Clinical Practice Guidelines

General Statement on UPMC Health Plan’s Clinical Practice Guidelines: UPMC Health Plan develops or adopts clinical practice guidelines that support the practice of evidence-based medicine. Adopted guidelines are from nationally recognized sources and are reviewed annually or more frequently, as needed. They are intended as reference guides to assist physicians and non-physician providers in the diagnosis and management of selected conditions. These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations.

See additional member resources below.*

In addition to this webpage, providers receive notification of new or updated guidelines in the Provider Partner Update (PPU).

For further assistance, call Provider Services at 1-866-918-1595.

Guideline Limitations:

• Guidelines may not apply to every patient or clinical situation; some variation from guidelines is expected. Provider judgment and knowledge of an individual patient supersedes clinical guidelines.
• Guidelines do not determine insurance coverage of health care services or products. Coverage decisions are based on member eligibility, contractual benefits, and determination of medical necessity.

Pediatric Preventive Guidelines:

Approved June 2019

Children and Adolescents' Access to Primary Care Practitioners HEDIS®

The percentage of members 12 months-19 years of age who had a visit with a PCP. Four rates are reported:

• Children 12-24 months and 25 months-6 years who had a visit with a PCP during the measurement year.
• Children 7-11 years and adolescents 12-19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year.

Nationally Recognized Source

Recommendations for Preventive Pediatric Health Care – Bright Futures/American Academy of Pediatrics
Copyright 2019 by the American Academy of Pediatrics, updated March 2019

Adult Diabetes:

Approved June 2019

Adults Diabetes Management

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Comprehensive Diabetes Care HEDIS®

• Screening or monitoring for diabetic retinal eye disease with a dilated retinal eye exam in the measurement year
• Screening or monitoring for diabetic nephropathy in the measurement year
• Measurement of HbA1c during the measurement year
• Screening for blood pressure control during the measurement year

Nationally Recognized Source

American Diabetes Association Guideline for the Diagnosis and Management of Diabetes

Depression:

Approved June 2019

Managing Adults with Depression in the Primary Care Setting

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Antidepressant Medication Management HEDIS®

The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates reported:

• Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks)
• Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months)

Nationally Recognized Source

Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder: A Clinical Practice Guideline from the American College of Physicians

ADHD:

Approved June 2019

Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention-Deficit Disorder in Children and Adolescents in the Primary Care Setting

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Follow-Up Care for Children Prescribed ADHD Medication HEDIS®

The percentage of children newly prescribed attention-deficit/hyperactivity disorder medication (ADHD) who had at least three follow-up visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates reported:

• Initiation Phase: The percentage of members 6-12 years of age with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.
• Continuation and Maintenance Phase: The percentage of members 6-12 years of age with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

Nationally Recognized Sources

ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Clinical Practice Guideline from the American Academy of Pediatrics

Substance Abuse:

Approved June 2019

Treatment of Adults (18 years and older) with Substance Abuse Disorders in the Primary Care Setting

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment HEDIS®

The percentage of adult members (age 18+) with a new episode of alcohol or other drug (AOD) dependence who received the following:

• Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis.
• Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit.

Nationally Recognized Source

Unhealthy Alcohol and Drug Use: Adult, Primary Care, Clinical Practice Guideline

Anxiety:

Approved June 2019

Treatment of Adults (18 years and older) with General Anxiety Disorder (GAD) in the Primary Care Setting

Nationally Recognized Source

American Academy of Family Physicians: Anxiety Disorders

Asthma:

Approved June 2019

Management of all members with asthma

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Medication Management for People with Asthma HEDIS®

The percentage of members 5-64 years of age who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates reported:

• The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
• The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.

