Clinical Practice Guidelines
ADHD:
Approved September 2024
Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention-Deficit Disorder in Children and Adolescents in the Primary Care Setting
Follow-Up Care for Children Prescribed ADHD Medication (ADD) HEDIS®
The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up visits within a 300-day (10-month) period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported:
- Initiation Phase: The percentage of members 6–12 years old with a 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 old with a 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
Clinical Practice Guideline from the American Academy of Pediatrics
AAFP: ADHD in Children and Adolescents
CDC: Clinical Care of ADHD
ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Update to American Academy of Pediatrics article
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (aappublications.org)
Wolraich ML, Hagan JF, Allan C, et al; Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528 (aappublications.org)
Anxiety:
Approved September 2024
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
AAFP – Anxiety Disorders
AAFP – Benzodiazepines for Panic Disorder in Adults
Generalized Anxiety Disorder (fpnotebook.com)
Generalized Anxiety Disorder – StatPearls – NCBI Bookshelf (nih.gov)
Anxiety:
Approved September 2024
Treatment of Children and Adolescents with Anxiety Disorders
Nationally Recognized Sources
Journal of the American Academy of Child & Adolescent Psychiatry
Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders
AAFP – Anxiety Disorders in Children and Adolescents
Topic | AAFP
Depression:
Approved September 2024
Managing Adults with Depression in the Primary Care Setting
Antidepressant Medication Management (AMM) 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 Sources
Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder: A Clinical Practice Guideline from the American College of Physicians
Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder: A Clinical Practice Guideline from the American College of Physicians
VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder
VA/DoD Major Depressive Disorder CPG Clinician Summary
Depression:
Approved September 2024
Managing Depression in Children and Adolescents less than 18 years old in Primary Care Setting
Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) HEDIS®
The percentage of members 12 years of age and older who were screened for clinical depression using a standardize instrument and, if screened positive, received follow-up care.
- Depression Screening. The percentage of members who were screened for clinical depression using a standardized instrument.
- Follow-Up on Positive Screen. The percentage of members who received follow-up care within 30 days of a positive depression screen finding.
Depression Remission or Response for Adolescent and Adults (DRR-E) HEDIS®
The percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission 120-240 days (4-8 months) of the elevated score
- Follow-up PHQ-9. The percentage of members who have a follow-up PHQ-0 score documented within 120-240 days (4-8 months) after the initial elevated PHQ-0 score.
- Depression remission. The percentage of members who achieved remission within 120-240 days (4-8 months) after the initial elevated PHQ-9 score.
- Depression response. The percentage of members who showed response within 120-240 days (4-8 months) after the initial elevated PHQ-9 score.
Nationally Recognized Source
American Academy of Pediatrics
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management (aap.org)
Depression in children and adolescents in primary care – Cheung – Pediatric Medicine (amegroups.com)
Opioid Use:
Approved September 2024
Use of Opioids at High Dosage (HDO) HEDIS®
The percentage of members 18 years of age and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose (MME) ≥ 90) for ≥ 15 days during the measurement year. Note: A lower rate indicates better performance.
Use of Opioids from Multiple Providers (UOP) HEDIS®
The percentage of members 18 years of age and older, receiving prescription opioids for ≥15 days during the measurement year, who received opioids from multiple providers. Three rates are reported:
- Multiple prescribers: The percentage of members receiving prescriptions for opioids from four or more different prescribers during the measurement year
- Multiple pharmacies: The percentage of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
- Multiple prescribers and multiple pharmacies The percentage of members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year
Risk of Continued Opioid Use (COU) HEDIS®
The percentage of members 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:
- The percentage of members with at least 15 days of prescription opioids in a 30-day period
- The percentage of members with at least 31 days of prescription opioids in a 62-day period
Note: A lower rate indicates better performance.
