProPrIatE MEdICatIons for PEoPlE WItH astHMa
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6. National Committee on Quality Assurance. 2009. Insights for Improvement: Advancing COPD Care Through Quality Measurement.
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annual MonItorIng for PatIEnts on PErsIstEnt MEdICatIons
1. Center for Disease Control and Prevention. 2008. Medication Safety Basics. http://www.cdc.gov/MedicationSafety/basics.html (June 1, 2011)
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antIdEPrEssant MEdICatIon ManagEMEnt
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5. Smith, J.P., G.C. Smith. 2010. long-term economic costs of psychological problems during childhood. Social Science and Medicine.
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11. Hunot, V.M., R. Horne, M.N. leese, R.C. Churchill. 2007. A cohort study of adherence to antidepressants in primary care: the influence of
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folloW-uP aftEr HosPItalIZatIon for MEntal IllnEss
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InItIatIon and EngagEMEnt of alCoHol and otHEr drug dEPEndEnCE trEatMEnt
1. Substance Abuse and Mental Health Services Administration (SAMHSA). 2009. Results from the 2009 National Survey on Drug Use and
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2. National Institute on Drug Abuse (NIDA). 2011. NIDA InfoFacts: Nationwide Trends. http://www.drugabuse.gov/pdf/infofacts/
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4. National Institute on Drug Abuse. 2010. Monitoring the Future: National results on adolescent drug use. http://monitoringthefuture.org/
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5. keyes, k.M., M.l. Hatzenbuehler, k.A. Mclaughlin, b. link, M. olfson, b.f. Grant. 2010. Stigma and Treatment for Alcohol Disorders in
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aPProPrIatE tEstIng for CHIldrEn WItH PHaryngItIs
1. Wisconsin Department of Health Services. 2010. Disease Fact Sheet Series: Streptococcal Pharyngitis. http://www.dhs.wisconsin.gov/
communicable/factSheets/StreptococcalPharyngitis.htm (May 31, 2011)
2. Huhtala, T.A. 2011. Updates on Sinusitis, Pharyngitis and UTI. february 27–March 4, Salt lake City, Utah.
3. Wessels, M.R. 2011. Streptococcal Pharyngitis. New England Journal of Medicine 364: 648–55.
4. Gerber, M.A., R.S. baltimore, C.b. Eaton, M. Gewitz, A.H. Rowley, S.T. Shulman, k.A. Taubert. 2009. Prevention of Rheumatic fever and
Diagnosis and Treatment of Acute Streptococcal Pharyngitis: A Scientific Statement from the American Heart Association Rheumatic fever,
Endocarditis, and kawasaki Disease Committee of the Council on Cardiovascular Disease in the young, the Interdisciplinary Council on
functional Genomics and Translational biology, and the Interdisciplinary Council on Quality of Care and outcomes Research: Endorsed
by the American Academy of Pediatrics. Circulation 119: 1541–51.
5. lee, G.M., J.A. Salomon, C. Gay, J.k. Hammitt. 2010. Preferences for health outcomes associated with Group A Streptococcal disease
and vaccination. Health and Quality of Life Outcomes 8:28.
6. Undeland, D.k., T.J. kowalski, W.l. berth, J.D. Gundrum. 2010. Appropriately Prescribing Antibiotics for Patients with Pharyngitis: A
Physician-based Approach vs a Nurse-only Triage and Treatment Algorithm. Mayo Clin Proc 85(11): 1011–15.
7. Pfoh, E., M.R. Wessels, D. Goldmann, G.M. lee. 2008. burden and Economic Cost of Group A Streptococcal Pharyngitis. Pediatrics
121(2): 229–34.
8. Ayanruoh, S., M. Waseem, frances Quee, Alyssa Humphrey, Toussaint Reynolds. 2009. Impact of Rapid Streptococcal Test on Antibiotic
Use in a Pediatric Emergency Department. Pediatric Emergency Care 25(11): 748–50.
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WEll-CHIld vIsIts In tHE fIrst 15 MontHs of lIfE and In tHE tHIrd, fourtH, fIftH and sIxtH yEars of lIfE
1. Child Trends Data bank. 2010. Well-Child Visits. http://www.childtrendsdatabank.org/?q=node/85 (June 2011)
2. brown, b., M. Weitzman, et al., The Commonwealth fund. Early Child Development in Social Context: A Chartbook.
http://www.commonwealthfund.org/Content/Publications/Chartbooks/2004/Sep/Early-Child-Development-in-Social-Context--A-
Chartbook.aspx (June 2011)
3. National Institutes of Health Medline Plus. Well-child Visits. Updated January 17, 2011. http://www.nlm.nih.gov/medlineplus/ency/
article/001928.htm (June 2011)
4. Chung, P.J., T.C. lee, J.l. Morrison, M.A. Schuster. 2006. Preventive Care for Children in the United States: Quality and barriers. Annual
Review of Public Health; 27: 491–515.