Asthma Medication Ratio HEDIS®

The percentage of members 5-64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater

Nationally Recognized Source

2018 GINA Report, Global Strategy for Asthma Management and Prevention

Cardiovascular Risk Factors and Coronary Artery Disease:

Approved June 2019

Recommendations for all adult members without known Coronary Heart Disease (CHD) whose symptoms suggest chronic stable angina, members with known stable angina, asymptomatic members with evidence suggesting CHD on previous testing or with risk factors that predispose them to CHD and those who have had a past MI or coronary artery revascularization procedure

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Statin Therapy for Patients with Cardiovascular Disease HEDIS®

The percentage of males 21-75 years of age and females 40-75 years of age who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria:

• Received Statin Therapy: Members who were dispensed at least one high or moderate-intensity statin medication
• Statin Adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period

Persistence of Beta-Blocker Treatment After a Heart Attack HEDIS®

The percentage of members 18 years of age and older who were hospitalized and discharged with a diagnosis of Acute Myocardial Infarction (AMI) who received persistent beta-blocker treatment for six months after discharge.

Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia HEDIS®

The percentage of members 18-64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test.

Nationally Recognized Sources

AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update A Guideline from the American Heart Association and American College of Cardiology Foundation

2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

COPD:

Approved June 2019

Management of adult members with stable COPD and acute exacerbations of COPD

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Use of Spirometry Testing in the Assessment and Diagnosis of COPD HEDIS®

The percentage of members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis

Pharmacotherapy Management of COPD Exacerbation HEDIS®

The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED visit during the measurement year and who were dispensed appropriate medications. Two rates reported:

• Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event
• Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event

Nationally Recognized Source

The Global Initiative for Chronic Obstructive Lung Disease (GOLD)

Hypertension Management:

Approved June 2019

Management of all members ages 18-85 with hypertension

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Controlling High Blood Pressure HEDIS®

The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mmHg) during the measurement year

Nationally Recognized Sources

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

JNC 8 Guidelines for the Management of Hypertension in Adults

Prenatal Clinical Practice Guidelines:

Approved June 2019

Care provided throughout the course of an entire pregnancy with the goal of preventing and/or minimizing complications as well as decreasing the incidence of maternal and perinatal mortality

Quality Performance Indicators

(Clinical Indicators Measured by UPMC Health Plan via HEDIS)

Prenatal and Postpartum Care HEDIS®

The percentage of deliveries of live births assessing the following facets of prenatal and postpartum care

• Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit in the 1st trimester, on the enrollment start date or within 42 days of enrollment
• Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery

Nationally Recognized Sources

U.S. Preventive Services Task Force

American Congress of Obstetricians and Gynecologists (ACOG)

Adult Cholesterol Management:

Approved June 2019

Statin Therapy for Patients with Cardiovascular Disease HEDIS®

The percentage of males ages 21-75 and females ages 40-75 who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. Two rates are reported:

• Received Statin Therapy. Members who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year.
• Statin Adherence 80%. Members who remained on a high-intensity or moderate-intensity statin medication of any intensity for at least 80% of the treatment period.

Nationally Recognized Source

Report of the American College of Cardiology/American Heart Association Task Force: 2018 Guideline on the Management of Blood Cholesterol

Heart Failure Guidelines:

Approved June 2019

Persistence of Beta-Blocker treatment After a Heart Attack HEDIS®

The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.

Controlling High Blood Pressure HEDIS®

The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mm Hg) during the measurement year.

Nationally Recognized Sources

JACC: 2017 The American College of Cardiology / American Heart Association/Heart Failure Society of America Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

2013 ACCF/AHA Guideline for the Management of Heart Failure

Adult Preventive Guidelines:

Approved June 2019

Adults' Access to Preventive/Ambulatory Health Services HEDIS®

The percentage of members 20 years and older who had an ambulatory or preventive care visit. Three rates are reported:

• Medicaid and Medicare members who has an ambulatory or preventive care visit during the measurement year.
• Commercial members who has an ambulatory or preventive care visit during the measurement year or two years prior to the measurement year.

Nationally Recognized Source

Adult Preventive Health Care Schedule: Recommendations from the USPSTF (as of June 1, 2018) – aafp.org

Opioid Use:

Approved September 2019

Adult Opioid Prescription Management

Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS®)

Use of Opioids at High Dosage (HDO) HEDIS®

Members 18 years old and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose (MME ≥ 90) for ≥ 15 days during the measurement year.

