Quality Improvement Program - Scott & White Health Plan

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011IntroductionScott and White Health Plan is a federally qualified, not-for-profit, Mixed Model Health Plan. Its firstBoard meeting was on August 30, 1979 under the name of Centroplex Health Plan. With the aid of a$200,000 federal planning grant, a base staff for operations was established and marketing of theHealth Plan began in March/April of 1980. The Health Plan officially began on January 1, 1982when it signed up its first group, the Scott and White Hospital and Clinic employees. In 1984, thename was officially changed to Scott and White Health Plan (SWHP). SWHP is one component ofan integrated delivery system that includes the Scott & White Memorial Hospital (SWMH), and theScott and White Clinic (SWC).There are currently two service areas defined by the State and Federal Government for the HealthPlan and the SeniorCare Plan. SWHP’s total service area encompasses all or part of 52 counties.The four major product areas and their membership are specified below:ProductEffective DateDecember 1, 2010Membership% of Total MembersCommercial Group 1-1-82 101,976 62%4-1-91 23,967 15%Medicare(excluding Part D)Self Insured 2-1-97 27,497 17%Individual 10,689 6%Total 164,129 100%SWHP members receive the majority of their hospital services through 10 affiliated Scott and Whitehospitals. These services include Inpatient Acute Care, Observation, and Day Surgery services.SWHP contracts with 24 hospitals in the service area to provide the remaining hospital services.Hospital contracts stipulate participation in SWHP’s Quality Improvement (QI)/UtilizationManagement (UM) activities and access to medical records.SWMH, SWC and contracted providers provide routine Adult Mental Health/Substance Abuse,Child/Adolescent Mental Health/Substance Abuse and Eating Disorders services to SWHP Members.MissionScott and White Health Plan adopted the mission statement of the Scott and White (SW) Institution,which is “To provide the most personalized, comprehensive, and highest quality health care enhancedby medical education and research.”Scope of the QI ProgramThe scope of the QI Program is to monitor, evaluate and improve: The quality and safety of clinical care and quality of practitioners and providers The quality of service provided by the Health Plan

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011QI Program Goals - ObjectivesA. Improve Member Outcomes – through prevention, decision making assistance and diseaseguidance, and case management for members with complex health needsB. Increase Customer Satisfaction - by prompt identification and resolution of dissatisfactionwith administrative or medical processes and evaluation of processes for improvement whenappropriateC. Improve Medical Safety -by fostering a supportive environment that helps providers toimprove the safety of their practice, conducting continuous improvement activities devoted toimproving SWHP pharmacy medication safety, and providing Members with information thatimproves their knowledge about clinical safety in their own care.D. Organizational Effectiveness - By achieving statistically significant improvements in HEDISmeasurements and meeting or exceeding national averagesE. Decrease Cost – through reducing the variations in clinical care and member servicesF. Meet the cultural and linguistic needs of the Membership by providing translators services,translated materials, cultural diversity educational offerings and a network that hasmultilingual providersExternal DelegationCredentialing/Recredentialing:The SWHP Board delegates responsibility for practitioner credentialing and recredentialing,including primary source verification, office site visits and maintenance of files to: The credentialing office of Physicians of King's Daughters P.A. for King’s Daughters’ physicians Shannon Clinic credentialing office for all Shannon physiciansSW Medical Staff Office for Scott & White practitionersThe credentialing office of the Regional Healthcare Alliance for Trinity Mother Francespractitioners(SWHP may conduct peer review and retains the right to approve, suspend and terminate individualpractitioners, providers and sites when given reason to do so).For all other practitioners, primary source verification and file maintenance is delegated toMedAdvantage.Disease Guidance:Disease or Condition Guidance Programs (Health Coaching) for commercial and self-fundedmembers have been delegated to Health Dialog, Inc.

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Program StructuresThe following committees support the Quality Improvement Program:See Attachment A for committee reporting structure1. SWHP Board of DirectorsRole: acts as the Governing Body for the SWHP and is the driving force to insure quality andsafety for Plan members. Meets quarterly.Composition:Officers-Alfred B. Knight, M.D., PresidentAndrejs Avots-Avotins, M.D., Vice PresidentDonald R. Grobowsky, Sec./Treas.Directors-Jeffrey Michael HunterJanann WilliamsL. Ann Farris, PhDLouis Casey, Jr.Gail L. PeekGabe SansingKeifer Marshall, Jr.Garlyn O. SheltonPhil ScanioGovernors-Luther M. Brewer, M.D.Jesse D. Ibarra, Jr., M.D.C. David Morehead, M.D.Other Officers-Allan Einboden, Chief Executive OfficerMarylou Buyse, M.D., Chief Medical OfficerFunction: Approves the QI Program Description, Work Plan, and Annual EvaluationDelegation responsibilities include: Delegates externally, credentialing/recredentialing decisions and oversight of verification asdefined on the previous page. Delegates oversight of delegated credentialing activities to the SWHP Credentials Committee Delegates the peer review function and credentialing/recredentialing final approval ofpractitioners and providers, as applicable, to the SWHP Credentials Committee Delegates approval of the Health Plan credentialing policies and procedures to the SWHPCredentials Committee

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION20112. SWHP Board Quality Improvement Committee (QIC)Role: The QIC is a sub-committee of the SWHP Board of Directors. Meets quarterly.Composition:Marylou Buyse, MD, Chief Medical Officer, ChairpersonJames Rohack, MD, SWHP Medical Director for System ImprovementMike Averitt, DO, Vice President-Medical DirectorAlfred Knight, MD, President and CEOL. Ann Farris, Ph.D., Board MemberGail L. Peek, Board MemberGabe Sansing, Board MemberAllan Einboden, SWHP Chief Executive OfficerEx-Officio:Associate Vice President, Medical ServicesQI DirectorHealthcare Improvement DirectorFunctions: Reviews and evaluates the QI Program Description, QI Work Plans, and the AnnualEvaluation Reviews select monthly QI Sub-committee reports that delineate recommendations, actionstaken and improvements made Ensures that the QI Program and Work Plan are implemented effectively and result inmeaningful improvements in care, safety and service Approves the development and implementation of disease guidance programs3. Quality Improvement Sub-committee (QIS)Role: Establishes strategic direction and monitors and supports the implementation of the QIProgram and Work Plan throughout SWHP. The QIS is scheduled to meet monthly and is amulti-disciplinary committee. The Chairman of QIS is also the Chairman of the Board QIC andacts as a conduit for communications/activities between the two groups. All designatedphysicians have sufficient authority and time to devote to QI activities.Composition:Chief Medical Officer, ChairVice President-Medical Director is Vice-ChairMedical Director for System ImprovementMedical Director for Quality, SW Healthcare2 Primary Care Physicians, Regional RepresentativesBehavioral Health PractitionerChief Operations OfficerAssociate Vice President, Medical ServicesSW Senior Vice President, Quality and SafetyVice President Medical Delivery DevelopmentQuality Improvement DirectorHealthcare Improvement Director

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Utilization/Case Management DirectorMember Representative(s)Clinical Pharmacy Services DirectorSW President (Ex-officio)Medical Director, SW Clinic (Ex officio)Functions: Annually develops and oversees the QI Program Description and Work Plan Annually evaluates the effectiveness of the QI Program Receives, reviews, and analyzes status reports from quality subcommittees, includingaggregate trend reports of clinical, safety, and service indicators, clinical studies, andmember/provider satisfaction Reviews aggregated, trended reports focusing on variances, contributing causes, andappropriateness of action plans Evaluates data for quantitative and qualitative trends and variances especially as it relates tomedical safety Promotes benchmarks and/or performance goals Identifies and analyzes SWHP quality activities, directs action plan(s) for improvement andevaluates outcomes of action plan implementation Directs the prioritization of SWHP quality improvement initiatives to ensure that resourcesare adequate Reports to the SWHP Board QIC Reviews the UM Program Description, UM Program Evaluation, and UM Criteria, annually. Oversees adoption of clinical practice guidelines and medical record standards Recommends disease guidance programs to the Board QIC and monitors effectiveness ofprograms Oversees the evaluations of approved delegated QI activities Reviews minutes of Safety Committee4. Technology Assessment CommitteeRole: Develops recommendations for SWHP coverage of new, emerging and/or updatedtherapies, which are then referred for review by the SWHP Utilization Management Committeeand approval by SWHP QIS. Results are then reported to the SWHP Board of Directors. Meetsmonthly, as needed, but not less than annually.Composition: SWHP Medical Directors SWMH) Chief Medical Officer SWHP Medical Director for System Improvement SWHP Associate Vice President - MedicalServices SWMH Chief Nursing Officer/Chief OperatingOfficer SWMH Chief Nursing Executive and SystemDirector of Quality, Safety and Regulatory Serv. SWHC- Round Rock Chief Medical Office SWHC Chief Medical Officer SWHC Associate Chief Medical Officer SWHC Chairman of Department of Medicine SWHC Chairman of Department of OrthopedicSurgery SWHC Chairman of Department of Surgery

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011 Hillcrest Baptist Medical Center Chief MedicalOfficer and Executive Vice President Scott & White Healthcare (SWHC) ChiefOperation Officer SWHC Vice President Revenue Cycle OperationsHospital Division SWHC Vice President, Managed Care andDecision Support SWHC Chief Financial Officer SWHC Vice President, Pharmacy Services SWHC Director of Sourcing and ContractingFunctions: Reviews/analyzes the literature review provided by the clinical participants regarding thetopic of review Makes recommendations regarding SWHP coverage of the therapy under review, includingany prior-authorization review criteria needed by the Plan Maintains minutes as documentation of the outcome of the assessments and determinationsmade Publishes outcomes of reviews to Practitioner(s)/Providers and/or Members as appropriate5. SWHP Utilization Management CommitteeRole: Monitors for over and under-utilization. Summary and trend data are reported to theSWHP QIS. Meets Quarterly or as needed.Composition:Utilization/Case Management Director, ChairChief Operating OfficerChief Financial Officer3 Vice Presidents-Medical DirectorsDirector-Claims ManagementConfiguration Analyst IIIConfiguration AnalystDirector-Provider RelationsAssociate Vice President, Medical ServicesMedical Claims DirectorUtilization ManagerPharmacy DirectorPharmacy Clinical SpecialistMedical AnalystFunctions: Analyzes utilization reports Determine if patterns of fraudulent billing exist Identifies opportunities for controlling utilization and/or for cost-savings Reviews/approves any UM policy and procedure issues

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION20116. SWHP Credentials CommitteeRole: Performs all credentialing functions and oversight for all credentialing activities.Meetings are held monthly.Composition:SWHP Staff -Medical Director of System Improvement, ChairmanChief Medical Officer, Vice-Chair3 Vice President- Medical DirectorsAssociate Vice President-Medical DirectorNetwork Members -OB/GYN practitioner3 Family Practice physicians (Northside in Temple, Caldwell & Waco)SurgeonFunctions: Review credentialing and re-credentialing data for all network providers and practitioners whowill be rendering care to SWHP enrollees Review and approve Credentialing Policies and Procedures, including performance criteria Perform Peer Review of providers who fail to meet the performance criteria and decide onappropriate action(s) Provide oversight of all delegated credentialing programs and activities Review applicants’ credentials and approves or denies the applications Medical Director is responsible for the day-to-day handling of feedback on network providersand complaints/grievances7. SWHP Pharmacy and Therapeutics CommitteeRole: Oversees pharmacy issues. Reports to the SWHP QIS. Meets monthly, except during themonths of July and December.Composition includes but may not be limited to:SWHP Vice President- Medical Director, Co-ChairmanBruce Kohler, MD, Co-ChairmanAt least seventeen (17) Physician Representatives (including Behavioral Health)Vice President of Pharmacy Services (SWMH)Vice President of Pharmacy Services (SWHP)Director of Pharmacy (Clinical)Administrative Director, Department of PharmacyDirector of Pharmacy (Inpatient Pharmacy Services)Director, Pharmacy Retail OperationsB/CS Pharmacy Store ManagerClinical Pharmacy Administration, UT RepresentativeInternal Medicine, UT RepresentativeClinical Specialist Ambulatory Care, Women’s HealthClinical Specialist Pediatrics2 Clinical Pharmacy Specialists

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Functions:To develop and approve policies and procedures relating to the selection, distribution, handling, use, andadministration of drugs for the Scott & White Health Plan (SWHP) approved providers.To develop an evidence-based formulary of drugs accepted for use in the institution and provide for itsconstant revision.To establish programs and procedures that help ensure cost-effective drug therapy.To participate in quality-assurance activities related to the distribution, administration and the use ofmedications.To oversee medication-use review programs and studies and review the results of such activities.To advise the pharmacy in the implementation of effective drug distribution and control procedures.8. Cultural Diversity CommitteeRole: Oversees cultural diversity activities/issues. Determines if there are significant social orethnic disparities in membership and develops action plans to address them. Reports to theSWHP QIS. Meets at least annually.Composition includes but may not be limited to:QI Director, chairpersonQI SpecialistQI CoordinatorRepresentatives from:Finance/UnderwritingCustomer Advocacy ManagerUM Manager4 Marketing Regional DirectorsMarketing Administrative Services ManagerProvider Relations DirectorVice President-Medical Delivery DevelopmentFunctions: Reviews and analyzes race/ethnicity and preferred language data, making recommendations tothe Quality Improvement Subcommittee, as needed Monitors interpreter usage and Health Plan materials available in other than English Establishes programs, policies and procedures that address cultural diversity Review regulatory regulations and accrediting standards to ensure Health Plan compliance Identifies areas where there is ethnic or racial disparity in care provided Develops action plans to address one or more areas of disparity among minority groups in thenetwork

9. Safety CommitteeSCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Role: Oversees safety issues and investigates them across the network. Reports to the SWHPQIS. Meets Quarterly.Composition includes but may not be limited to:Vice President-Medical Director is ChairChief Executive OfficerChief Financial OfficerChief Operations OfficerAssociate Executive Director, Health ServicesProvider Relations DirectorAssistant General CounselQI CoordinatorFunctions: Review all safety issues Review complaints regarding safety Look for “never events”, falls, avoidable infections, adverse events and other clinicalsafety issues Directs the investigation of inappropriate or adverse outcomes; reports findings to decisionmaking bodies for actionThe SWHP QI Program is also supported by the following Health PlanDepartments/Divisions/Individuals:1. SWHP Administration (Chief Executive Officer/Associate Executive Director)The CEO and/or designee supports the QI Program through oversight and participation in theSWHP QIC and QIS. The allocation of resources, attendance to multiple committees that supportthe QI Program, and formal reports to the Board are coordinated through Administration.2. SWHP Quality Improvement DivisionSWHP QI Division’s major functions include but are not limited to those on Attachment B andthe following: Provide staff support for QI initiatives, as needed Develop initial drafts of program documents for review and approval by the QIS Develop a QI Program Description and work plan identifying the responsibilities of operationsthat support program implementation, and provide direction to the regions for QI initiatives Formulate scheduled reports for external review agencies