Nationally Recognized Sources
CDC Guideline for Prescribing Opioids for Pain (updated 11/04/2022)
CDC Opioid Prescribing Guideline
PA Opioid Prescribing Guidelines
PA Department of Health Opioid Prescribing Guidelines
Pain Management Best Practices Inter-Agency Task Force Report (U.S. Department of Health and Human Services)
Pain Management Best Practices Inter-Agency Task Force Report (HHS.gov)
Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists (Journal of Addiction Medicine)
Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists (journals.lww.com)
Substance Abuse:
Approved September 2024
Treatment of Adults (18 years old and older) with Substance Abuse Disorders in the Primary Care Setting
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET) HEDIS®
The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported:
- Initiation of SUD treatment. The percentage of new SUD episodes that result in treatment initiation through an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth or medication treatment within 14 days.
- Engagement of SUD treatment. The percentage of new SUD episodes that have evidence of treatment engagement within 34 days of initiation.
Nationally Recognized Sources
Unhealthy Alcohol and Drug Use: Adult, Primary Care, Clinical Practice Guideline
Unhealthy Alcohol and Drug Use: Adult, Primary Care, Clinical Practice Guideline (dartmouth-hitchcock.org)
Screening for Substance Use in the Family Medicine/Obstetrics Setting (National Institute on Drug Abuse)
Screening for Substance Use in the Family Medicine/Obstetrics SettingThe American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder
psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder (psychiatryonline.org)
Treating Concurrent Substance Use Among Adults (SAMHSA)
Treating Concurrent Substance Use Among Adults (samhsa.gov)
Adult Cholesterol Management:
Approved September 2024
Statin Therapy for Patients with Cardiovascular Disease (SPC) 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. 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 for at least 80% of the treatment period
Nationally Recognized Sources
Report of the American College of Cardiology/American Heart Association Task Force: 2018 Guideline on the Management of Blood Cholesterol
Guidelines Made Simple Tool – 2018 (acc.org) Cholesterol Management Guide for Health Care Practitioners (heart.org)American Academy of Family Physicians (AAFP)
Cholesterol – Clinical Practice Guideline (AAFP)
Adult Diabetes:
Approved September 2024
Adult Diabetes Management
Glycemic Status Assessment for Patients with Diabetes (GSD) HEDIS®
The percentage of members 18-75 years of age with diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) was at the following levels during the measurement year:
- Glycemic status <8.0%
- Glycemic status >9.0%
Blood Pressure Control for Patients with Diabetes (BPD) HEDIS®
The percentage of members 18-75 years of age with diabetes (types 1 and 2) whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year
Eye Exam for Patients with Diabetes (EED) HEDIS®
The percentage of members 18-75 years of age with diabetes (types 1 and 2) who had a retinal eye exam
Kidney Health Evaluation for Patients with Diabetes (KED) HEDIS®
The percentage of members 18-85 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatine ratio (uACR), during the measurement year
Nationally Recognized Sources
American Diabetes Association Guideline for the Diagnosis and Management of Diabetes
Summary of Revisions: Standards of Care in Diabetes—2024 | Diabetes Care | American Diabetes Association (diabetesjournals.org)
Volume 42 Issue 2 | Clinical Diabetes | American Diabetes Association (diabetesjournals.org)
Asthma:
Approved September 2024
Management of all members with asthma
Asthma Medication Ratio (AMR) 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 during the measurement year
Nationally Recognized Source
2024 GINA Report, Global Strategy for Asthma Management and Prevention
Cardiovascular Risk Factors and Coronary Artery Disease:
Approved September 2024
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
Statin Therapy for Patients with Cardiovascular Disease (SPC) HEDIS®
The percentage of males 21-75 years of age and females 40-75 years of age during the measurement year 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 during the measurement year
- 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 (PBH) HEDIS®
The percentage of members 18 years of age and older 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 (SMC) HEDIS®
The percentage of members 18-64 years of age with schizophrenia or schizoaffective disorder and cardiovascular disease, who had an LDL-C test during the measurement year
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
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update (ahajournals.org)
2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk
2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (ahajournals.org)
2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk (ahajournals.org) [wrong link in Word doc]
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (ahajournals.org)
COPD:
Approved September 2024
Management of adult members with stable COPD and acute exacerbations of COPD
Pharmacotherapy Management of COPD Exacerbation (PCE) HEDIS®