5. National Survey of Children’s Health. NSCH 2007. Child and Adolescent Health measurement Initiative, Data Resource Center for Child
and Adolescent Health. http://nschdata.org (June 2011)
6. Hakim, R.b., D.S. Ronsaville. 2002. Effect of Compliance with Health Supervision Guidelines Among U.S. Infants on Emergency
Department Visits. Archives of Pediatric and Adolescent Medicine; 156: 1015–20.
7. Rosenberg, S.A., D. zhang, C.C. Robinson. 2008. Prevalence of Developmental Delays and participation in Early Intervention Services for
young Children. Pediatrics; 121(6): e1503–e1509.
8. Sice, l. The Commonwealth fund. 2007. Developmental Screening in Primary Care: The Effectiveness of Current Practice and
Recommendations for Improvement. http://www.commonwealthfund.org/usr_doc/1082_Sices_developmental_screening_primary_care.
pdf?section=4039 (June 2011)
9. Honeycutt, A.A., S.D. Grosse, l.J. Dunlap et al. 2003. Economic Costs of Mental Retardation, Cerebral Palsy, Hearing loss, and Vision
Impairment. In b.M. Altman, S.N. barnett, G.E. Hendershot, S.A. larson, eds., Using Survey Data to Study Disability: Results from the
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adolEsCEnt WEll-CarE vIsIts
1. National Quality Measures Clearinghouse. Adolescent Well-care Visits. http://www.qualitymeasures.ahrq.gov/content.aspx?id=15051
(June 2011)
2. American Medical Association. Guidelines for Adolescent Preventive Services: Recommendations Monograph. http://www.ama-assn.
org//resources/doc/ad-hlth/gapsmono.pdf (June 2011)
3. American Academy of Pediatrics. 2008. Achieving Quality Health Services for Adolescents. Pediatrics. 121(6):1263–270.
4. Centers for Disease Control and Prevention. youth Risk behavior Surveillance: Tobacco Use. http://apps.nccd.cdc.gov/youthonline/App/
Default.aspx (June 2011)
5. National Institutes of Health. PubMed Health: Obesity. Updated october 12, 2010. http://www.ncbi.nlm.nih.gov/pubmedhealth/
PMH0004552/ (June 2011)
6. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
http://brightfutures.aap.org/pdfs/Preventive%20Services%20PDfs/forward%20and%20Introduction.pdf (June 2011)
7. Irwin, C.E., Jr., S.H. Adams, M.J. Park, P.W. Newacheck. 2009. Preventive Care for Adolescents: few Get Visits and fewer Get Services.
Pediatrics. 123(4): e565–72.
8. finkelstein, E.A., P.S. Corso, T.R. Miller. 2006. Incidence and Economic Burden of Injuries in the United States. New york: oxford
University Press
9. Park, M.J., T.M. Macdonald, E.M. ozer, et al., 2001. Investing in Clinical Preventive Health Services for Adolescents. University of
California, San francisco
10. Health Resources and Services Administration. Child Health USA 2010. http://www.mchb.hrsa.gov/chusa10/hstat/hsa/pages/200hsa.
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CHIldrEn and adolEsCEnts’ aCCEss to PrIMary CarE PraCtItIonErs
1. American Academy of Pediatrics. Scope of Health Care Benefits for Children From Birth Through Age 21. http://aappolicy.
aappublications.org/cgi/reprint/pediatrics;117/3/979.pdf (June 2011)
2. Hensley-Quinn, M., E. osius. National Academy for State Health Policy. 2008. SCHIP and Adolescents: An Overview and Opportunities
for States. http://www.nashp.org/sites/default/files/shpbriefing_adolescents.pdf (June 2011)
3. Starfield, b., l. Shi, J. Macinko. 2005. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly. 83(3): 457–502.
4. Chung, P.J., T.C. lee, J.l. Morrison, M.A. Schuster. 2006. Preventive Care for Children in the United States: Quality and barriers. Annual
Review of Public Health. 27: 491–515.