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION20113. Designated Participating Practitioners/ Behavioral Health Care PractitionerDesignated participating providers and a behavioral health care practitioner serve on the QIS, crossfunctionaloperational and administrative committees, and other subcommittees. They advise QISregarding the community’s standards of care and resources available. Designated participatingproviders also use their medical knowledge to assist SWHP to identify high risk, problem-proneaspects of care, and to recommend clinical priorities for monitoring and evaluation. The designatedbehavioral health care practitioner advises the QIS on behavioral health and related continuity of careissues.Other responsibilities may include: Review, evaluate, and make recommendations for credentialing and recredentialing files Review individual medical records reflecting adverse occurrences Review proposed practice guidelines and clinical protocols Review proposed QI study designs Participate in the development of action plans to improve levels of care, safety and service4. Credentialing Offices and Credentialing Verification OrganizationSWHP delegates the primary source verification and administrative file function to the SWMHMedical Staff Office, MedAdvantage, Shannon Clinic Credentialing Office, Trinity Mother FrancesHospitals & Clinics Credentialing Office and the Physicians of King's Daughters P.A CredentialingOffice. SWHP Credentials Committee, Quality Improvement Division and the Provider RelationsDepartment are responsible for working with these credentialing offices to assure that all regulatoryand accrediting standards are being followed.In addition to the above activities, the SWMH Medical Staff Office, Shannon Clinic CredentialingOffice, Mother Frances Hospitals & Clinics Credentialing Office and the office of Physicians ofKing's Daughters P.A., are responsible for compliance with the Health Plan’s policies andprocedures, including gathering all applications, and providing complete data regarding findings ordecisions to the SWHP Credentials Committee for their review.SWHP QI Coordinator provides a monthly list of the practitioners and providers credentialed/recredentialed to the Credentialing Committee.5. Customer Advocacy Dept.This department is responsible for resolving customer service inquiries received over the phone, inthe front lobby, and through the web page. The Customer Service Advocates are trained to own andresolve issues. The goal of the group is to provide one-stop resolution of member, employer, andprovider inquiries including benefit inquiries, ID card issues, PCP changes, claim status inquiries,member education, and other assistance as needed.6. Provider Relations/Contracted NetworksThe Director of Provider Relations assists Administration in the contracting functions and updating ofprovider manuals. This department provides support through participation in various QI/advisorycommittees. They provide on-site education of Health Plan processes and regulations for providers

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011and ongoing communication to providers and practitioners through newsletters (The Inside Story)andthe Health Plan website (www.swhp.org).7. Utilization/Chronic and Complex Care Guidance (Management) Under the direction of theChief Medical Officer, medical directors, Associate Vice President, Medical and the Director ofUtilization/Case Management, the SWHP Health Services Division performs utilization and careguidance functions. Routine reports that show physician profiling with HEDIS utilization parametersare evaluated and reported to UM Committee for tracking over/under utilization and to QIS and areused for credentialing/ recredentialing purposes. Continuing Care Coordinators implement the UMpolicies and procedures, including the gathering of data regarding adverse occurrences, which arereviewed by Vice Presidents-Medical Directors. The Vice Presidents-Medical Directors will decide ifoccurrences should be referred to Credentials Committee or Safety Committee.The Care Guidance program includes complex and chronic care guidance (management). Theprogram objectives are to improve outcomes, provide education, assist with health system navigationand negotiate benefits. For details refer to Care Guidance Program Description.8. Administrative SubcommitteeThis group is a subcommittee of the Board Executive Committee and is composed of the President ofthe Board and SWHP CEO, Vice Presidents-Medical Directors, and operational leaders. Meetingsare weekly or as needed.Functions: Serves as the primary operations committee for management discussion of cross functionalissues which impact the Health Plan; establish policy, including perceived benefitshortcomings, customer service problems, access problems, member survey summaries,and logistical problems related to network arrangements Involved in the development and implementation of privacy/confidentiality policies andmechanisms to oversee their application, including levels of user access and mechanisms tolimit access to personal health information (PHI) Reviews practices regarding the collection, use and disclosure of PHI9. Risk ManagementRisk management is a function of the Scott & White integrated system. A SWHP Vice President-Medical Director participates with the SW system Risk Management Department and reviewspotential risk management concerns. SWHP Continuing Care Coordinators and QI Coordinators mayidentify potential risk management cases through concurrent or retrospective reviews. Claims reviewnurses and the Utilization/Claims Management Group review claims data for potential fraud andabuse in billing practices. Any identified risk management cases are brought to the attention of theRisk Management Department, the medical directors, and/or administration.10. MarketingThe Marketing Division Account Representatives work with their employer group contacts/HRDirectors to assess members’ needs and to improve services. They provide program information to

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011members and employers as requested regarding the existing and proposed member benefits, generalguidelines and limitations of the contract, and rates. They help inform the membership andemployers about preventive health services offered by the Plan.11. ResourcesStaffing: SWHP QI division is staffed with a QI Manager, Research Scientist I, QI Coordinators,Quality Data Specialists, a Quality Analyst, a Health Risk Coordinator, and secretarial support. TheChief Medical Officer leads the division, with assistance from the QI and Healthcare ImprovementDirectors.Data: SWHP utilizes AMISYS software as a Claims Payment system, as well as, a membership andprovider database. There is network support for the employees of the Plan, including access to theInternet. The SWHP utilizes external vendors to assist with the HEDIS reporting and the CAHPSsurvey. The SWHP Pharmacy system has its own network and a relationship with an external vendorthat is able to provide member, physician, and drug utilization data. SW Medical InformationService assists at intervals as a benefit to the Plan through the system integration.Analytic Capabilities: SWHP QI Coordinators have access to statistical software, SPSS, and aretrained in statistical principles. Many other statistical resources are within the SW system such as theBiostatistics Department. The Research Scientist uses SAS software for statistical analyses.12. Quality TrainingQuality education may include formal classroom, “just in time” training and/or the QualityImprovement Internet/Intranet sites. Presentation topics are based on participants’ feedback andrecommendations.Quality Improvement Process:The improvement effort follows the Continuous Improvement CycleIdentify CustomerNeeds/ExpectationsMeasurementImplementImprovementActPlanCheckDo

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011QI Work PlanSWHP develops a QI Work Plan annually. The Work Plan covers the scope of the QI Program andincludes: Written measurable yearly objectives for the quality and safety of clinical care and qualityof service activities scheduled, including Behavioral Health improvement initiatives Yearly objectives and planned activities, time frames for achieving, and those responsible Monitoring of previously identified issues Schedule for evaluation of the QI ProgramDisease Guidance ProgramsSee Attachment CQuality Improvement Annual EvaluationAn annual written evaluation of the QI Program is submitted to the QIS, Board QIC and the SWHPBoard of Directors and is the basis for the upcoming year’s work plan.The QI evaluation includes: Description of completed and ongoing QI activities that address quality and safety ofclinical care and quality of service, including delegated functions. Trending of quality and safety measures and comparison with established thresholdsAnalysis of whether there has been demonstrated improvements, including barrier analysiswhen goals are not met. Analysis is conducted with participation of staff who have directexperience with the processes that have presented barriers to improvement. Evaluation of the overall effectiveness of the program includes progress toward influencingnetwork-wide safe clinical practices, adequacy of resources, committee structure,practitioner participation, leadership involvement and any determination of restructure orchange(s) to be made for the subsequent year, based on findings.ConfidentialityConfidentiality is the responsibility of every SWHP employee. Upon being hired, every newemployee is informed of our Confidentiality policies and guidelines during New Hire Orientation andthe departmental orientation. The policies are also available in the Employee Handbook, CorporateCompliance Handbook, and on the Intranet. Unauthorized access, discussion, or release of patient orother confidential information may result in disciplinary action up to, and including, termination ofemployment. Confidentiality expectations continue after termination of employment with Scott &White Health Plan.Access to files (manual and computerized) is provided with a security clearance at the time ofemployment and revoked formally at the time of termination. Staff are expected to report violationsor possible violations of patient confidentiality to their supervisor, Human Resources, or theCompliance Hotline (1-888-800-1096) for investigation and appropriate follow-up actions. The Planprovides a section in the member contract regarding the Plan’s commitment to confidentialityregarding accessing information and the use of that information. (See SWHP Health CareAgreements, Page 14-1, Confidentiality.) Members of the QIS demonstrate their commitment toprivacy by signing a confidentiality statement.

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Approval:SWHP Board of Directors, ChairDateSWHP President and Chief Executive OfficerDateQIS ChairpersonDate

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Attachment AQuality Improvement CommitteesReporting StructureSWHPBoard of Directors(Governing Body)DelegationSWHPBoard QI Committee(Oversight)SWHPQI Subcommittee(Working)Policies OnlySWHP CredentialsSubcommitteeSWHP Pharmacy& TherapeuticsCommitteeSWHP Complaint& Appeals ProcessMedication SafetyCouncilSWHP RetailPharmacyMedication SafetyTeamSWHP TechnologyAssessmentCommitteeSWHP UMCommitteeCultural DiversityCommitteeNetwork IssuesCommitteeSafety CommitteeReportingReporting/Approval

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Attachment B

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011Basic Disease guidanceAttachment CScott & White Health Plan (SWHP) Basic Disease guidance programs actively intervene to helpmembers with chronic diseases such as Asthma, Diabetes, Coronary Artery Disease, CongestiveHeart Failure, Chronic Obstructive Pulmonary Disease and Hypertension.The basic disease guidance programs include the following: Condition monitoring Patient adherence to the program’s treatment plans Consideration of other health conditions Lifestyle issues, as indicated by practice guidelinesMembers may be identified using one or more of the following methods: Claim or encounter data Pharmacy data, if applicable Health risk appraisal results Laboratory results, if applicable Data collected through the Utilization Management or case management process Member and practitioner referralsEligible members are provided with information about the program that includes use of services, howmembers become eligible to participate and how to opt-in or opt-out.Program interventions are based on stratification and assessment.At least annually, satisfaction with the Basic Disease Guidance Programs is measured andparticipation rate is reported to the Quality Improvement Subcommittee. Program effectiveness isevaluated by measuring at least one area of performance for each disease guidance programNetwork Practitioners are provided with written information about the program including instructionsof how to use disease guidance services and how the organization works with practitioner’s patientsin the program.SWHP strives to integrate information for continuity of care from the following: Health Information and Nurse Advice Line Disease Guidance Program Case Management Program Utilization Management Program Wellness ProgramCareDisease/Condition Care Guidance ProgramsThese programs address 65 different diseases and conditions and are available to Scott & WhiteHealth Plan commercial members. Participants are identified through medical & RX claims data,health risk assessments, physician referrals, alternate levels of care, self-referrals, diagnosis, ER

SCOTT AND WHITE HEALTH PLANQUALITY IMPROVEMENT PROGRAM DESCRIPTION2011utilization, lab/diagnostic data and/or predictive modeling. Members are contacted by registerednurses, licensed practical nurses, dieticians, respiratory therapists, social workers, and healtheducators. Individualized support is given to members to help them discuss their treatment optionswith their physicians and/or manage their condition. Health coaches provide health care systemnavigation support, including how to best use the services available to them.

SCOTT AND WHITE HEALTH PLANMEDICAL RECORD REVIEW STANDARDSInitial Adoption Date: February 1995; Revision Dates: January 2001,September 2002, September 2003, March 2007; Reviewed Dates: November 2008Policy QI 13 Attachment 1The Scott & White Health Plan Quality Improvement Sub-Committee has adopted the followingStandards for written or electronic medical records:Medical Record Documentation1. All services provided directly by a PCP.2. There is evidence of all ancillary services and diagnostic tests ordered by a practitioner.3. There are reports of all diagnostic and therapeutic services for which a member wasreferred by a practitioner such as:-Home Health Nursing Reports-Specialty Physician Reports-Physical Therapy Reports-Hospital Discharge Summaries-Other4. History and physicals are included in each medical record. History includes past medical,surgical and substance abuse (tobacco, alcohol, and/ or other substances for 14 years andolder).5. Allergies and adverse reactions are included in each medical record. If the patient has noknown allergies or history of adverse reactions, this is noted in the record.6. The record contains a problem list.7. The record includes medications.8. There is documentation of clinical findings and evaluation for each visit.9. Preventive services / risk screening are included in each medical record (at leastimmunizations).Confidentiality and Organization / Availability of Medical Record10. The Staff receive periodic training in confidentiality of member information.11. Records are organized and stored in a manner that allows for easy retrieval.12. Records are stored in a secure manner that allows access by authorized personnel only.C:\Temp\GWViewer\MR RevStds 11-08.docx

Scott & White Health PlanProvider ManualSection 3: Clinical Practice andPreventive Health GuidelinesAll Scott & White Health Plan guidelines are available at the following:1. Internet:OnlineProviderManual–www.swhp.org.Clickon“Providers”greentab.Clickon“QualityImprovement”.Clickon“ClinicalGuidelines”.. ApapercopyisavailableuponrequestfromtheScott&WhiteProviderRelationsDepartment.Calltollfree18003217947ext.3064or2542983064.

Tier #2: Address the management of a disease process managed by multipleorganizational units or departments.

Scott and White Health Plan Treatment Guideline for HypertensionDeveloped by: Scott and White Physicians Approved: 10/14/2003 Reviewed: 10/2005; Revised 12/2007, 11/2009, 9/2011, 5/2012, 5/2014Baseline workup (ECG & Lab: BMP, Lipid Panel, UA)Assess for Major CVD risk factors- See Figure 1Adult aged ≥18 years with hypertensionImplement lifestyle interventions (Continue throughout management)See Figure 2Set blood pressure goal and initiate blood pressure loweringmedicationbased on age, diabetes, and chronic kidney disease (CKD)General Population - (no diabetes or CKD)Diabetes or CKD presentAge ≥60 yearsAge

*This guideline is not meant to substitute for the provider’s clinical judgment*If BP is 55 for men,>65 forwomen)Family history of premature CVD(men age

Chronic Obstructive Pulmonary Disease (COPD) GuidelineTier 2 GuidelineDeveloped by: The Scott & White COPD CHASM Working groupContact physician: Dr. Jim Barker, MDDate of adoption: November 2009 Revision date: January 2014SWHP COPD GUIDELINE, 2014.This is an evidence based guideline built by the CHASM COPD working group and based onmultiple published guidelines. Please see references at end.COPD (Chronic Obstructive Pulmonary Disease) is, in general, a combination of ChronicBronchitis and Pulmonary Emphysema. It may also be seen in patients with other obstructivelung diseases such as asthma, bronchiectasis, and bronchopulmonary dysplasia when thoseindividuals have smoked. The pathogenesis is by far tobacco smoking related. The 10 to 15% ofindividuals with COPD (at least in the United States) who are never smokers have had secondhand smoke exposure, occupational exposure, or a genetic proclivity. Patients who grew up inthird world countries could also develop fixed obstructive lung disease (COPD) from inhalingburning biomass under poor ventilation.COPD is the third leading cause of death in the United States and is very expensive in loss ofhealth care dollars. See Figure 1.Specific recommendations are the following:1. Prevention:a. Teens and pre-teens are high risk for smoking onset if their peers or parentssmoke. SWHP should partner with community agencies to actively deter onsetof smoking in these high risk individuals.2. Screening:a. Smokers or former smokers age 40 or older should be screened with a simplefive question questionnaire. See Figure 2. A score of 5 or higher (out of apossible 10) should trigger a diagnostic spirometry test.b. Others should be screened if there is a high index of suspicion such as positivefamily history, daily productive cough two years in a row, or significantoccupational exposure.c. Alpha 1 antitrypsin testing should be done on those with COPD onset at age lessthan 45, familial COPD, or low alpha 1 serum levels.