Use of Opioids from Multiple Providers (UOP) HEDIS®

Members 18 years old and older, receiving prescription opioids for ≥15 days during the measurement year who receive opioids from multiple providers. Three rates are reported:

• Multiple prescribers: The proportion of members receiving prescriptions for opioids from four or more different prescribers during the measurement year
• Multiple pharmacies: The proportion of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
• Multiple prescribers and multiple pharmacies The proportion of members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.

Nationally Recognized Sources

CDC Guideline for Prescribing Opioids for Chronic Pain (Updated 8/28/2019)
PA Opioid Prescribing Guidelines

PA Opioid Prescribing Guidelines

*Additional Resources for UPMC Health Plan Members

• UPMC MyHealth 24/7 Nurse Line is staffed by experienced registered nurses and is available 24/7 to provide telephone support to members. Call 1-866-918-1591. TTY users should call 711.
• Health coach Programs provide intensive case management for members with specific chronic illnesses or conditions. The programs are built upon best practices and accepted clinical guidelines and include:
  • Diabetes
  • Respiratory
  • Asthma
  • COPD
  • Behavioral health
  • Depression
  • Cardiovascular
  • Heart failure
  • Coronary artery disease
  • Hypertension
  • Hyperlipidemia

Members and providers can get additional health coaching program information by calling 1-866-778-6073.

UPMC Prescription for Wellness is a physician-prescribed, EMR-integrated and practice-supported health coaching program to support you, your office staff, and—most importantly—your patients and their family. Our programs extend your influence between office visits by helping your patients stay with the care plans you create for them. You simply “prescribe” healthier behaviors, common disease management skills, or decision making skills with a UPMC Health Plan health coach by “writing” a Prescription for Wellness that is placed along with all other orders at the time of the visit. Instruct the patient to read the printed prescription and call in immediately to talk to a coach. Providers can write a Prescription for Wellness in EpicCare or through Provider OnLine. You may select from the following list of health management programs and write in any concerns to be addressed. The order automatically generates a referral to the Health Plan with the referral information. If we don’t hear from your patient in 48 hours, we call the patient to get them started on their way to better health and care. Within 30 days you receive a follow-up note on your patient’s progress in EpicCare or Provider OnLine. Patients are much more likely to complete a program if their doctor “prescribes” healthy behaviors and self-management. Engagement rates in health coaching programs through Prescription for Wellness are two to 10 times greater compared to other referral routes.

Health Management Programs

• Physical health conditions
  • Respiratory health
    • Asthma (for adults and parents/caregivers)
    • COPD
  • Cardiovascular health
    • Heart failure
    • Coronary artery disease
    • Hypertension
    • Hyperlipidemia
    • A-fib
    • Post MI/CABG
  • Diabetes (for adults and parents/caregivers)
    • Low back pain
    • Chronic kidney disease
    • ESRD
• Behavioral health
  • ADHD (for parents and caregivers)
  • Anxiety
  • Depression
  • Substance use
  • High-risk behavioral health
  • Beating the Blues US®
• Lifestyle coaching
  • Weight management
  • Physical activity
  • Nutrition basics
  • Stress management
  • Tobacco cessation
• Rare and chronic conditions
  • Rheumatoid arthritis
  • Parkinson’s disease
  • Sickle cell anemia
  • Hemophilia
  • Epilepsy
  • Multiple sclerosis
  • Inflammatory bowel disease
  • Hepatitis C
• Care management (CM)
  • Adult
  • Maternity
  • Pediatrics
  • Start SMART Program (Seizure management awareness and recognition)

For additional information:

• Providers can call 1-855-772-8762 or email healthplansparef@upmc.edu.
• Members can call 1-866-778-6073.

Online interactive preventive health programs and resources are available in partnership with WebMD at www.upmchealthplan.com.

• MyHealth Ready to Quit®
• MyHealth Step Up to Wellness®
• MyHealth Eating Well
• MyHealth Weigh to Wellness®
• MyHealth Less Stress
• Emotional health program