5. National Survey of Children’s Health (NSCH). 2007. Child and Adolescent Health Measurement Initiative, Data Resource Center for Child
and Adolescent Health. http://nschdata.org (June 2011)
6. Chipman, S.A., J. lan, C. Chang, D.C. Goodman. 2010. Geographic Maldistribution of Primary Care for Children. Pediatrics. 127(6): e1626.
7. friedberg, M.W., P.S. Hussey, E.C. Schneider. 2010. Primary Care: A Critical Review of the Evidence on Quality and Costs of Health
Care. Health Affairs. 29(5): 766–72.
8. bodenheimer and fernandez. 2005. High and Rising Health Care Costs. Part 4: Can Costs be Controlled While Preserving Quality? Ann
Intern Med. 143:26–31.

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9. American Academy of Pediatrics. 2008. Achieving Quality Health Services for Adolescents. Pediatrics. 121(6):1263–270.
10. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd Edition.
http://brightfutures.aap.org/pdfs/Preventive%20Services%20PDfs/forward%20and%20Introduction.pdf (June 2011)
folloW-uP CarE for CHIldrEn PrEsCrIbEd adHd MEdICatIon
1. Visser, S.N., R.H. bitsko, M.l. Danielson, R. Perou, S.J. blumberg. 2010. Increasing Prevalence of Parent-Reported Attention-Deficit/
Hyperactivity Disorder Among Children - United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44):1439–43.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w (June 10, 2011)
2. Centers for Disease Control and Prevention. 2010. Attention-Deficit / Hyperactivity Disorder (ADHD) Symptoms and Diagnosis.
http://www.cdc.gov/ncbddd/adhd/diagnosis.html (June 10, 2011)
3. Centers for Disease Control and Prevention. 2010. Attention-Deficit / Hyperactivity Disorder (ADHD) Other Concerns & Conditions.
http://www.cdc.gov/ncbddd/adhd/conditions.html (June 10, 2011)
4. Guevara, J., P. lozano, T. Wickizer, l. Mell, H. Gephart. 2002. Psychotropic medication use in a population of children who have
attention-deficit/hyperactivity disorder. Pediatrics. 109(5):733–9.
5. National Institutes of Health fact Sheet. 2011. Attention Deficit Hyperactivity Disorder (ADHD). http://report.nih.gov/NIHfactsheets/
ViewfactSheet.aspx?csid=25&key=A#A (June 10, 2011)
6. Pelham, W.E, E.M. foster, J.A. Robb. 2007. The economic impact of attention-deficit/hyperactivity disorder in children and adolescents. J
Pediatr Psychol. 32(6):711–27.
7. Matza, l.S., C. Paramore, M. Prasad. 2005. A review of the economic burden of ADHD. Cost Eff Resour Alloc. 3:5.
8. brown, R.T., R.W. Amler, W.S. freeman, J.M. Perrin, M.T. Stein, H.M. feldman, k. Pierce, M.l. Wolraich. 2005. Treatment of Attention-
Deficit/Hyperactivity Disorder: overview of the Evidence. Pediatrics. 115(6):e749–57.
aPProPrIatE trEatMEnt for CHIldrEn WItH uPPEr rEsPIratory InfECtIon
1. Hart, A.M. 2007. An Evidence-based Approach to the Diagnosis and Management of Acute Respiratory Infections. Journal for Nursing
Practitioners 3(9): 607–11.
2. lucile Packard Children’s Hospital at Stanford. 2011. Upper Respiratory Infection (URI, or Common Cold). http://www.lpch.org/
DiseaseHealthInfo/Healthlibrary/respire/uricold.html (June 1, 2011)
3. Wong, D.M., D.A. blumberg, l.G. lowe. 2006. Guidelines for the Use of Antibiotics in Acute Upper Respiratory Tract Infections. Am Fam
Physician 74(6): 956–66.
4. Centers for Disease Control and Prevention. 2011. Get Smart: know When Antibiotics Work. facts About Antibiotic Resistance. http://
www.cdc.gov/getsmart/antibiotic-use/fast-facts.html#ref2 (May 26, 2011)
5. ong, S., J. Nakase, G.J. Moran, D.J. karras, M.J. kuehnert, D.A. Talan. 2007. Antibiotic Use for Emergency Department Patients with
Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction. Ann Emerg Med 50: 213–20.
6. fendrick, A.M., A.S. Monto, b. Nightengale, M. Sarnes. 2003. The Economic burden of Non-Influenza-Related Viral Respiratory Tract
Infection in the United States. Arch Intern Med 163: 487–94.