3. Diagnosis:a. Spirometry is the gold standard. Spirometry should be done in any individualsuspected of having COPD. Spirometry can be office based or PulmonaryFunction hospital laboratory based. A high quality test is present when valuesare reproducible on at least three attempts +/- 3%. An FEV1 less than 80% andFEV1/FVC ratio below 70% is considered abnormal and proof of disease, inappropriate settings. Post bronchodilator results are the preferred ones(according to GOLD criteria).b. Suggestive symptoms are shortness of breath with minor exertion, dailyproductive cough, and wheezing. However, these are non-specific.c. All patients who have a positive population health screener or who aresuspected of having COPD should have spirometry. Other lung diseases or evenanemia can induce shortness of breath. An accurate diagnosis is alwaysdesirable!4. Emergency Department and Inpatient Diagnosis and Treatment:a. The recommended corticosteroid dose is 40 mg/day of oral prednisone (orequivalent intravenously) for 10 days or less.b. Frequent albuterol inhalations via MDI or nebulizer are recommended.c. Antibiotics are useful in an exacerbation especially if increased sputum and feverare present.d. Arterial Blood Gases are recommended in those patients who appear ill.(Difficulty speaking, tachypnea, altered mental status, sternocleidomastoidaccessory muscle use for example.) ABGs allow stratification of severity.Consider ICU admission if respiratory acidosis is present.e. Indications for hospitalization may include:i. High risk co-morbid conditions such as pneumonia, CHF, cardiacarrhythmias.ii. Failed outpatient management.iii. Unrelieved dyspneaiv. Inability to eat or sleep due to dyspnea.v. Progressive hypoxemia or hypercarbiavi. Altered mental statusvii. Inability to care for oneself at home.viii. Marked worsening from baselinef. Indications for Intensive Care Admission may include:i. Respiratory Failure requiring mechanical ventilation or continuous noninvasiveventilationii. Presence of other end organ dysfunction: shock, renal failure, coma,myocardial infarction and so on.iii. Hemodynamic instability.iv. Inability to clear secretionsv. Respiratory acidosis or impending respiratory failure

g. Indications for Non-Invasive Ventilation:i. Respiratory acidosis with pH < 7.36 and PaCO2 > 45 torr.ii. Tachypnea with breath rate > 25/miniii. Intact gag reflexiv. Able to cooperate and follow commandsv. Consider ICU admission if non-invasive ventilation is initially continuous.h. Consider the addition of ipratropium to albuterol if unrelieved tachypnea ordyspnea.i. Consider Pulmonary Medicine consultation if the patient fails to improvepromptly.j. Consider other precipitating causes for COPD exacerbation (besides viral orbacterial bronchitis) such as:i. Congestive Heart Failureii. Community Acquired Pneumoniaiii. DVT/PEk. Oxygen therapyi. Commonly needed during exacerbations because of V/Q mismatching.ii. Prescribe to attain SaO2 at least 88% or PaO2 at least 60 mm Hg.l. Criteria for Discharge:i. Symptoms returning to baseline. Patient able to eat and sleep.ii. Hemodynamics stable.iii. Able to ambulate (presuming ambulatory pre-hospitalization)iv. Understands home medications.v. Able to go at least four hours in between albuterol usages.m. Transition of care issues:i. Consider Outpatient Pulmonary Consult if frequent admissions orexacerbations are occurring.ii. See PCP within 7 days of discharge.iii. May need short term oxygen. Re-assess after 30 days or when stable athome.5. Outpatient maintenance therapya. Smoking cessation.i. This is the only intervention proven to change disease trajectory andlengthen lifespan.ii. Severely addicted patients will need adjunctive therapy.1. The absolute best results occur with group therapy, nicotinereplacement, and bupropion. Bupropion may be needed forseveral months in some individuals.b. Frequent exacerbations:i. One hospitalization or more per year and/or two or more exacerbationsof COPD/year = frequent.

ii. Review for possible reasons of exacerbation: CHF, poorly controlledhypertension, bronchiectasis, continued smoking.iii. Medical therapy:1. Inhaled corticosteroid (Advair; Symbicort; others) with a longacting Beta agonist OR2. A PGE2 inhibitor such as theophylline or roflumilast (daliresp) OR3. A macrolide such as azithromycin or erythromyciniv. Pulmonary Medicine consultationc. Corticosteroidsi. Only indicated for exacerbations and should be used in doses of 40 mgprednisone or less over 7 to 10 days.d. Vaccinationsi. Yearly influenza vaccine.ii. Pneumovac is recommended although efficacy is in question from recentstudies.e. GOLD STAGING:i. A. Minimal symptoms, no hospitalizations in the previous year, and mildto moderate obstruction on Spirometry.ii. B. More symptoms. No recent hospitalizations. Mild to Moderateobstruction on Spirometry. Dyspnea with exercise or ADLs.iii. C. Moderate to Severe Obstruction on Spirometry. Hospitalized withinlast year or 2 or more exacerbations. Minimal baseline symptoms orDyspnea.iv. D. Moderate to Severe Obstruction on Spirometry. Hospitalized withinlast year or 2 or more exacerbations. Quite symptomatic.f. Therapy by GOLD Stage:i. Prn Albuterol inhaler 2 puffs every four hours indicated for all groups.ii. Some patients will benefit from addition of Ipratropium (combiventrespimat inhaler). It is unclear which patients fit this however.iii. Groups B through D benefit significantly from Pulmonary rehabilitation.1. PFTs do not typically improve but Quality of Life scores improve,exacerbations and doctor visits decrease, and hospitalizationsdecrease.2. Pulmonary Rehab programs include education including tips forself-management and graded exercise to improve flexibility andendurance.iv. Group B:1. Long acting anticholinergic such as Tiotropium 18 mcg , 1 puff aday OR2. Long acting beta inhaler such as Formoterol or Salmeterol.v. Group C:

1. Long acting anticholinergic such as Tiotropium 18 mcg , 1 puff aday OR2. Combination long acting Beta Agonist/Corticosteroid agonist suchas Advair 250/50 1 puff twice a day.vi. Group D:1. Long acting anticholinergic such as Tiotropium 18 mcg , 1 puff aday AND2. Combination long acting Beta Agonist/Corticosteroid agonist suchas Advair 500/50 1 puff twice a day.g. Oxygeni. Oxygen is indicated for those patients with baseline hypoxemia (PaO2

2. Global Strategy for the Diagnosis, Management, and Prevention of ChronicObstructive Pulmonary Disease, GOLD Executive SummaryJørgen Vestbo1,2, et al. Am J Respir Crit Care Med Vol 187, Iss. 4, pp. 347–365, Feb15, 20133. Global Initiative for Chronic Obstructive Lung Disease, Global Strategy for theDiagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,Feb 1, 2013. RR Roison and J Vestbo, for the GOLD Committee. GOLD website.4. NICE Guideline, 2013 update, National Clinical Guideline Centre, United Kingdom.Chronic obstructive pulmonary disease: Management of chronic obstructivepulmonary disease in adults in primary and secondary care,http://guidance.nice.org.uk/CG101/Guidance/pdf/English5. Anderson B, Conner K, Dunn C, Kerestes G, Lim K, Myers C, Olson J, Raikar S, SchultzH, Setterlund L. Institute for Clinical Systems Improvement. Diagnosis andManagement of Chronic Obstructive Pulmonary Disease (COPD). Updated March2013.6. Diagnosis and Management of Stable Chronic Obstructive PulmonaryDisease: A Clinical Practice Guideline from the American Collegeof PhysiciansAmir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Paul Shekelle, MD, PhD;Katherine Sherif, MD; Timothy J. Wilt, MD, MPH;Steven Weinberger, MD; and Douglas K. Owens, MD, MS, for the Clinical EfficacyAssessment Subcommittee of the American College of Physicians* Ann Intern Med.2007;147:633-638.7. Diagnosis and Management of Chronic Obstructive Pulmonary Disease:The Swiss Guidelines Official Guidelines of the Swiss Respiratory Society E.W. Russi aW. Karrer d M. Brutsche e et al. Respiration 2013;85:160–174.8. Primary Care–Relevant Interventions for Tobacco Use Prevention andCessation in Children and Adolescents: A Systematic Evidence Reviewfor the U.S. Preventive Services Task Force.Carrie D. Patnode, PhD, MPH; Elizabeth O’Connor, PhD; Evelyn P. Whitlock, MD,MPH; Leslie A. Perdue, MPH; Clara Soh, MPA;and Jack Hollis, PhD Ann Intern Med. 2013;158:253-260. www.annals.org9. Management of Acute Exacerbations of COPD* A Summary and Appraisal ofPublished Evidence Douglas C. McCrory, MD, MHSc; Cynthia Brown, MD; Sarah E.Gelfand, BA; and Peter B. Bach, MD CHEST 2001; 119:1190–120910. COPD updates: What’s new in pathophysiology and management? Carlos Noujeimand Pierre Bou-Khalil (Lebanon). Expert Rev. Respir. Med. 7(4), 429–437 (2013).

Depressed PatientTier 2 GuidelineManagement of Major Depressive Disorder, Non-PsychoticAcute PhaseDate of Adoption: March, 2001 Revision Dates: 02/2003, 09/2004, 08/2006, 11/2008, 10/2010 Reviewed: 12/2012Contact Physician: Dr. Virginia Maxanne Flores, MD; S&W Department of PsychiatryAcute Phase Treatment Practitioner Contact RecommendationsThree patient contacts in the 12 week period.Suicide risk?Bipolar?Psychotic or history of psychosis?History of ECT?Alcohol or Drug Dependence?Other Complicating Factors or Co-MorbidPsychiatric Issues (e.g., eating disorders, schoolphobia)?YesConsider referral toBehavioral Health specialistNoMajorDepression?NoYes1) Due toGeneral MedicalCondition?2) Medicationinduced?Yes(1) Treat General MedicalCondition(2) Reconsider MedicationsIf adolescent/child, individual &family psychotherapy isrequired.NoNoPatientimproves?Prior MajorDepression?YesMonotherapy of Depressiona) Prior effective agentb) SSRIc) Wellbutrin, Effexor, Remeron or Cymbaltad) Tricyclic (with pain)YesNoOptions:a) Psychotherapyb) Empirical Medication trialc) MonitorGood Response?(Remission within 4 to6 weeks)YesEnter Continuation PhaseNoOptions1. Refer to Psychiatry2. Continue Monotherapy of Depression3. Change to a different agentGood Response?(Remission within 4 to 6weeks)YesIs patientImproved?NoNoRefer to PsychiatryDeveloped by physicians from the Departments ofPsychiatry, Family Medicine, and InternalMedicineandbyHealthIntegrated. Basedonbestpractice recommendations of the Agency forHealthcare Research and Quality (AHRQ) and theTexas Algorithm Project.Yes(See page 2 for Continuation and Maintenance Phases)Page1of2Treatment Ends

Tier 2 GuidelineManagement of Major Depressive Disorder, Non-PsychoticContinuation and Maintenance PhasesDate of Adoption: March, 2001 Revision Dates: 02/2003, 09/2004, 08/2006, 11/2008, 10/2010Contact Physician: Dr. Virginia Maxanne Flores, MD; S&W Department of PsychiatryEnter Continuation PhaseContinuation Phase Treatment Recommendations1. Medication duration: 6 - 9 months aftercompletion of the acute phase of treatment . (Acute +Continuation =total of 9 to 12 months of treatment)2. Practitioner Contacts: Evaluate at least onceevery 3 months during continuation treatment(preferably 1-2 months)Developed by physicians from the Departments ofPsychiatry, Family Medicine, and InternalMedicine and by Health Integrated. Based on bestpractice recommendations of the Agency forHealthcare Research and Quality (AHRQ) and theTexas Algorithm Project.Continued GoodResponse?YesEvaluate for Maintenance Phase:(1) 3 or more episodes,or(2) 2 episodes, with-family history-recurrence in 1 year after stopping Tx-family history, Major Depressive Disorder-early onset, (before age 20)-severe, sudden, life-threatening episodewithin 3 yearsor(3) other factors judged by clinicianNoReturn to Acute PhaseAre Criteria met?YesMaintenanceContinue at full doses.Duration may be:a) 1 yearb) 2 to 5 yearsc) LifetimeNoFor initial episodes of Depression(1) Taper and discontinue over 2-3 months(2) And then follow every 2 to 4months for 8 monthsTreatment EndsPage 2 of 2

Scott and White Health Plan-Tier 2 GuidelineTreatment Algorithm for Attention-Deficit/Hyperactivity Disorder (ADHD) inChildren and Adolescents for Use in Primary Care (Without Co-morbidities)Adopted : 6/16/99 Last Revised: 9/2001, 11/2002, 11/2004, 01/2005, 01/2006, 08/2006, 12/2006, 08/2008, 08/2010, 08/2012Population: Patients 18 yr. or younger Contact Physician: John Q. Thompson, Jr., DOTable 3Me dicationFor mular yEffectDurationin Hoursmethylphenidate IR(Ritalin®,Methylin®) Yes 3-6dextroamphetamine(Dexedrine®,DextroStat®) Yes 1-6dexmethylphenidate(Focalin®) No 6methylphenidate SR(Ritalin-SR®) Yes 8methylphenidate ER(Metadate®,ER,No 8Methylin®ER)methylphenidate ER(Metadate®CD) Yes 8methylphenidate LA(Ritalin®LA) Yes 10-12amphetamine-dextroamphetamine (Adderall®) Yes 4-6dextroamphetamine spansule(Dexedrine®Yes 6-8Spansule®)methylphenidate ER(Concerta®) Yes 12amphetamine-dextroamphetamine XRYes 12(AdderallXR®)atomoxetine(Strattera®) Yes 24dexmethylphenidateXR(Focalin®XR) No 8-12methylphenidate transdermal patch-extended Yes 9release(DaytranaTransdermalPatch) Shouldwear 9 hours with effects lasting for 3-4 hoursafte r re moval of pa tch.lisdexamfetamine dimesylate(Vyvanse) Yes 12* LEGENDMAS-Mixed Amphetamine SaltsDEX-DextroamphetamineNICHQ-National Initiative forChildren’s Healthcare QualityTable 4Alternative Non-Stimulant Medica tions(to be considered after failure of stages 1-3)buproprion(Wellbutrin®)guanfacine(Tenex®) -short-actingguanfacine(Intuniv®) -long-actingclonidine(Catapres®)Exc ept for guanfacine (Intuniv®) - long-acting,theseare notFDAindicatedforthetreatmentofADHD;butChild&AdolescentPsychiatrymayconsiderthesefouralternativesifthepatientneedscombinationtherapyoralongerdurationofaction,hasadverseeventsfromstimulantsorhasco-morbidconditionswhichrequirethem.ThesemedicationsaregenerallyusedmoreoftenbyChildandAdolescentPsychiatristsorDevelopmentalBehaviorPediatricians.Source: American Academy of Child and Adolescent Psychiatry (AACAP, 2006), The Texas Children’s Medication Algorithm Project, and theAmerican Academy of Pediatrics (AAP, 2001).Developed by: Physicians from the Departments of Psychiatry & Pediatrics, Health Integrated; and the clinical Pharm D Staff.Reviewed and Approved by: Members of the Quality Improvement Sub-committee.** HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).L:\QI\NCQA\Clinical Guidelines\Current Tier 2 INTER dept\ADHD\Current stuff\ADHD for Approval Aug 2012.docx

Asthma GuidelinesDeveloped by: SWHP Asthma Intervention TeamContact Person: Felix R. Shardonofsky, M.D.Source: NHBLI Practical Guide for the Diagnosis & Management of AsthmaAdopted: SWHP Quality Improvement Committee 11/12/2002: Revision/Approval: Quality Improvement Subcommittee 10/04, 10/06,9/12/2008, 8/10, 10/12IntermittentAsthmaStep 1Preferred:SABA PRNStep 2Persistent Asthma: Daily MedicationConsult with asthma specialist if step 3 care or higher is required.Consider consultation at step 2.Step 4Preferred:Preferred:Step 5High-dose ICS +eitherStep 6Preferred:High-dose ICS +eitherLABA orStep 3 LABA or MontelukastPreferred:Medium-doseMedium-doseICS + eitherLABA orPreferred: ICS MontelukastLow-dose ICSAlternative:MontelukastMontelukastOral systemiccorticosteroidsPatient Education and Environmental Control at Each StepStep up ifneeded(first, checkadherence,inhalertechnique, andenvironmentalcontrol)AssesscontrolStep down ifpossible(and asthma iswell controlledat least3 months)Quick-Relief Medication for All PatientsSABA as needed for symptoms. Intensity of treatment depends on severity of symptoms.With viral respiratory infection: SABA q 4–6 hours up to 24 hours (longer with physician consult). Consider shortcourse of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severeexacerbations.Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations oninitiating daily long term control therapy 1