The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED visit on or between Jan. 1 and Nov. 30 of the measurement year and who were dispensed appropriate medications. Two rates are 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 Sources
The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease
AAFP COPD: Clinical Guidance
COPD: Clinical Guidance and Practice Resources
Heart Failure Guidelines:
Approved September 2024
Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) 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 the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for 180 days (six months) after discharge
Controlling High Blood Pressure (CBP) HEDIS®
The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year
Nationally Recognized Sources
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines (ahajournals.org)
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (ahajournals.org)
Hypertension Management:
Approved September 2024
Management of all members ages 18-85 with hypertension
Controlling High Blood Pressure (CBP) HEDIS®
The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement year
Nationally Recognized Sources
Journal of the American College of Cardiology
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 (jacc.org)American College of Cardiology
Older Adults and Hypertension: Beyond the 2017 Guideline for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults – American College of Cardiology (acc.org)
Lung Cancer Screening:
Approved September 2024
Medical Assistance With Smoking and Tobacco Use Cessation (MSC) HEDIS®
The following components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation:
- Advising Smokers and Tobacco Users to Quit – A rolling average represents the percentage of members 18 years of age and older who were current smokers or tobacco users and who received advice to quit during the measurement year
- Discussing Cessation Medications – A rolling average represents the percentage of members 18 years of age and older who were current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year
- Discussing Cessation Strategies – A rolling average represents the percentage of members 18 years of age and older who were current smokers or tobacco users and who discussed or were provided cessation methods or strategies during the measurement year
Nationally Recognized Sources
United States Preventive Service Task Force (USPSTF)
Recommendation: Lung Cancer: Screening (uspreventiveservicestaskforce.org) Recommendation: Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions (uspreventiveservicestaskforce.org)
National Cancer Institute (NCI)
Lung Cancer Screening (PDQ®) – NCAmerican College of Radiology (ACR)
acr.org/-/media/ACR/Files/RADS/Lung-RADS/Lung-RADS-2022.pdfAdult Preventive Guidelines:
Approved September 2024
Adults' Access to Preventive/Ambulatory Health Services (AAP) HEDIS®
The percentage of members 20 years of age and older who had an ambulatory or preventive care visit. The organization reports three separate percentages for each product line:
- Medicaid and Medicare members who had an ambulatory or preventive care visit during the measurement year
- Commercial members who had an ambulatory or preventive care visit during the measurement year or the two years prior to the measurement year
Nationally Recognized Source
Adult Preventive Health Care Schedule: Recommendations from the USPSTF USPSTF Health care Schedule 2023 (aafp.org) A and B Recommendations – United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
Prenatal Clinical Practice Guidelines:
Approved September 2024
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
Prenatal and Postpartum Care (PPC) HEDIS®
The percentage of deliveries of live births on or between Oct. 8 of the year prior to the measurement year and Oct. 7 of the measurement year. For these members, the measure assesses the following facets of prenatal and postpartum care:
- Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit in the first trimester on or before the enrollment start date or within 42 days of enrollment in the organization
- 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
Guidelines for Perinatal Care (acog.org)
Clinical Search Results – ACOG
Pediatric Preventive Guidelines:
Approved September 2024
The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:
- Well-Child Visits in the First 15 Months. Children who turned 15 months old during the measurement year: Six or more well-child visits
- Well-Child Visits for Age 15 Months–30 Months. Children who turned 30 months old during the measurement year: Two or more well-child visits
Child and Adolescent Well-Care Visits (WCV) HEDIS®
The percentage of members 3–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year
Nationally Recognized Sources
Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule) – June 2024
Periodicity Schedule (aap.org)
2024 Recommendations for Preventive Pediatric Health Care
2024 Recommendations for Preventive Pediatric Health Care: Policy Statement | Pediatrics | American Academy of Pediatrics (aap.org)**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.
Learn More About Prescription for WellnessHealth 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
- Respiratory health
- Behavioral health
- ADHD (for parents and caregivers)
- Anxiety
- Depression
- Substance use
- High-risk behavioral health
- 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