7. linder, J.A. 2007. Improving Care for Acute Respiratory Infections: better Systems, Not better Microbiology. Clin Infect Dis 45(9): 1189–91.
8. friedman, b., D. Schwabe-Warf, R. Goldman. 2011. Reducing inappropriate antibiotic use among children with influenza infection. Can
Fam Physician 57(1): 42–4.
CHIldHood IMMunIZatIon status
1. Centers for Disease Control and Prevention. 2009. Vaccines & Immunizations: How Vaccines Prevent Disease. http://www.cdc.gov/
vaccines/vac-gen/howvpd.htm (June 1, 2011)
2. Centers for Disease Control and Prevention. 2011. Vaccines & Immunizations: Infants and Toddlers. http://www.cdc.gov/vaccines/specgrps/infants-toddlers.htm
(June 1, 2011)
3. Centers for Disease Control and Prevention. 2010. Vaccines & Immunizations: 10 Things You Need to Know About Immunizations. http://
www.cdc.gov/vaccines/vac-gen/10-shouldknow.htm (June 6, 2011)
4. Centers for Disease Control and Prevention. 2011. General Recommendations on Immunization: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (MMWR). January 28, 2011. 60(RR02);1–60.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm?s_cid=rr6002a1_e
5. American Academy of Pediatrics. Children’s Health Topics: Immunizations/Vaccines. http://www.aap.org/healthtopics/immunizations.
cfm (June 6, 2011)
6. HealthyChildren. American Academy of Pediatrics. 2011. Safety & Prevention: Why Immunize Your Child. http://www.healthychildren.
org/english/safety-prevention/immunizations/Pages/Why-Immunize-your-Child.aspx?nfstatus=401&nftoken=00000000-0000-0000-
0000-000000000000&nfstatusdescription=ERRoR%3a+No+local+token (June 1, 2011)
7. Immunization Action Coalition. 2010. Vaccines work! CDC statistics demonstrate dramatic declines in vaccine-preventable diseases when
compared with the pre-vaccine era. http://www.immunize.org/catg.d/p4037.pdf (June 6, 2011)
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8. zhou, f. Updated economic evaluation of the routine childhood immunization schedule in the United States. Presented at the 45th National
Immunization Conference. Washington, DC; March 28–31, 2011.
9. Centers for Disease Control and Prevention. 2011. Ten Great Public Health Achievements—United States, 2001—2010. MMWR
Morbidity and Mortality Weekly Report May 20, 2011. 60(19):619-623.
10. kennedy, A., M. basket, k. Sheedy. 2011. Identifying and Addressing Vaccine-Safety Concerns Among Parents: Vaccine Attitudes,
Concerns, and Information Sources Reported by Parents of young Children: Results from the 2009 HealthStyles Survey. Pediatrics 2011;
127 (Suppl 1):S92–S99.
11. Centers for Disease Control and Prevention. 2011. Vaccines & Immunizations. Statistics and Surveillance: U.S. Vaccination Coverage
Reported via NIS. http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nis (July 12, 2011)
12. U.S. National library of Medicine. MedlinePlus. 2011. Childhood Immunization. http://www.nlm.nih.gov/medlineplus/
childhoodimmunization.html (June 6, 2011)
IMMunIZatIons for adolEsCEnts
1. American Medical Association. 2008. Improving Adolescent Immunizations. http://www.ama-assn.org/resources/doc/public-health/
ad_immunizations_mon.pdf (June 8, 2011)
2. Centers for Disease Control and Prevention. 2011. Preteen and Teen Vaccines: For Parents. http://www.cdc.gov/vaccines/who/teens/
for-parents.html (June 7, 2011)
3. Centers for Disease Control and Prevention. 2011. Preteen and Teen Vaccines: Tdap Vaccine for Preteens and Teens. http://www.cdc.
gov/vaccines/who/teens/vaccines/tdap.html (June 8, 2011)
4. Immunization Action Coalition. 2010. Vaccines work! CDC statistics demonstrate dramatic declines in vaccine-preventable diseases when
compared with the pre-vaccine era. http://www.immunize.org/catg.d/p4037.pdf (June 6, 2011)
5. National foundation for Infectious Diseases. 2009. Adolescent Vaccination. 10 Reasons To Be Vaccinated. http://www.adolescentvaccination.
org/ten_reasons.htm (June 9, 2011)
6. broder, k.R., A.C. Cohn, b. Schwartz, J.D. klein, M.M. fisher, D.b. fishbein, C. Mijalski, G.b. burstein, M.E. Vernon-Smiley, M.M.