IntermittentAsthmaStep 1Preferred:SABA PRNStep 2Preferred: LowdoseICSAlternative:LTRA orTheophyllinePersistent Asthma: Daily MedicationConsult with asthma specialist if step 4 care or higher is required.Consider consultation at step 3.Preferred:EITHER:Step 3Low-dose ICS +either LABA,LTRA, orTheophylline orMedium-doseICSStep 4Preferred:Medium dose ICS+ LABAAlternative:Medium-dose ICS+ either LTRA orTheophyllineStep 5Preferred: HighdoseICS + LABAAlternative:High-dose ICS +either LTRA orTheophyllineEach step: Patient education, environmental control, and management of comorbidities.Steps 2−4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).Quick-Relief Medication for All Patients:Step 6Preferred:High-dose ICS+ LABA + oralsystemiccorticosteroidAlternative:High-dose ICS +either LTRA orTheophylline +oral systemiccorticosteroidSABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3treatments at 20 –minute intervals as needed. Short cause of oral systemic corticosteroids may beneeded.Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB)generally indicates inadequate control and the need to step up treatment.Step up ifneeded(first, checkadherence,inhalertechnique,environmentalcontrol, andcomorbidconditions)AssesscontrolStep down ifpossible(and asthma iswell controlledat least3 months) 2

USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS INCHILDREN* Systemic CorticosteroidsMethylprednisolone 2, 4, 8, 16, 0.25–2 mg/kg daily 0.25–2 mg/kg daily • For long-term treatment of severe32 mg tablets in single dose in in single dose in persistent asthma, administera.m. or qod as a.m. or qod as single dose in a.m. either daily orneeded needed on alternate days (alternate-daytherapy may produce less adrenalsuppression). 5 mg tablets, 5 for control for control • Short courses or “bursts” are effectivemg/5 cc,for establishing control when initiating15 mg/5 cc Short-course Short-course therapy or during a period of gradual“burst”: 1–2 “burst”: 1–2 deterioration. 1, 2.5, 5, 1 0, mg/kg/day, mg/kg/day, • There is no evidence that tapering the20, 50 mg tablets; maximum maximum dose following improvement in5 mg/cc 60 mg/day for 3– 60 mg/day for 3– symptom control and pulmonary5 mg/5 cc 10 days 10 days function prevents relapse.Patients receiving the lower dose (1mg/kg/day) experience fewerbehavioral side effects (Kayani andShannon 2002), and it appears to beequally efficacious (Rachelefsky2003).For patients unable to tolerate theliquid preparations, dexamethasonesyrup at 0.4 mg/kg/day may be analternative. Studies are limited,however, and the longer duration ofactivity increases the risk of adrenalsuppression (Hendeles 2003)Long-Acting Beta2-Agonists (LABAs)• Should not be used for symptomrelief or exacerbations. Use onlywith ICSs.Should not be used alone –use incombination with an asthmacontroller medication.Decreased duration of protection againstSalmeterol DPI 50 mcg/ blister Safety and efficacy 1 blister q 12 hours EIB may occur with regular use.not established in• Most children

USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONSIN CHILDREN* (CONTINUED)Medication Dosage Form 0–4 years 5–11 years CommentsCombined MedicationFluticasone/ DPI 100 mcg/ Safety and 1 inhalation bid • There have been no clinical trials inSalmeterol 50 mcg efficacy notchildren

USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONSIN CHILDREN* (CONTINUED)Factors Affecting Serum Theophylline Concentrations †Decreases TheophyllineIncreases TheophyllineFactor Concentrations ConcentrationsFood ↓ or delays absorption of ↑ rate of absorptionsome sustained-release (fatty foods)theophylline (SRT)productsDiet ↑ metabolism (high protein) ↓metabolism(highcarbohydrate)Systemic, febrileviral illness (e.g.,influenza)Hypoxia, corpulmonale, anddecompensatedcongestive heartfailure, cirrhosis↓ metabolism↑ metabolismAge metabolism (1–9 years) ↓ metabolism(

USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONSIN CHILDREN*Medication Dosage Form 0–4 Years 5–11 YearsInhaled Short-Acting Beta2-AgonistsCommentsAlbuterol HFALevalbuterol HFAPirbuterol CFCAutohaler90 mcg/puff,200 puffs/canister45 mcg/puff,200 puffs/canister200 mcg/puff,400 puffs/canister2 puffs every 4–6hours as neededSafety andefficacy notestablished inchildren

USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS INCHILDREN* (CONTINUED)MedicationDosageForm 0–4 Years 5–11 YearsCommentsAnticholinergicsIpratropium HFA17 mcg/puff, Safety and Safety and200 puffs/ efficacy not efficacy notcanister established established0.25 mg/mL Safety and Safety and(0.025%) efficacy notestablishedefficacy notestablishedSystemic CorticosteroidsMethylprednisolone 2, 4, 6, 8,16,32mgtabletsPrednisolone 5 mgtablets,5 mg/5 cc, 15mg/5 ccPrednisone 1, 2.5, 5, 10,20, 50 mgtablets; 5mg/cc, 5 mg/5ccShort course Short course“burst”: 1–2 “burst”: 1-2mg/kg/day,maximummg/kg/day,maximum60 mg/day, for 60 mg/day, for3–10 days 3–10 days• Evidence is lacking for anticholinergicsproducing added benefit to beta2-agonistsin long-term control asthma therapy.• See “Management of Acute Asthma” fordosing in ED.•Short courses or “bursts” are effective forestablishing control when initiating therapyor during a period of gradual deterioration.The burst should be continued until patientachieves 80% PEF personal best orsymptoms resolve. This usually requires3–10 days but may require longer. Thereis no evidence that tapering the dosefollowing improvement prevents relapse.•(Methylprednisolone 40 mg/mL 7.5 mg/kg IM 240 mg IM • May be used in place of a short burst ofacetate) 80 mg/mL once once oral steroids in patients who are vomitingor if adherence is a problem.Key: CFC, chlorofluorocarbon; ED, emergency department; EIB, exercise-induced bronchospasm; HFA, hydrofluoroalkane;IM, intramuscular; MDI, metered-dose inhaler; PEF, peak expiratory flow*Dosages are provided for those products that have been approved by the U.S. Food and Drug Administration or havesufficient clinical trial safety and efficacy data in the appropriate age ranges to support their use. 7

IntermittentAsthmaStep 1Preferred:SABA PRNPersistent Asthma: Daily MedicationConsult with asthma specialist if step 4 care or higher is required.Consider consultation at step 3.Step 2Preferred: LowdoseICSAlternative:LTRA orTheophyllineStep 3Preferred:Low-doseICS + LABAORMedium-dose ICSAlternative:Low-dose ICS +either LTRA,Theophylline, orZileutonEach step: Patient education, environmental control, and management of comorbidities.Steps 2−4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).Quick-Relief Medication for All Patients:SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed.Preferred:Step 4Medium-dose ICS+ LABAAlternative:Medium-dose ICS+ either LTRA,Theophylline, orZileutonStep 5Preferred:High-doseICS + LABAANDConsiderOmalizumab forpatients who haveallergiesStep 6Preferred:High-doseICS + LABA + oralcorticosteroidANDConsiderOmalizumab forpatients who haveallergiesStep up ifneeded(first, checkadherence,environmentalcontrol, andcomorbidconditions)AssesscontrolStep down ifpossible(and asthma iswell controlledat least3 months)Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate controland the need to step up treatment. ⎯ 8

USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONSFOR YOUTHS ≥12 YEARS OF AGE AND ADULTSMedication Dosage Form Adult Dose CommentsInhaled Corticosteroids (ICS) Systemic CorticosteroidsMethylprednisolonePrednisolonePrednisone2, 4, 8, 16, 32 mgtablets5 mg tablets,5 mg/5 cc,15 mg/5 cc1, 2.5, 5, 10, 20, 50 mgTablets;tablets;5 mg/cc,7.5–60 mg daily in asingle dose in a.m. orqod as needed forcontrolShort-course “burst”: toachieve control, 40–60mg per day as single or2 divided doses for 3–10 daysFor long-term treatment of severepersistent asthma, administer singledose in a.m. either daily or onalternate days (alternate-day therapymay produce less adrenalsuppression). Short courses or“bursts” are effective for establishingcontrol when initiating therapy orduring a period of gradualdeterioration.There is no evidence that tapering thedose following improvement insymptom control and pulmonaryfunction prevents relapse.Inhaled Long-Acting Beta2-Agonists (LABA) • Should not be used for symptomrelief or exacerbations. Use withICS.*Should not be used alone-use inCombination with an asthmacontroller medication.SalmeterolFormoterolCombined MedicationDPI 50 mcg/blisterDPI 12 mcg/single-use capsule1 blister q 12 hours • Decreased duration of protectionagainst EIB may occur with regularuse.1 capsule q 12 hours •Each capsule is for single use only;additional doses should not beadministered for at least 12 hours.Capsules should be used only withthe Aerolizor TM inhaler and shouldnot be taken orally.Fluticasone/Salmeterol DPI 1 inhalation bid; dose • 100/50 DPI or 45/21 HFA for100 mcg/50 mcg,250 mcg/50 mcg, ordepends on severity ofasthmapatient not controlled on low- tomedium-dose ICS500 mcg/50 mcgHFA250/50 DPI or 115/21 HFA forpatients not controlled on medium- tohigh-dose ICS45 mcg/21 mcg115 mcg/21 mcg230 mcg/21 mcgBudesonide/ HFA MDI 2 inhalations bid; dose • 80/4.5 for patients who have asthmaFormoterol 80 mcg/4.5 mcg depends on severity of not controlled on low- to medium-160mcg/4.5 mcg asthma dose ICS160/4.5 for patients who have asthmanot controlled on medium- to highdoseICS 9

USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONSFOR YOUTHS ≥12 YEARS OF AGE AND ADULTS (CONTINUED)Leukotriene ModifiersLeukotriene Receptor AntagonistsMontelukast 4 mg or 5 mg 10 mg qhs • Montelukast exhibits a flat dosechewabletabletresponse curve. Doses >10 mg will10 mg tablet not produce a greater response inadults.Zafirlukast 10 or 20 mg tablet 40 mg daily • For zafirlukast, administration with(20 mg tablet bid) meals decreases bioavailability; takeat least 1 hour before or 2 hoursafter meals.Monitor for signs and symptoms ofhepatic dysfunction.5-Lipoxygenase InhibitorZileuton 600 mg tablet 2,400 mg daily • For zileuton, monitor hepatic(give tablets qid)enzymes (ALT).Zileuton CR 600 mg tablet 2,400 mg daily • CR tablets given within one hour(give tablets bid) • after morning and evening meals.MethylxanthinesTheophylline Liquids, sustained- Starting dose 10 mg/ • Adjust dosage to achieve serumrelease tablets, and kg/day up to 300 mg concentration of 5–15 mcg/mL atcapsules maximum; usual steady-state (at least 48 hours on samemaximumdosage).800 mg/dayDue to wide interpatient variability intheophylline metabolic clearance,routine serum theophylline levelmonitoring is important.See next page for factors that canaffect theophylline levels.ImmunomodulatorsOmalizumab Subcutaneous injection, 150–375 mg SC q • Do not administer more than 150 mg150 mg/1 .2 mL following 2–4 weeks, depending per injection site.reconstitution with 1 .4 mL on body weight and • Monitor for anaphylaxis for 2 hourssterile water for injection pretreatment serum following at least the first 3IgE levelinjections. Anaphylaxis has beenreported for up to one year after initiation of therapyKey: DPI, dry powder inhaler; EIB, exercise-induced bronchospasm; HFA, hydrofluoroalkane; IgE, immunoglobulin E;MDI, metered-dose inhaler; SABA, short-acting beta2-agonist10

USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS FORYOUTHS ≥12 YEARS OF AGE AND ADULTS (CONTINUED)Factors Affecting Serum Theophylline Concentrations*Decreases Theophylline Increases TheophyllineFactor Concentrations ConcentrationsFood ↓ or delays absorption of rate of absorption (fattysome sustained-releasefoods)theophylline (SRT)productsDiet↑ metabolism (high protein)↓ metabolism(highcarbohydrate)Systemic, febrileviral illness (e.g.,influenza)Hypoxia, corpulmonale, anddecompensatedcongestive heartfailure, cirrhosisAgePhenobarbital,phenytoin,carbamazepine↑ metabolism (1–9 years)↑ metabolism↓ metabolism↓ metabolism↓ metabolism(

USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS FORYOUTHS ≥ 1 2 YEARS O F AGE AND ADULTSMedication Dosage Form Adult Dose CommentsInhaled Short-Acting Beta2-Agonists (SABA)Albuterol HFAPirbuterol CFCAutohalerLevalbuterol HFA90 mcg/puff,200 puffs/canister200 mcg/puff,400 puffs/canister45 mcg/puff,200 puffs/canister2 puffs every 4-6 hoursas neededNot recommended for long-term dailytreatment. Regular use exceeding 2days/week for symptom control (notprevention of EIB) indicates the need tostep up therapy.Differences in potency exist, but allproducts are essentially comparable ona per puff basis.May double usual dose for mildexacerbations.Should prime the inhaler by releasing 4actuations prior to use.Periodically clean HFA activator, as drugmay block/plug orifice.Nonselective agents (i.e., epinephrine,isoproterenol, metaproterenol) are notrecommended due to their potential forexcessive cardiac stimulation, especiallyin high doses.AlbuterolLevalbuterol(R-albuterol)0.63 mg/3 mL1.25 mg/3 mL2.5 mg/3 mL 5mg/mL (0.5%)0.31 mg/3 mL0.63 mg/3 mL1.25 mg/0.5 mL1.25 mg/3 mL1.25-5 mg in 3 cc of salineq 4-8 hours as needed0.63 mg – 1.25 mg q 8hours as neededMay mix with budesonide inhalantsuspension, cromolyn or ipratropiumnebulizer solustions. May double dosefor severe exacerbations.Compatible with budesodine inhalantsuspension. The product is a sterilefilled,preservative-free, unit dose vial. 12

USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS FOR YOUTHS ≥ 12 YEARS O F AGE AND ADULTS ( Continued)Medication Dosage Form Adult Dose CommentsAnticholinergicsIpratropium HFA 17 mcg/puff, 2-3 puffs q 6 hours Evidence is lacking for anticholinergics200 puffs/canister producing added benefit to beta2-agonists in long-term control asthma therapy.0.25 mg/mL (0.025%) 0.25 mg q 6 hoursIpratropium with 18 mcg/puff of ipratropium 2-3 puffs q 6 hoursalbuterolbromide and 90 mcg/puffof albuterol200 puffs/canister0.5 mg/3 mL ipratropium 3 mL q 4-6 hours Contains EDTA to prevent discolorationbromide and 2.5 mg/3 mLof the solution. This additive does notalbuterolinduce bronchospasm.Methylprednisolone 2, 4, 8 16, 32 mg tablets Short course “burst”: 40-60 Short course or “bursts” are effective formg/day as single or 2 establishing control when initiatingdivided doses for 3-10 therapy or during a period of gradualdays.deterioration.Prednisolone 5 mg tablets, The burst should be continued until5 mg/5 cc, symptoms resolve and the PEF is at15 mg/5cc least 80 percent of personal best. Thisusually requires 3-10 days but mayPrednisone 1, 2.5, 5, 10, 20, 50 mg require longer. There is no evidencetablets; 5 mg/cc, 5 mg/5ccthat tapering the dose followingimprovement prevents relapse.(Methylprednisolone 20mg/mL 240 mg IM once May be used in place of a short burse ofacetate) 40 mg/mL oral steroids in patients who are80 mg/mL vomiting or if adherence is a problem.Key: CFC, chlorofluorocarbon; EIB, Exercise-induced bronchospasm; HFA, hydrofluoroalkane; IM, intramuscular; MDI, metered-dose inhaler:PEF, peak expiratory flow. 13

MANAGEMENT OF ASTHMA EXACERBATIONS: HOME TREATMENTAssess SeverityPatients at high risk for a fatal attack (see figure 5–2a) require immediate medical attention after initialtreatment.Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness, inability to speakmore than short phrases, use of accessory muscles, or drowsiness (see figure 5–3) should result in initial treatmentwhile immediately consulting with a clinician.Less severe signs and symptoms can be treated initially with assessment of response to therapy and further steps aslisted below.If available, measure PEF—values of 50–79% predicted or personal best indicate the need for quick-relief mediation.Depending on the response to treatment, contact with a clinician may also be indicated. Values below 50% indicatethe need for immediate medical care.Initial TreatmentInhaled SABA: up to two treatments 20 minutes apart of 2–6 puffs bymetered-dose inhaler (MDI) or nebulizer treatments.Note: Medication delivery is highly variable. Children and individuals whohave exacerbations of lesser severity may need fewer puffs thansuggested above.Good ResponseNo wheezing or dyspnea(assess tachypnea in youngchildren).PEF ≥80% predicted orpersonal best.Contact clinician forFollow-up instructions andfurther management.May continue inhaledSABA every 3–4 hours for 24–48 hours.Consider short course of oralsystemic corticosteroids.Incomplete ResponsePersistent wheezingand dyspnea(tachypnea). PEF50–79% predictedor personal best.Add oralsystemiccorticosteroid.Continue inhaled SABA.Contact clinician urgently (thisday) for further instruction.Poor ResponseMarked wheezing and dyspnea.PEF

Comprehensive Risk Reduction for Patients withAtherosclerotic Cardiovascular Disease(Tier #2 Guideline)Purpose: To delineate periodic examination requirements for adults with Atherosclerotic Cardiovascular DiseasePatient Population: Patients who have had a ST Elevation Myocardial Infarction, Coronary Artery Bypass Graft, or PercutaneousTransluminal Coronary AngioplastyDeveloped by: Catherine J McNeal, M.D., Eugene Terry, M.D., Michael M. Hawkins, M.D. and SWHP Secondary Prevention of CoronaryArtery Disease WorkgroupClinical Resource: The American College of Cardiology and the American Heart Association (ACC/AHA) Practice Guidelines updateDecember 2007.Adopted: SWHP Quality Improvement Committee 7/21/99 Revised: February 2008, March 2012, April 2014 Reviewed: February, 2010Treatment of Blood Cholesterol to Reduce AtheroscleroticCardiovascular Disease Risk in Adults: Synopsis of the 2013ACC/AHA Cholesterol GuidelineNeil J. Stone, MD; Jennifer G. Robinson, MD, MPH; Alice H. Lichtenstein, ScD; David C. Goff Jr., MD, PhD;Donald M. Lloyd-Jones, MD, ScM; Sidney C. Smith Jr., MD; Conrad Blum, MD; and J. Sanford Schwartz, MD,for the 2013 ACC/AHA Cholesterol Guideline Panel*Description: In November 2013, the American College of Cardiologyand American Heart Association (ACC/AHA) released a clinicalpractice guideline on the treatment of blood cholesterol to reducecardiovascular risk in adults. This synopsis summarizes the majorrecommendations.Methods: In 2008, the National Heart, Lung, and Blood Instituteconvened the Adult Treatment Panel IV (ATP-IV) to update the2001 ATP-III cholesterol guidelines using a rigorous process tosystematically review randomized, controlled trials (RCTs) andmeta-analyses of RCTs that examined cardiovascular outcomes. Thepanel commissioned independent systematic evidence reviews onlow-density lipoprotein cholesterol and non–high-density lipoproteincholesterol goals in secondary and primary prevention and theimpact of lipid drugs on atherosclerotic cardiovascular disease(ASCVD) events and adverse effects. In September 2013, the panel’sdraft recommendations were transitioned to the ACC/AHA.Recommendations: This synopsis summarizes key features of theguidelines in 8 areas: lifestyle, groups shown to benefit from statins,statin safety, decision making, estimation of cardiovascular diseaserisk, intensity of statin therapy, treatment targets, and monitoringof statin therapy.Ann Intern Med.For author affiliations, see end of text.www.annals.orgAtherosclerotic cardiovascular disease (ASCVD) is theleading cause of death, decreased quality of life, andmedical costs in the United States. Nearly 1 in 3 Americansdie of heart disease and stroke (1). Most ASCVD ispreventable through a healthy lifestyle and effective treatmentof cholesterol and blood pressure. The 2013 “Guidelineon the Treatment of Blood Cholesterol to ReduceAtherosclerotic Cardiovascular Risk in Adults” from theAmerican College of Cardiology and American Heart Association(ACC/AHA) provides an evidence-based approachto reducing ASCVD risk (2).GUIDELINE DEVELOPMENT PROCESSIn 2008, the National Heart, Lung, and Blood Institute(NHLBI) convened the Adult Treatment Panel IV(ATP-IV) to update the 2001 ATP-III cholesterol guidelinesusing a rigorous systematic process to identify andreview randomized, controlled trials (RCTs) with cardiovascularoutcomes and meta-analyses of these RCTs. Thepanel comprised experts and clinicians from the fields ofcardiology, epidemiology, primary care, and endocrinology(2) and received support from the Lifestyle Managementand Risk Assessment Work Groups (3, 4).Systematic evidence reviews conducted according toprinciples recommended by the Institute of Medicine (5)were performed to answer 3 questions relevant to clinicalcare. Two questions focused on the evidence supportinglow-density lipoprotein cholesterol (LDL-C) and non–high-density lipoprotein cholesterol (HDL-C) levels as targetsof treatment. One question examined the reduction inASCVD events and adverse effects for each cholesterolloweringdrug class. The panel synthesized the evidencefrom these 3 reviews as well as from Lifestyle Managementand Risk Assessment Work Groups reviews (3, 4) that addressed5 additional critical questions.Systematic electronic searches of relevant databases ofthe peer-reviewed English-language literature publishedfrom 1 January 1995 through 1 December 2009 for eachcritical question were conducted by an NHLBI-selectedindependent contractor and focused on RCTs and systematicreviews and meta-analyses of RCTs assessed as fair togood quality. In addition, RCTs with ASCVD outcomes* For a list of the members of the 2013 ACC/AHA Cholesterol Guideline Panel, see the Appendix (available at www.annals.org).This article was published online first at www.annals.org on 28 January 2014.

that included coronary heart disease, stroke, and cardiovasculardeaths published after that date were eligible for considerationthrough July 2013. Evidence tables were constructedand the strength of evidence was rated accordingto the NHLBI (Table 1 of the Supplement, available atwww.annals.org). Recommendations were graded accordingto criteria from the NHLBI (Table 2 of the Supplement)and ACC/AHA (Table 3 of the Supplement). Becauseof the inherent differences in grading systems and theclinical questions driving the recommendations, alignmentbetween the NHLBI and ACC/AHA formats was imperfect.A complete description of the methods used and resultsof the evidence review are provided in the guideline(2) and the NHLBI evidence report (www.nhlbi.nih.gov/guidelines/cholesterol/ser/index.htm).To help clinicians estimate CVD risk, the risk assessmentworking group developed the Pooled Cohort Equationsusing data from 5 NHLBI-sponsored longitudinal,population-based cohorts of African American and non-Hispanic white men and women to estimate risk for a firstmyocardial infarction, coronary heart disease death, or fatalor nonfatal stroke on the basis of age, sex, race, smokingstatus, total cholesterol level, HDL-C level, systolic bloodpressure, antihypertensive therapy, and diabetes (4, 6).These equations significantly advance ASCVD risk estimationby providing sex- and race-specific estimates and includingstroke as an outcome. The earlier Framinghamequations calculated only coronary heart disease risk fornon-Hispanic whites.The draft recommendations were reviewed by 23 expertsand representatives of federal agencies identified bythe NHLBI. In September 2013, the recommendationsdeveloped by the panel were transitioned to the ACC/AHAand had additional review by 4 experts nominated by theACC Foundation and the AHA. The governing bodies ofthe ACC and AHA approved the guideline, which alsoreceived endorsement from the American Association ofCardiovascular and Pulmonary Rehabilitation, AmericanPharmacists Association, American Society for PreventiveCardiology, Association of Black Cardiologists, PreventiveCardiovascular Nurses Association, and WomenHeart:The National Coalition for Women with Heart Disease.RECOMMENDATIONSThe guideline focuses on treatment of blood cholesterolto reduce ASCVD risk in adults. Major recommendationsare summarized here and in Table 1. The guidelinereport provides a complete listing of recommendations andsupporting evidence behind each recommendation (2).1. Encourage Adherence to a Healthy LifestyleA healthy lifestyle is the foundation for cardiovascularhealth. The panel endorsed the 2013 ACC/AHA LifestyleManagement Guideline (3) for a diet that is low in saturatedfat, trans fat and sodium; emphasizes vegetables,fruits, whole grains, low-fat dairy products, poultry, fish,legumes, nontropical vegetable oils, and nuts; and limitssweets, sugar-sweetened beverages, and red meats and engagein regular aerobic physical activity. Adults also shouldmaintain a healthy body weight, avoid smoking, and controlhypertension and diabetes when present.2. Statin Therapy is Recommended for Adults in GroupsDemonstrated to BenefitStrong RCT evidence shows that reduction inASCVD events from statin therapy exceeds adverse eventsfor 4 patient groups: those with clinical ASCVD (acutecoronary syndromes, myocardial infarction, stable angina,coronary or other arterial revascularization, stroke, transientischemic attack, or peripheral arterial disease of atheroscleroticorigin) when statins are used for secondary prevention,and those with LDL-C levels of 190 mg/dL orgreater; those aged 40 to 75 years with diabetes andLDL-C levels of 70 to 189 mg/dL; and those aged 40 to 75years without diabetes and with a 10-year ASCVD risk of7.5% or greater when statins are used for primary prevention.Moderate evidence supports consideration of statintherapy for primary prevention in individuals with a 10-year ASCVD risk of 5% to less than 7.5%. Routine initiationof statin therapy is not recommended in adults withNew York Heart Association heart failure class II to IV orthose receiving maintenance hemodialysis. Randomized,controlled trials in these groups showed no reduction inASCVD.3. Statins have an Acceptable Margin of Safety whenUsed in Properly Selected Individuals and AppropriatelyMonitoredStrong RCT evidence supports safety of statins whenthey are used as directed in conjunction with regularfollow-up assessments in properly selected patients. Adjustmentof statin intensity is recommended in individualsolder than 75 years with a history of statin intolerance orother characteristics (2) or those receiving drug therapythat may increase statin adverse events.Routine monitoring of hepatic aminotransferase levelor creatine kinase level is not recommended unless clinicallyindicated by symptoms suggesting hepatotoxicity ormyopathy. Given statin therapy’s potential for decreasingASCVD events and death, it is important to confirm therelationship of muscle and other symptoms to statin treatment.Therefore, eliciting a history of muscle symptomsbefore statin initiation and carefully monitoring symptomsduring statin discontinuation and rechallenge is recommended.Severe myopathy, rhabdomyolysis, and possiblyhemorrhagic stroke are rare complications of statintherapy.Although statin therapy modestly increases the risk fortype 2 diabetes, ASCVD risk reduction outweighs the excessrisk for diabetes for high-intensity statins in secondaryprevention or for 10-year ASCVD risk of 7.5% or greater.Similarly, ASCVD risk reduction outweighs the excess riskfor diabetes for moderate-intensity statin therapy in adultswith a 10-year ASCVD risk of 5% or greater.

Table 1. Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults*†Healthy lifestyle habits should be encouraged for all persons.The appropriate intensity of statin therapy should be initiated or continued:Clinical ASCVD‡Persons aged ~75 y with no safety concerns: high-intensity statin (class I, level A)Persons aged >75 y or with safety concerns: moderate-intensity statin (class I, level A)Primary prevention: primary LDL-C level ~190 mg/dLRule out secondary causes of hypercholesterolemiaPersons aged ~21 y: high-intensity statin (class I, level B)Achieve ~50% reduction in LDL-C level (class IIa, level B)May consider LDL-C–lowering nonstatin therapy to further reduce LDL-C levels (class IIb, level C)Primary prevention: persons with diabetes aged 40–75 y with an LDL-C level of 70–189 mg/dLModerate-intensity statin (class I, level A)Consider high-intensity statin when 10-y ASCVD risk is ~7.5% (class IIa, level B)Primary prevention: persons aged 40–75 y without diabetes with an LDL-C level of 70–189 mg/dLEstimate 10-y ASCVD risk (risk calculator based on Pooled Cohort Equations recommended)§ in those not receiving a statin; estimate risk every 4–6 y (class I,level B)To determine whether to initiate a statin, engage in clinician–patient discussion of potential for ASCVD risk reduction, adverse effects, drug–drug interactions,and patient preferences (class IIa, level C). Re-emphasize healthy lifestyle habits and address other risk factors. If statin therapy is chosen:Persons with ~7.5% 10-y ASCVD risk: moderate- or high-intensity statin (class I, level A)Persons with 5% to