McCauley, C.J. Wibbelsman. 2008. Adolescent Immunizations and other Clinical Preventive Services: A Needle and a Hook? Pediatrics
121(Suppl 1):S25–S34.
7. lee, G.M., S.A. lorick, E. Pfoh, k. kleinman, D. fishbein. Adolescent Immunizations: Missed opportunities for Prevention. 2008.
Pediatrics 122(4):711–17.
lEad sCrEEnIng In CHIldrEn
1. Needleman, H.l. 2004. lead poisoning. Annual Review of Medicine 55:209–22.
2. Environmental Protection Agency. Lead in Paint, Dust, and Soil: Health effects of lead. http://www.epa.gov/lead/pubs/leadinfo.
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3. General lead Information. National Center for Environmental Health http://www.cdc.gov/nceh/lead/ (May, 2011)
4. United States Preventive Services Task force (USPSTf). 1996. Chapter 23, Screening for Elevated lead levels in Childhood and
Pregnancy. Guide to Clinical Preventive Services. Second Edition. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hscps2ed1996&
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5. lustberg, M., E. Silbergeld. blood lead levels and mortality. 2002. Arch Intern Med Nov 25;162(21):2443–9.
6. lead: Prevention Tips. National Center for Environmental Health. Updated June 2009. http://www.cdc.gov/nceh/lead/tips.htm (May 2011)
7. Trasande, l., y. liu. Reducing The Staggering Costs of Environmental Disease in Children. 2011. Health Affairs, 30(5): 863–70.
8. Jones, et al. 2009. Trends in blood lead levels and blood lead Testing Among US Children Aged 1 to 5 years, 1988–2004. Pediatrics
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WEIgHt assEssMEnt and CounsElIng for nutrItIon and PHysICal aCtIvIty for CHIldrEn/adolEsCEnts
1. American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity: About Childhood Obesity.
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2. National Child Care Information and Technical Assistance Center. 2010. Childhood Obesity Prevention. http://nccic.acf.hhs.gov/
poptopics/childobesity.html (June 9, 2011)
3. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Data and Statistics. http://www.cdc.gov/obesity/
childhood/data.html (June 9, 2011)
4. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Causes and Consequences. http://www.cdc.gov/obesity/
causes/index.html (June 9, 2011)
5. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Basics About Childhood Obesity. http://www.cdc.gov/
obesity/childhood/basics.html (June 9, 2011)
6. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Economic Consequences. http://www.cdc.gov/obesity/
causes/economics.html (July 12, 2011)

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7. finkelstein, E.A., J.G. Trogdon, J.W. Cohen, W. Dietz. 2009. Annual medical spending attributable to obesity: Payer- and service-specific
estimates. Health Affairs 28(5): w822–w831.
8. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Basics About Childhood Obesity. http://www.cdc.gov/
obesity/childhood/basics.html (June 9, 2011)
fall rIsk ManagEMEnt
1. American occupational Therapy Association. 2010. Analysis of Medicare Policy in Relation to Preventing Falls Among Older Adults.
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2. American Geriatrics Society. 2010. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice
Guideline for Prevention of Falls in Older Persons. http://www.americangeriatrics.org/files/documents/health_care_pros/JAGS.falls.
Guidelines.pdf. (May 27, 2011)
3. Centers for Disease Control and Prevention. 2010. Falls Among Older Adults: An Overview. http://www.cdc.gov/
HomeandRecreationalSafety/falls/adultfalls.html (May 27, 2011)
4. Centers for Disease Control and Prevention. 2008. Self-Reported falls and fall-Related Injuries Among Persons Aged >65 years—United
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5. business Group on Health. 2011. Injuries from falls: fact Sheet. http://www.businessgrouphealth.org/pdfs/04811%20NbGH%20
InjuryPrevnt%20factSheet_fAllS.pdf (May 27, 2011)
6. Centers for Disease Control and Prevention. 2011. Cost of fall Injuries in older Persons in the United States. http://www.cdc.gov/
HomeandRecreationalSafety/falls/data/cost-estimates.html (May 27, 2011)
7. Centers for Disease Control and Prevention. 2011. Cost of fall Injuries in older Persons in the United States. http://www.cdc.gov/
HomeandRecreationalSafety/falls/data/cost-estimates.html (May 27, 2011)
MEdICatIon In tHE EldErly
1. budnitz, D., et al. 2006. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296:1858–66.