4. Engage in a Clinician–Patient Discussion BeforeInitiating Statin Therapy, Especially for PrimaryPrevention in Patients with Lower ASCVD RiskDecisions to initiate statin therapy in primary preventionshould be based on clinical judgment and preferencesof informed patients. In adults without clinical ASCVD ordiabetes whose LDL-C level is less than 190 mg/dL, calculatingthe estimated 10-year ASCVD risk should be thestart of the clinician–patient discussion and should notautomatically lead to statin initiation. As the absolute riskfor ASCVD events decreases, so does the net benefit of theintervention. Therefore, discussion of the potential forASCVD event reduction, adverse effects, drug–drug interactions,and patient preferences is especially important forlower-risk primary prevention. The discussion provides theopportunity to encourage healthy lifestyle habits and controlother risk factors.Additional factors may be considered when a riskbaseddecision is uncertain, including LDL-C levels of 160mg/dL or greater, family history of premature ASCVD,elevated lifetime ASCVD risk, high-sensitivity C-reactiveprotein level of 2.0 mg/L or greater, coronary artery calcificationscore greater than 300 Agatston units, and ankle–brachial index less than 0.9. After age 75 years, comorbidconditions, anticipated longevity, safety considerations,and patient preferences should play a large role in decisionmaking.5. Use the Newly Developed Pooled Cohort Equationsfor Estimating 10-Year ASCVD RiskThe Pooled Cohort Equations are currently the bestavailable method for estimating 10-year ASCVD risk toguide statin initiation (4, 6). Application of the inclusionand exclusion criteria from RCTs is cumbersome and resultsin under-identifying high-risk and over-identifyinglow-risk individuals for statin treatment.The Pooled Cohort Equations were developed usingrecent data from 5 NHLBI-sponsored, longitudinal,population-based cohorts of African American and whitemen and women (ARIC [Atherosclerotic Risk in Communities],CHS [Cardiovascular Health Study], CARDIA[Coronary Artery Risk Development in Young Adults],and the original Framingham Heart Study and its OffspringCohorts). When the Pooled Cohort Equations werevalidated in 2 independent contemporary cohorts (MESA[Multi-Ethnic Study of Atherosclerosis] and REGARDS[Reasons for Geographic and Racial Differences inStroke]), discrimination and calibration ranged from“good” to “fair.” Some overestimation of ASCVD risk wasobserved, primarily in higher-risk individuals, perhaps dueto high rates of statin initiation after baseline examinationsin these cohorts and limited duration of follow-up. Modestoverestimation of ASCVD risk generally will not affectmost decisions to recommend statin treatment for adultsTable 2. High-, Moderate-, and Low-Intensity StatinTherapy*StatinTherapyDaily DoseHigh-Intensity† Moderate-Intensity‡Low-Intensity§Atorvastatin 4011–80 mg 10 (20) mg –Rosuvastatin 20 (40) mg (5) 10 mg –Simvastatin – 20–40 mg 10 mgPravastatin – 40 (80) mg 10–20 mgLovastatin – 40 mg 20 mgFluvastatin – 80 mg (Fluvastatin XL) 20–40 mgFluvastatin – 40 mg** –Pitavastatin – 2–4 mg 1 mgFDA = U.S. Food and Drug Administration; LDL-C = low-density lipoproteincholesterol; XL = extended-release.* Individual responses to statin therapy varied in randomized, controlled trials andvary in clinical practice. A less-than-average response may have a biologic basis.Statins and dosages in bold were reduced in major cardiovascular events in randomized,controlled trials. Statins and doses in italics were approved by the FDAbut were not tested in randomized, controlled trials.† Daily dose decreases LDL-C levels by an average of ~50%.‡ Daily dose decreases LDL-C levels by an average of 30% to

year ASCVD risk, an LDL-C level of 160 to 189 mg/dL,or additional factors that may influence ASCVD risk. Lowintensitystatin therapy may be used when high- ormoderate-intensity statins are not tolerated.7. Evidence is Inadequate to Support Treatment toSpecific LDL-C or Non–HDL-C GoalsRandomized, controlled trials of statins, nonstatindrugs, or both did not compare titration to differentLDL-C goals. Thus, the panel was unable to make anyevidence-based recommendations about use of treatmentgoals for guiding therapy. “Treating to goal” may result intreatment with less-than-optimum statin intensity or addingnonstatin therapy in the absence of RCT evidence thatcombination therapy improves outcomes.8. Regularly Monitor Patients for Adherence to Lifestyleand Statin TherapyRandomized, controlled trials of statins regularly assessedadherence and safety. A fasting lipid panel is neededafter initiation of or changes in statin or other drug therapy.Percentage reductions in LDL-C level should not beused as treatment goals or performance measures butshould be used to assess and provide feedback to promoteadherence to healthy lifestyle behaviors and statin therapy.Safety measurements should be assessed as clinicallyindicated.In patients with a less-than-anticipated therapeutic responseor intolerance of recommended statin therapy intensity,adherence to healthy lifestyle behaviors and medicationsshould be re-emphasized and secondary causes ofhyperlipidemia excluded. A nonstatin LDL-C–loweringdrug, preferably one that reduced ASCVD events in RCTs,can be considered in higher-risk adults, including thosewith genetic dyslipidemias, such as familial hypercholesterolemia,if the potential for additional ASCVD risk reductionoutweighs the potential for adverse effects.statin, are available in the United States as low-costgenerics.The Pooled Risk Equations, which were developed ina geographically diverse sample of African Americans andnon-Hispanic whites, identify adults at increased risk foran ASCVD event (including stroke as well as heart disease).They represent important steps forward in the abilityto match intensity of preventive treatment to level ofASCVD risk. These risk equations will be reevaluated andrevised as additional information becomes available, includingresearch assessing other potentially useful markersof ASCVD risk and data required to develop equationsspecific to other ethnic groups.Until heart-healthy lifestyles are adopted throughoutthe lifespan, the need for preventive measures usingevidence-based drug therapy will remain high. As with allclinical guidelines, the 2013 ACC/AHA cholesterol guidelinesmust be implemented in conjunction with soundclinical judgment. These evidence-based recommendationsfocus statin treatment on patients likely to obtain the greatestbenefit, thereby reducing the ASCVD burden in adults.From Northwestern University, Chicago, Illinois; University of Iowa,Iowa City, Iowa; Tufts University, Boston, Massachusetts; University ofColorado, Aurora, Colorado; University of North Carolina, Chapel Hill,North Carolina; Columbia University Medical Center, New York, NewYork; and University of Pennsylvania, Philadelphia, Pennsylvania.Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0126.Corresponding Author: J. Sanford Schwartz, MD, University of Pennsylvania,Blockley 1101, 423 Guardian Drive, Philadelphia, PA 19104;e-mail, schwartz@wharton.upenn.edu.Current author addresses and author contributions are available atwww.annals.org.SUMMARYMillions of U.S. adults are at increased ASCVD risk—some because they have had an ASCVD event, others becauseof ASCVD risk factors. Adherence to healthy lifestylebehaviors, control of blood pressure and diabetes, andavoidance of smoking is recommended for all adults. Statintherapy should be used to reduce ASCVD risk in individualslikely to have a clear net benefit (those with clinicalASCVD) or in primary prevention for adults with LDL-Clevels of 190 mg/dL or greater, those aged 40 to 75 yearswith diabetes, and those with a 10-year ASCVD risk of7.5% or greater without diabetes. A clinician–patient discussionthat considers potential ASCVD risk reduction,adverse effects, and patient preferences is needed to decidewhether to initiate statin therapy, especially in lower-riskprimary prevention.Appropriate intensity of statin therapy based onASCVD risk and potential for adverse effects is recommendedrather than focusing on specific LDL-C or non–HDL-C goals. Five of 7 statins, including a high-intensity

References1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al; American Heart Association Statistics Committee and StrokeStatistics Subcommittee. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation.2013;127:e6-e245. [PMID: 23239837]2. Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, et al. 2013 ACC/AHA Guideline on the Treatment ofBlood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines. J Am Coll Cardiol. 2013. [PMID: 24239923]3. Eckel RH, Jakicic JM, Ard JD, Miller NH, Hubbard VS, Nonas CA, et al. 2013 AHA/ACC Guideline on Lifestyle Management to ReduceCardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J AmColl Cardiol. 2013. [PMID: 24239922]4. Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB Sr, Gibbons R, et al. 2013 ACC/AHA Guideline on the Assessment ofCardiovascular Risk: A Report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines.Circulation. 2013. [PMID: 24222018]5. Graham R, Mancher M, Wolman DM, Greenfield S, Steinberg E, eds; Institute of Medicine. Clinical Practice Guidelines We Can Trust.Washington, DC: National Academies Pr; 2011.6. American Heart Association. 2013 Prevention Guidelines Tools: CV Risk Calculator. Dallas, TX: American Heart Association; 2013.Accessed at http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp on 10 January 2014.7. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013;382:1762-5. [PMID: 24268611]8. Lloyd-Jones DM, Goff D, Stone NJ. Statins, risk assessment, and the new American prevention guidelines [Letter]. Lancet. 2013. [PMID:24315619]Current Author Addresses: Dr. Stone: Feinberg School of Medicine, Northwestern Medical Faculty Foundation, NorthwesternUniversity, 676 North St. Clair, Suite 600 (Cardiology), Chicago, IL 60611.Dr. Robinson: Department of Epidemiology, University of Iowa, 200 Hawkins Drive, SE 226 GH, Iowa City, IA 52242Dr. Lichtenstein: Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston,MA 02111.Dr. Goff: Colorado School of Public Health, University of Colorado, Building 500, 3rd Floor, Suite 300, Anschutz Medical Campus,Aurora, CO 80045.Dr. Lloyd-Jones: Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago,IL 60611.Dr. Smith: UNC Health Care System, 101 Manning Drive, Chapel Hill, NC 27514.Dr. Blum: Columbia College, P & S, 16 East 60th Street, New York, NY 10022.Dr. Schwartz: University of Pennsylvania, Blockley 1101, 423 Guardian Drive, Philadelphia, PA 19104.APPENDIX: 2013 ACC/AHA CHOLESTEROLGUIDELINE PANELThe members of the 2013 ACC/AHA Cholesterol Guideline Panel are Neil J. Stone, MD (Chair); Jennifer G.Robinson, MD, MPH (Vice-Chair); Alice H. Lichtenstein, ScD (Vice-Chair); Donald M. Lloyd-Jones, MD, ScM (Co-Chair, ASCVD Risk Assessment Expert Work Group); Robert H. Eckel, MD (Co-Chair, Lifestyle Management ExpertWork Group); C. Noel Bairey Merz, MD; Conrad B. Bloom, MD; Anne C. Goldberg, MD; David Gordon, MD; DanielLevy, MD; Patrick McBride, MD, MPH; Susan T. Shero, MS, RN; Karol Watson, PhD; and Peter W.F. Wilson, MD.Although he is not a member of the ACC/AHA Cholesterol Guideline Panel, David C. Goff Jr., MD, PhD, is Co-Chair ofthe ASCVD Risk Assessment Expert Work Group

Tier 2 GuidelineMicrohematuria Without Evidence of Primary Renal Disease In Adults(Confirmed by Microscopic Analysis)Date of Adoption: September 14, 2010 Revision Dates: 8/2013Contact Physician: Dr. Erin Bird, MD; S&W Department of UrologyInternal Medicine/Family Medicine: Microscopic Evaluation of urineto confirm presence of RBC’sExclude benign causesSigns or symptoms of infection, (e.g. dyspsuria, frequency, flank/CVA pain, leukocyte esterase, nitrites, white blood cells, bacteria)?YesNoTreat infection; confirmresolution of microscopichematuria with follow-upurinalysis six weeks aftercompletion of therapy.ResolvedNoYesReleasefromCareFindings in support of primaryrenal disease/glomerular cause(e.g. proteinuria, elevatedcreatine level, red cell casts,dysmophic RBC’s)?Elevated creatinineYesRefer to nephrologysubspecialistOREvaluate for primary renaldiseaseRefer to urology based onresults of imaging/cytologyComplete Evaluation(Upper Tract ImagingCytologyCystoscopy)Urology ConsultationOrTreatPCP may elect tocoordinate upper tractimaging (US C.T.)cytologyNoOrRefer to urologyPrepare patient forpartial/ complete evalNegativePositiveUrinalysis, BloodPressure andCytology at6, 12, 24 and 36monthsTreatPersistent hematuria,hypertension, and/orproteinuriaEvaluate for primaryRenal DiseaseNegative 3 YearsNo further urologicmonitoring neededGross hematuria,abnormal cytology,persistent irritative voidingsymptomsRepeat completeevaluationPage 1 of 1Source: American Urological Association (AUA)

Diabetes Annual AssessmentPurpose: To delineate yearly examination requirements for adults with diabetes.Patient Population: Patients, age 18 to 75, with diabetes.Developed by: SWHP Diabetes Team 12/18/97 Contact Person: Veronica Piziak, M.D.Adopted: 1/21/98 Date of Last Reviews: April 2004, April 2006, April 2008, and April 2010Next Review Date: May 2016Approved by SWHP Quality Improvement Sub-Committee: April 13, 2010, April 10, 2012, May13, 2014TIME FRAME FOR REQUIRED TESTSExaminationInitialVisitTwice per Year1. Eye Exam (By Optometrist or Ophthalmologist) X X2. Hemoglobin A1c Control – goal

SCOTT AND WHITE HEALTH PLANCLINICAL PRACTICE GUIDELINES FOR DIABETESSWHP has adopted the 2011 Clinical Practice Recommendations of the National Quality Forum(NQF) endorsed Diabetes Standards submitted by the National Committee for QualityAssurance (NCQA) located at the following internet website link:http://www.qualityforum.org/Measures_List.aspx#k=Diabetes&e=1&st=&sd=549%7C798&s=&p=1SWHP Guideline Approval Body: SWHP Quality Improvement SubcommitteeDate of Adoption: December 7, 2011Review Dates: April 2012, April 2014, May 2016Physician Sponsor: Veronica K. Piziak, M.D., Ph.D.Scott &White HealthcareProfessor of Medicine and Endocrinology, Texas A&M Health ScienceCenter College of MedicineBoard Certification by the American Board of Internal Medicine inEndocrinology and MetabolismPaper Copy: A paper copy of this Guideline is available upon request by contacting the SWHPQuality Improvement Division. Call toll free 1-800-321-7947 ext. 3516.L/QI/NCQA/Clinical Guidelines/Current Tier 2 INTER dept/Diabetes

SCOTT AND WHITE HEALTH PLANCLINICAL PRACTICE GUIDELINE FOR THE TREATMENT OFOSTEOARTHRITIS OF THE KNEEScottandWhiteHealthPlan(SWHP)hasadoptedthe“Treatment of Osteoarthritis of the Knee” datedMay18,2013oftheAmericanAcademyofOrthopaedicSurgeons,asaclinicalpracticeguidelineforSWHP’sproviders 1 .Theguidelineislocatedatthefollowinginternetwebsite:http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdfAdditional Resources for Care: SWHP VitalCare Shared Decision-Making Program 2 :https://www.swhp.org/sites/default/files/SharedDecisioinMakingRef_FAX.pdf SWHP Formulary:https://swhp.org/providers/pharmacyservices/prescriptiondruglists Notes:1. Specificrecommendationsforcareshouldbediscussedwithyourpatient.AllmedicationsnotedinthisguidelinemaynotbeintheSWHPFormulary;however,sinceSWHPhasanOpenFormulary,nonFormularymedicationsareavailablewithauthorizationatthenonFormularycopayment.2. SWHP’sSharedDecisionMakingprogramofferspreferencesensitiveconditionsupport.Preferencesensitiveconditionsupportextendstoconditionsforwhicheithersciencesupportsmultipleacceptabletreatmentoptions,orthereisinadequatescientificinformationaboutthetreatmentchoices.OurHealthCoachescanhelpyourpatientmakeaninformeddecisionaboutthetreatmentheorshewouldliketoreceive.Decisionsupportforpreferencesensitiveconditionsaddressesawiderangeoftopics,includingosteoarthritis.SWHP Guideline Approval Body:SWHPQualityImprovementSubcommitteeDate of Adoption:Review Dates:March8.2011Physician Sponsor:MichaelHawkins,MDPaper Copy:Ifyouhavedifficultydownloadinginformationorwouldlikeapapercopy,pleasecontactSWHPProviderRelationsDepartmenttollfreeat8003217947ext.3064ordirectat2542983064

Tier #1: Address the expected practice or management of a specific condition ordisease process within an organizational unit, i.e. division or department; may bedistributed outside the respective organizational unit.

Scott and WhiteHealthPlanClinical Practice Guideline (Tier 1)forUse by Mental Health Specialists inPharmacologic Management of Major Depression (Non-Psychotic, Non-Bipolar)Approved: December 1999 Revised: 2/2003; 2/2007 Reviewed: 2/2005; 2/2009,12/2010, 12/2012Source: Texas Medication Algorithm ProjectPhysician Contact: Dr. Virginia Maxanne Flores, M.D.Reviewed in 2010 by: Department of Psychiatry, Scott &WhiteClinicsMajorDepressionMonotherapy(1) Previous effective drug(2) SSRI* or(3) Bup*, Vlf*, Mirtazapine,DuloxetineStage 1Good Response?YesContinuation Phase(see page 2)NoStage 2Revised* LEGEND:Bup – Bupropion or Bupropion SRECT – Electroconvulsive therapyMAOI – Monoamine Oxidase Inhibitor.SSRI – Selective Seratonin ReuptakeInhibitorsTCA – Tricyclic antidepressantVlf – Venlafaxine or Venlafaxine XRStage 3Revised(1) Alternate Monotherapy(SSRI*, Bup*, Vlf*, TCA*, MAOI*, Mirtazapine,Duloxetine)or(2) Augmentation(Lithium, Thyroid, Buspirone, stimulant)or(3) Combination (TCA*+SSRI*)Good Response?No(1) Alternate Monotherapyor(2) Augmentationor(3) Combination(TCA* + SSRI*)YesContinuation Phase(see page 2)Good Response?YesContinuation Phase(see page 2)NoStage 4ECT*Good Response?YesContinuation Phase(see page 2)NoStage 5Reassess:(1) Augmentation(Olanzapine, Lamotrigine)or(2) Combination(SSRI* + Bup*, TCA* + MAOI*)orReturn to Stages 3 or 4Maintenance Phase(see page 2)Page 1

Scott and White Health PlanClinical Practice Guideline (Tier 1) for Use by Mental Health Specialists inPharmacologic Management of Major Depression (Non-Psychotic, Non-Bipolar)Continuation and Maintenance PhasesApproved: December 1999 Revised: 2/2003; 2/2007 Reviewed: 2/2005; 2/2009, 12/2010Source: Texas Medication Algorithm ProjectPhysician Contact: Dr. Virginia Maxanne Flores, M.D.Reviewed in 2010 by: Department of Psychiatry, Scott & White ClinicsAcute PhaseTreatmentSymptomRemission?YesEnter Continuation Phase6 to 9 monthsNoReturn to AcuteTreatment AlgorithmEvaluate for Maintenance Phase:(1) 3 or more episodes,or(2) 2 episodes, with:-family history, Bipolar Disorder-recurrence in 1 year after stopping Tx.-family history, Major Depressive Disorder-early onset (before age 20)-severe, sudden, life-threatening in 3 yearsNoBegin Maintenance?Yes(1) Taper anddiscontinue over 2 to 3monthsand(2) Follow every 2 to 4months for 8 monthsContinue at full dose(1 year to lifetime)Page 2

Scott and White Health PlanClinical Practice Guideline for Mental Health Specialists (Tier 1)STRATEGIES FOR ALCOHOL WITHDRAWAL MANAGEMENTAdopted: 12/1998 Reviewed: 2/2003; 2/2005; 9/2009 Revised: 2/2007; 7/2011; 8/2011*Physician Contact: Virginia Maxanne Flores, MDReviewed in 2011 by: Department of Psychiatry, Scott & White ClinicsA. Thiamine 100 mg I.M. x 1, then 100 mg p.o. daily x 5 daysB. Folate 1 mg p.o. dailyC. Multivitamin 1 p.o. dailyD. Nurse monitors and documents Abstinence SymptomEvaluation (ASE’s) q 4 hours.E. Magnesium Sulfate 1 gram q 8 hours I.M. x 2, as indicatedPatient enters inpatienttreatment facility foralcohol withdrawal.During 1 st 24 hours ofmonitoring ASE scores, is ASEscore increase by 3 points betweenassessments?No+/- Acamprosate+/- Naltrexone+/- AntabuseYesIs theresignificant hepaticimpairment?Yes72 hours (FixedSchedule)Encourage patient tocall MH provider foroutpatient referral ifpatient changes mindNoRefer toOutpatient CarePatient agreesto OutpatientCare?NoWill treatmentduration be 24 or72 hours?Yes24 hours (Front-Loading Schedule)72 hours (FixedSchedule)Diagnosis ofalcoholdependence?YesNoDiazepam 20 mg p.o.q 2 hours until ASE’s

Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – 2013.(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars inFigure 1. To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are in bold.Vaccines Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 19–23 mos 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13–15 yrs 16–18 yrsHepatitis B 1 (HepB)1 st dose2 nd dose3 rd doseRotavirus 2 (RV) RV-1 (2-dose series);RV-5 (3-dose series)Diphtheria, tetanus, & acellularpertussis 3 (DTaP: 7 yrs)(Tdap)Haemophilus influenzae type b 5 (Hib)1 st dose2 nd doseSeefootnote 53 rd or 4 th dose,see footnote 5Pneumococcal conjugate 6a,c (PCV13)1 st dose2 nd dose3 rd dose4 th dosePneumococcal polysaccharide 6b,c(PPSV23)Inactivated Poliovirus 7 (IPV)( 6 weeks;MCV4-D>9 mos; MCV4-CRM > 2 yrs.)(3-doseseries)see footnote 131 st doseboosterRange of recommendedages for all childrenRange of recommended agesfor catch-up immunizationRange of recommended agesfor certain high-risk groupsRange of recommended ages duringwhich catch-up is encouraged and forcertain high-risk groupsNot routinelyrecommendedThis schedule includes recommendations in effect as of January 1, 2013. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use ofa combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP)statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow vaccination should be reported to the Vaccine AdverseEvent Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department.Additional information, including precautions and contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines) or by telephone (800-CDC-INFO [800-232-4636]).This schedule is approved by the Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/acip/index.html), the American Academy of Pediatrics (http://www.aap.org), the AmericanAcademy of Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).NOTE: The above recommendations must be read along with the footnotes of this schedule.FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —United States, 2013The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless ofthe time that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in conjunction with Figure 1 and the footnotes that follow.Persons aged 4 months through 6 yearsVaccineMinimumAge forDose 1Minimum Interval Between DosesDose 1 to dose 2 Dose 2 to dose 3 Dose 3 to dose 4 Dose 4 to dose 5Hepatitis B 1 Birth 4 weeks8 weeks and at least 16 weeks after first dose; minimum age forthe final dose is 24 weeksRotavirus 2 6 weeks 4 weeks 4 weeks 2Diphtheria, tetanus, pertussis 3 6 weeks 4 weeks 4 weeks 6 months 6 months 3Haemophilus influenzae type b 5Pneumococcal 66 weeks6 weeks4 weeks if first dose administered atyounger than age 12 months8 weeks (as final dose) if first dose administered at age 12–14monthsNo further doses needed if first dose administered at age 15months or older4 weeks if first dose administered at younger than age 12 months8 weeks (as final dose for healthy children) if first doseadministered at age 12 months or older or current age 24 through59 monthsNo further doses needed for healthy children if first doseadministered at age 24 months or older4 weeks 5 if current age is younger than 12 months8 weeks (as final dose) 5 if current age is 12 months or olderand first dose administered at younger than age 12 months andsecond dose administered at younger than 15 monthsNo further doses needed if previous dose administered at age15 months or older4 weeks if current age is younger than 12 months8 weeks (as final dose for healthy children) if current age is 12months or olderNo further doses needed for healthy children if previous doseadministered at age 24 months or olderInactivated poliovirus 7 6 weeks 4 weeks 4 weeks8 weeks (as final dose)This dose only necessary for childrenaged 12 through 59 months who received3 doses before age 12 months8 weeks (as final dose)This dose only necessaryfor children aged 12through 59 months who received 3 dosesbefore age 12 months or for children athigh risk who received 3 doses at any age6 months 7 minimum age 4 years forfinal doseMeningococcal 13 6 weeks 8 weeks 13 see footnote 13 see footnote 13Measles, mumps, rubella 9 12 months 4 weeksVaricella 10 12 months 3 monthsHepatitis A 11 12 months 6 monthsPersons aged 7 through 18 yearsTetanus, diphtheria; tetanus,diphtheria, pertussis 4 7 years 4 4 weeks4 weeks if first dose administered at younger than age 12 months6 months if first dose administered at 12 months or olderHuman papillomavirus 12 9 years Routine dosing intervals are recommended 126 months if first dose administered atyounger than age 12 monthsHepatitis A 11 12 months 6 monthsHepatitis B 1 Birth 4 weeks 8 weeks (and at least 16 weeks after first dose)Inactivated poliovirus 7 6 weeks 4 weeks 4 weeks 7 6 months 7Meningococcal 13 6 weeks 8 weeks 13Measles, mumps, rubella 9 12 months 4 weeksVaricella 1012 months3 months if person is younger than age 13 years4 weeks if person is aged 13 years or olderNOTE: The above recommendations must be read along with the footnotes of this schedule.

Footnotes — Recommended immunization schedule for persons aged 0 through 18 years—United States, 2013For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/pubs/acip-list.htm.1. Hepatitis B (HepB) vaccine. (Minimum age: birth)Routine vaccination:At birth globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) 1 to 2 months aftercompletion of the HepB series, at age 9 through 18 months (preferably at the next well-child visit). possible and, if she is HBsAg-positive, also administer HBIG for infants weighing ≥2,000 grams (no later than age 1 week).Doses following the birth dose age 6 weeks. HepB vaccine series should be administered no earlier than age 24 weeks, and at least 16 weeks after the first dose. the birth dose.Catch-up vaccination: 15 years. 2. Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV-1 [Rotarix] and RV-5 [RotaTeq]).Routine vaccination: 1. If RV-1 is used, administer a 2-dose series at 2 and 4 months of age.2. If RV-5 is used, administer a 3-dose series at ages 2, 4, and 6 months.3. If any dose in series was RV-5 or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should beadministered.Catch-up vaccination: 3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks)Routine vaccination: as early as age 12 months, provided at least 6 months have elapsed since the third dose.Catch-up vaccination: 4. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for Boostrix, 11 years forAdacel).Routine vaccination: regardless of number of years from prior Td or Tdap vaccination.Catch-up vaccination: not be given. (Td) booster doses every 10 years thereafter. or splenic dysfunction); treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkindisease; or solid organ transplantation, congenital immunodeficiency.7. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks)Routine vaccination: on or after the fourth birthday and at least 6 months after the previous dose.Catch-up vaccination: to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak). 8. Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV]; 2 years for live, attenuatedinfluenza vaccine [LAIV])Routine vaccination: 49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including 1) those with asthma,2) children 2 through 4 years who had wheezing in the past 12 months, or 3) those who have any other underlying medical conditionsat http://www.cdc.gov/mmwr/pdf/rr/rr5908.pdf. For children aged 6 months through 8 years: available at http://www.cdc.gov/mmwr/pdf/wk/mm6132.pdf. 9. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)Routine vaccination: may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remainsin an area where disease risk is high), and the second dose at least 4 weeks later. travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later.Catch-up vaccination: weeks.10. Varicella (VAR) vaccine. (Minimum age: 12 months)Routine vaccination: be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered atleast 4 weeks after the first dose, it can be accepted as valid.Catch-up vaccination: http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdfinterval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid);for persons aged 13 years and older, the minimum interval between doses is 4 weeks.11. Hepatitis A vaccine (HepA). (Minimum age: 12 months)Routine vaccination: can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age 11–12 years. 5. Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks)Routine vaccination: 6 months of age; however, if PRP-OMP (PedvaxHib or Comvax) is administered at 2 and 4 months of age, a dose at age 6 months is notindicated. One booster dose should be administered at age 12 through15 months. 1 dose of Hib.Catch-up vaccination: dose should be administered at age 12 through 15 months and at least 8 weeks after the second dose. 12 through 15 months, regardless of Hib vaccine (PRP-T or PRP-OMP) used for first dose. Vaccination of persons with high-risk conditions: to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functionalasplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions.6a. Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks)Routine vaccination: supplemental dose of 13-valent PCV (PCV13).Catch-up vaccination: Vaccination of persons with high-risk conditions: doses of PCV were received previously, or administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV were receivedpreviously. asplenia (including sickle cell disease), HIV infection or an immunocompromising condition, cochlear implant or cerebrospinal fluid leak.See MMWR 2010;59 (No. RR-11), available at http://www.cdc.gov/mmwr/pdf/rr/rr5911.pdf. (see footnotes 6b and 6c).6b. Pneumococcal polysaccharide vaccine (PPSV23). (Minimum age: 2 years)Vaccination of persons with high-risk conditions: (see footnote 6c). A single revaccination with PPSV should be administered after 5 years to children with anatomic or functional asplenia(including sickle cell disease) or an immunocompromising condition.6c. Medical conditions for which PPSV23 is indicated in children aged 2 years and older and for which use of PCV13 isindicated in children aged 24 through 71 months: (including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant. 18 months may be administered if immunity against hepatitis A virus infection is desired.Catch-up vaccination: Special populations: programs target older children, or who are at increased risk for infection.12. Human papillomavirus (HPV) vaccines. (HPV4 [Gardasil] and HPV2 [Cervarix]). (Minimum age: 9 years)Routine vaccination: may be used for females, and only HPV4 may be used for males. first dose and the third dose 6 months after the first dose (at least 24 weeks after thefirst dose).Catch-up vaccination: 13. Meningococcal conjugate vaccines (MCV). (Minimum age: 6 weeks for Hib-MenCY, 9 months for Menactra [MCV4-D], 2years for Menveo [MCV4-CRM]).Routine vaccination: with at least 8 weeks between doses. See MMWR 2011; 60:1018–1019 available at: http://www.cdc.gov/mmwr/pdf/wk/mm6030.pdf. Catch-up vaccination: minimum interval of at least 8 weeks between doses. Vaccination of persons with high-risk conditions: series of Hib-MenCY at 2, 4, 6, and 12-15 months. at 2, 4, 6, and 12 through 15 months or a 2-dose primary series of MCV4-D starting at 9 months, with at least 8 weeks between doses.of Hib-MenCY or MCV4-D, administer 2 primary doses of MCV4-D at least 8 weeks apart. sickle cell disease), who have not received a complete series of Hib-MenCY or MCV4-D, administer 2 primary doses of either MCV4-Dor MCV4-CRM. If MCV4-D (Menactra) is administered to a child with asplenia (including sickle cell disease), do not administer MCV4-Duntil 2 years of age and at least 4 weeks after the completion of all PCV13 doses. See MMWR 2011;60:1391–2, available at http://www.cdc.gov/mmwr/pdf/wk/mm6040.pdf. an age appropriate formulation and series of MCV4 for protection against serogroups A and W-135. Prior receipt of Hib-MenCY is notsufficient for children traveling to the meningitis belt or the Hajj. See MMWR 2011;60:1391–2, available at http://www.cdc.gov/mmwr/pdf/wk/mm6040.pdf. series of Hib-MenCY or MCV4. http://www.cdc.gov/vaccines/pubs/acip-list.htm#mening.Additional information should consult the relevant ACIP statement available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm. months. http://wwwnc.cdc.gov/travel/page/vaccinations.htm. secondary immunodeficiencies,” in General Recommendations on Immunization (ACIP), available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm; and American Academy of Pediatrics. Passive immunization. In: Pickering LK, Baker CJ, Kimberlin DW, Long