2. zhan, C., et al. 2001. Potentially inappropriate medication use in the community-dwelling elderly. JAMA 286(22):2823–68.
3. beers, M.H. 1997. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 157:1531–6.
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5. fick, D.M., et al. 2003. Updating the beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med 163:2716–24.
6. fick, D.M., l.C. Mion, M.H. beers, J.l. Waller. 2008. Health outcomes Associated With Potentially Inappropriate Medication Use in
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7. fu, A.z., J.A. Jiang, J.H. Reeves, J.E. fincham, G.G. liu, M. Perri. 2007. Potentially inappropriate medication use and healthcare
expenditures in the US community-dwelling elderly. Med Care 45:472–476.
8. Jano, E., R. Aparaus. 2007. Healthcare outcomes Associated with beers’ Criteria: A Systematic Review. Ann Pharmacother 41:438–48.
9. The American Geriatrics Society (AGS) and british Geriatrics Society (bGS). Panel on the Clinical Practice Guideline for the Prevention of
Falls in Older Persons. Clinical practice guideline: Prevention of falls in older persons. http://www.americangeriatrics.org/health_care_
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10. flores, E.k., R. Henry, D.W. Stewart. 2011. Pharmacist’s Role in an Interdisciplinary falls Clinic. SouthMed J 104(2):143–6.
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ManagEMEnt of urInary InContInEnCE In oldEr adults
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2. Morrison, A., R. levy. 2006. fraction of nursing home admissions attributable to urinary incontinence. Value Health 9(4):272.
3. Holroyd-leduc, J.M., S.E. Straus. 2004. Management of Urinary Incontinence in Women. JAMA 291(8):996–9.
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5. Gomelsky, A., R.R. Dmochowski. 2011. Urinary Incontinence in the Aging female: Etiology Pathophysiology and Treatment options.
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6. buckley, b.S., M.C. lapitan. 2010. Prevalence of urinary incontinence in men, women, and children—current evidence: findings of the
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7. levy, R., N. Muller. 2006. Urinary incontinence: economic burden and new choices in pharmaceutical treatment. Adv Ther 23(4):556–73.
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9. Society of obstetricians and Gynaecologists of Canada (SoGC). 2006. Conservative management of urinary incontinence. J Obstet
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PHysICal aCtIvIty In oldEr adults
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6. Chodzko-zajko, W.J., D. Proctor, f.M. Singh, C.T. Minson, et al. 2009. Exercise and Physical Activity for older Adults. Medicine &
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the American College of Sports Medicine and the American Heart Association. http://www.acsm.org/AM/Template.cfm?Section=home_
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glauCoMa sCrEEnIng In oldEr adults
1. Goldberg, l.D. 2008. The Case for Glaucoma Screening: A look at the effect of early detection on healthcare costs. Ophthalmology
Management. Available at http://www.ophmanagement.com/article.aspx?article=101274 (May 27, 2011)
2. The foundation of the American Academy of ophthalmology. 2007. Glaucoma. Eye Care America. http://eyecareamerica.org/
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197

ACkNoWlEDGMENTS
Health Plans
The 2011 State of Health Care Quality Report would not be possible without the public reporting
of performance results by the 740 HMo and PoS plans and 302 PPo plans this report analyzes.
Those plans collectively cover more than 118 million Americans, and are to be commended for
their commitment to quality improvement.
staff
NCQA employees who helped create this report include:
Communications
Ashley Carter
Paul Cotton
Andy Reynolds, MbA
Apoorva Stull, MA
Sarah Thomas, MS
data Collection operations
Garcene Duckett
felicia fridie
Robin Gant
Carla Pacheco
Michele Taylor
Information systems
bob Chisholm
Jonathan Cook
Paul Jackovich
Judy Jiao
bing li
bhuvaneshwari Maruthac
Raghav Seshadri
Subra Shanmugam
Helen zhang
T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • A C k N o W l E D G M E N T S
Performance Measurement
Dawn Alayon, MPH, CPH
Sepheen C. byron, MHS
Jennifer Chemi
Mohua Choudhury
Jeremy Gottlich
Candice Groseclose
benjamin Hamlin, MPH
Mallory l. N. Johnson, MPA
Divya Pamnani, MHSA
Milesh M. Patel, MS
bob Rehm, MbA
Dana T. Rey, MPH
Careema yusuf, MPH
Publications
Carolyn Moeller, MHS
Policy
Judy lacourciere
Quality solutions group
Phyllis Torda, MA
199

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