Post Natal Depression (PND) Prevention Program GuidelineAdopted: Feb. 2005 Revised: Feb. 2007 Reviewed: June 2011Physician Contact: Dr. Virginia Maxanne Flores, M.D.During the postpartum period, between 30 and 85% of women will experience symptoms of depression. These are usuallylimited to the “baby blues” and can be treated with education and reassurance. However, 13 to 18% of women will developmajor depression. These women require specific treatment for depression.I. ScreeningA. Recommend that all women be routinely assessed during the antenatal period for a history of depression or other mental healthhistory.B. Patients should be screened for the symptoms of depression in the postnatal period as a part of a screening program for PND.II. ManagementA. PND should be managed in the same way as depression at any other time, but with additional considerations regarding the use ofantidepressants when breast-feeding and in pregnancy. (See Scott & White Health Plan (SWHP) Tier 2 Clinical Practice Guideline“Pharmacological Management of Major Depressive Disorder, Non-Psychotic.”)B. Psychosocial interventions should be considered when deciding on treatment options for a mother diagnosed as suffering fromPND.Note: Patients with bipolar or psychotic symptoms should be referred to Psychiatry. Also suicidal patients should be evaluated foradmission, as well as patients who express fears of hurting their baby.III. PrescribingA. Establish a clear indication for drug treatment.B. Use treatments in the lowest effective dose.C. Drugs with a better evidence base (generally more established drugs) are preferable.D. Assess the benefit/risk ratio of the illness and treatment for both mother and baby/fetus, including consideration of:- 2X increased risk of congenital heart defects with paroxetine- 30% risk of neonatal abstinence syndrome after Selective Serotonin Reuptake Inhibitors (SSRI) exposure in latepregnancy- 6X increased risk to neonate of persistent pulmonary hypertension with SSRI exposure after 20 weeksE. The risks of stopping tricyclic or SSRI antidepressant medication should be carefully assessed in relation to the mother’s mentalstate and previous history. There is no indication to stop tricyclic or SSRI antidepressant medication (EXCEPT PAROXETINE) as amatter of routine in early pregnancy.F. There is no clinical indication for women treated with TCA’s, paroxetine, sertraline, or fluoxetine to stop breast feeding, provided theinfant is healthy and its progress monitored. Other modern antidepressants are probably also safe during lactation.Antidepressant Drug information:MedicationRating for use in Adverse effects on breast-fed infantspregnancy *(NA=Information not available)Dosage range (mg per day)+Selective Serotonin reuptakeinhibitors (SSRI)fluoxetine (Prozac) C Gastrointestinal effects, irritability, insomnia 20-40paroxetine (Paxil) D NA 20 to 50sertraline (Zoloft) C None 50-200citalopram (Celexa) C Somnolence, decreased feeding, weight loss 20 to 60escitalopram (Lexapro) C NA 10 to 20Tricyclics (tertiary)amitryptyline (Elavil) C None 75 to 300imipramine (Tofranil) D None 75 to 300Tricyclics (secondary)desipramine (Norpramin) C None 75 to 300nortriptyline (Pamelor) D None 25-150protriptyline (Vivactil) C NA 15-60MiscellaneousBupropion (Wellbutrin) C None 200-450mirtazapine (Remeron) C NA 15 to 45trazodone (Desyrel) C NA 150 to 600venlafaxine (Effexor XR) C NA 75 to 225Duloxetine (Cymbalta) C NA 40-60*--U.S. Food and Drug Administration drug rating for use of drugs in pregnancy: A=No risk in controlled human studies B=no evidence of risk to fetus; C=risk tofetus cannot be ruled out; D=evidence of risk to human fetus; + Adult daily dosages are adapted from AHCPR and women may need lower daily dosages.Guideline based on Recommendations of the Royal College of Physicians, Scotland; US Preventive Health Task Force; and other expert recommendations fromthe American Academy of Family Physicians. Scott and White Physicians from Dept. of Psychiatry, OB-GYN, and Family Medicine participated in thedevelopment and review of this guideline. 2007 reviewed by OB-GYN and Family Medicine physicians of the Scott and White Health Plan Prenatal Team. 2009reviewed by OB-GYN and Family Medicine physicians of the SWHP Prenatal Team, as well as Dept. of Psychiatry, Scott & White Clinics and Health Integrated, Inc.

OB-GYN Postpartum Dictation ReminderDemographics:Name of Primary Care Physician:Chief Complaint:Allergies:Subjective or History of Presenting Illness:Evaluation of Mood: Medications-Past Medical HistoryFamily Medical HistoryObjective:Vital Signs:General:Physical:PelvicCervixAssessmentPlanCourtesy Copy Postpartum Visit note to primary carephysicians that have no access to the electronic record.

Scott & White Health Plan Prenatal / Perinatal Guidelines for Normal PregnancyTier 2 GuidelinePurpose: To recommend prenatal / perinatal management of uncomplicated pregnancyPatient Population: Uncomplicated Pregnancy patientsOriginally Developed / Endorsed by: SWMH Obstetrics Quality Assurance Committee Adopted: Dec. 16, 1998 Contact Physician: Dr. Richard JonesRevised Dates: Feb. 1999; March 1999; Dec. 2000; Feb. 2001; April 2003; Feb. 2005; Feb. 2007; Feb. 2009; Dec. 2011; July 2013 Date to be reviewed: : Dec. : 2015Frequency of visits and care rendered should be determined by a woman’s individual needs and risk factors.SERVICESFIRST TRIMESTER(WEEKS0to13)SECOND TRIMESTER(WEEKS 14 to 28)THIRD TRIMESTER(WEEKS 29 to 42)POSTPARTUM(3 to 8 WEEKS AFTERDELIVERY)ObstetricalEvaluationsAn initial evaluation should be performedprior to 13 weeks including:- Comprehensive health history, includingprevious history of depression and/orpostpartum depression*- Family & Social history- Pregnancy history- Genetics screening and counseling abouttesting options, including information aboutoptional aneuploidy, cystic fibrosis, andhemoglobinopathy screening- Physical exam, including height, weight, &blood pressure- Ultrasonography to confirm or establishgestational dating if indicated- Screening for gestational diabetes if patientis at high risk (and repeat late 2 nd TM ifnegative during first TM)- advise ideal weight gain in pregnancy forpatient’s BMI- Psychosocial screening- Tobacco cessation mgmt plan if indicated-Between 16 to 19 weeks:Ultrasonography (if clinically indicated)-Between 15 to 18 weeks: performmaternal serum screening for aneuploidyand/or neural tube defect if desired.-Between 24 to 28 weeks: glucosetolerance screening (unless no riskfactors), and hematocrit.-At 28 weeks: If patient is Rh negativeand unsensitized, and Rh of baby’s fatheris positive or unknown, repeat antibodytesting and administer Rhogam. Testingurine at 28 weeks or as needed.At 35-37 weeks gestational age: vaginalculture for Group B streptococcus andHIV test.Administer Tdap vaccine during 3 rd TM(regardless of patient’s priorvaccination history).-Lab work to be obtained and reviewed by early second trimester: urine culture,hemogram, platelets (optional), blood type & Rh, antibody screen, hepatitis B surfaceantigen, rubella titer, syphilis screening, cervical cytology, hemoglobinopathy screening (ifindicated), gonorrhea & chlamydia screening (unless considered extremely low risk), andHIV testing (offered with counseling & explanation of possible consequences and benefits)-Multiparous patients do not require repeat rubella titer if previously documented asimmune, or repeat blood type & Rh.Routine OfficeVisitsEvery 4 to 6 weeks: Blood pressure, weight, screen for significant edema, fundal height,documentation of fetal heart activity (after approximately 10 weeks), and urine dipstick foralbumin and glucose.All women who will be pregnant during the influenza season (Oct – May) should bevaccinated, regardless of trimester.Every 2 to 4 weeks until 36 weeksgestation, then weekly until delivery:-Blood pressure, weight, screen forsignificant edema, fundal height,documentation of fetal heart activityand fetal presentation, urine dipstick forFollow-up on or between 21and 56 days after delivery:-Evaluation of weight, bloodpressure, breasts, abdomen andapelvicexam.-Screening for postpartum

Patient EducationInformationPresentedRegarding:-Nutrition, exercise, sexual activity, workactivity-Tobacco, alcohol, and drug restriction-Postpartum Depression-Preparation for childbirth (Refer toclasses)-Vaginal Birth After Cesarean(if indicated by patient’s history)-Breast feeding versus bottle-feeding-Family Planning*See also the Post Natal Depression Prevention Program GuidelineResources: Schedule is based on recommendations from: American College of Obstetricians and Gynecologists (ACOG)albumin and glucose-Breast feeding-Onset of labor, rupture ofmembranes, abnormal bleeding-Fetal activitydepression.*-Review Family Planning-Nutrition and exerciseanticipatory guidance

Colorectal Cancer ScreeningTier 2 GuidelinePurpose: To delineate screening for colorectal cancer.Patient Population:1. Low Risk – Age < 50 or > 83 with no major co-morbidities, risk factors, non-operative candidate, orlife expectancy < 3 years.2. Average Risk – Age 50 to 80 with no risk factors.3. High Risk - First degree relative < 70 with colon cancer, first degree relative < 60 with polyps, two firstdegree relatives with polyps and/or colon cancer, familial multiple cancer syndrome, or longstandinginflammatory bowel disease.Developed by: Physicians representative of the S&W Departments: Gastroenterology, Family Medicine,Internal Medicine and Surgery .Source: American Cancer Society, American College of Gastroenterology (ACG); AmericanGastroenterological Association (AGA) and the American Society of GastrointestinalEndoscopy (ASGE).Contact Person: Dr Andrejs Avots-Avotins (Department of Medicine, Division of Gastroenterology).SWHP Quality Improvement Committee Approved: June 1999.Date of Last Review: June 2004, August 2004, August 2006, August 2008, August 2010, andAugust 2012Scheduled Review Date: August 2016INITIATION OF SCREENING AND SUBSEQUENT SURVEILLANCE EXAMS INPATIENTS WITH INCREASED RISKFirst degree relative with polyps < age 60 or colon cancer < age 70Colonoscopy at age 50 or 10 years younger than the youngest affected family member,whichever is earlier. Colonoscopy to be performed at 5 year intervals.Hereditary Non-Polyposis Colorectal Cancer Syndrome - HNPCCColonoscopy beginning at age 25 or 5 years younger than the age at diagnosis of the youngest affectedrelative, whichever is earlier. Colonoscopy to be performed every 2 years and then annually after age 40.Genetic testing available.Familial Adenomatous Polyposis - FAPAnnual sigmoidoscopy beginning at age 10-12 years with colectomy when polyps identified.After age 40 sigmoidoscopy every 3-5 yrs if polyps have not been identified. Genetic testingavailable.Pancolonic inflammatory bowel diseaseSurveillance begins after 10 years of disease duration with colonoscopy every 2 years with systematicbiopsies to detect dysplasia.Left sided or segmental colitisSurveillance begins after 15 years of disease duration with colonoscopy every 2 years with systematicbiopsies to detect dysplasia.Page 1 of 2

NO SCREENING• Age < 50 & norisk factors• Age > 80 with moderateof severe co-morbidities orage 83-86 with no majorco-morbidities•Non-operativecandidate• Life expectancy < 3yrsNOTEPatients with fe def anemiaor patients with NON-analoutlet bleedingbe referred for GIconsultationColorectal Cancer ScreeningAVERAGE RISK• Age >50 & no risk factorsColonoscopy q 10 yrorFlex Sig and BE q 5 yror**FIT q 1 yr + Flex Sig q 5yrorFlex Sig q 5 yror**FIT q 1 yr(**Fecal Immunochemical Testing(FIT)3 card specimen)Significant Findings:Polyp > 0.5cmor ANY + FOBTColorectal Cancer SurveillanceHIGH RISK• 1 st degree relative < 70 withcolon cancer• 1 st Degree Relative < 60 with polyps• Two 1 st degree relatives with polypsand/or colon cancer• Familial multiple cancer syndrome• Longstanding inflammatory boweldiseaseComplete Colon ExamColonoscopy beginning at age 50or 10 yr younger than the youngestaffected family memberOR FORLongstanding inflammatory bowel disease-Colonoscopy beginning 10 yr after diseaseonsetLOW RISKNo polyps or hyperplasticrectosigmoid polyps on lastsurveillance colonoscopyNO Screening for 5 yr thenAVERAGE RISK - usually 10year follow-up unlessother risk factors presentINCREASED RISK• High risk family history of colon cancer or polyps withpreviously negative colonoscopy > 4 years ago• Multiple polyps (3 or more regardless of size)• Polyp > 1cm• CA in situ or low risk Duke’s A cancer in pedunculated polyp• Hx of colon cancer (assuming negative colonoscopy within12 mo of cancer resection)• Serrated adenoma of any siteCOLONOSCOPY warranted: Interval from lastcolonoscopybe determined by endoscopist (usually 1-5 years)References: Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the USMulti-Society Task Force on Colorectal Cancer Gastroenterology 2012;143-844-857. And - Colorectal Cancer Screening BeConsidered in Elderly Persons without Previous Screening? A Cost Effectiveness Analysis Annals Int Med 2014-160 (11):750-759 - possibly with hyperlinks.Page 2 of 2

CLINICAL PRACTICE GUIDELINES FOR COLORECTAL CANCER SCREENINGScott and White Health Plan (SWHP) has adopted American Cancer Society Guidelines for the EarlyDetection of Cancer located at the following internet website link:http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.aspandAmerican Society for Gastrointestinal Endoscopy (ASGE) guideline: colorectal cancer screening andsurveillance, Gastrointestinal Endoscopy Volume 63, No. 4 ; 2006 located at the following internetwebsite link:http://www.asge.org/WorkArea/showcontent.aspx?id=3334andAmerican College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008 locatedat the following internet website link:http://www.acg.gi.org/physicians/pdfs/CCSJournalPublicationFebruary2009.pdfSWHP Guideline Approval Body: SWHP Quality Improvement SubcommitteeDate of Adoption: August 10, 2010Physician Sponsor:Dr. Andrejs Avots-Avotins, M.D., Scott & White HealthcareDepartment of Medicine, Division of Gastroenterology.Board Certification American Board of Internal Medicine, (ABIM) andGastroenterology, (ABIM)

Disease Management ProgramsAsthma:Secondary Preventative Coronary Artery Disease:Two Months After Event: Four Months After Event:

Yearly And As needed: Diabetes and Congestive Heart Failure:

POLICY / PROCEDUREStandards for Timely Primary Care AccessTOPIC: Accessibility of ServicesCATEGORY: Quality ImprovementI. POLICY:Policy Number: QI 5.AOriginal Effective Date: October 1996 (100.2)Review w/o revision dates: 10/96; 12/99; 4/03, 2/06; 2/08; 9/10Revision Dates: 12/96; 2/97; 9/00Scope:Cross Reference:Originated by:Approved by:Health PlanNCQA QI 5A, TDI (28 TAC§11.1606), CMS (42 CFR§417.106)Quality Improvement(QIS Chairman) Level of CareStandard Preventive Primary Care Routine Primary Care () Urgent Primary Care () Emergency Care After-Hours Care fterhour

POLICY / PROCEDUREStandards for Timely Behavioral HealthAccess and Behavioral Health TelephoneAccessPolicy Number: QI 5.3Original Effective Date: 04/00/02Review w/o revision dates: 4/03, 2/06, 2/08, 12/10Revision Dates: 9/03Scope:Cross Reference:Originated by:Scott & White Health PlanNCQA Standard QI5, TDI (28TAC §1607), CMS (42 CFR§417.106)QI DivisionTOPIC: Accessibility of ServicesCATEGORY: Quality ImprovementApproved by:(QIS Chairman)I. POLICY:A. SWHPhasestablishedthefollowingstandardsfortimelyaccessibilityofbehavioralandmentalhealthcareservices:Routineofficevisitappointments 10workingdaysUrgentcare 24hours‡Nonlifethreateningemergencycare 6hours‡Lifethreateningemergencycare Immediately‡‡SWHPmembershavedirectaccesstoBehavioralHealthPractitionersbycallingtheirofficeorgoingtotheEmergencyRoom.B. TelephoneAccess:Nocentralizedscreeningortriageisused.