Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis

Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA) - convened Physician Consortium for Performance Improvement(R) (PCPI[R]) and the National Committee for Quality Assurance (NCQA). 

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Although advances in the management of HIV and AIDS diseases have been made, Pneumocystis carinii pneumonia (PCP) remains an important complication and cause of morbidity.  Without PCP prophylaxis, patients with HIV/AIDS are at increased risk of developing PCP, especially when CD4 cell counts fall 200mm3-250mm3 (Kaplan, 1998; Phair, 1990).  PCP prophylaxis is very effective and has been demonstrated to prolong life.   

Data from Kaiser Permanente suggests that a gap exists between what is recommended for patients with HIV infection, and what is actually performed.  According to 2005-2006 data from Kaiser Permanente California (both Northern and Southern), Georgia, and Oregon, only 71% of HIV-infected persons with a CD4<200mm3 received PCP prophylaxis (personal communication, 2007).

HIV-infected adults and adolescents, including pregnant women and those on HAART, should receive chemoprophylaxis against PCP if they have a CD4+T lymphocyte count of <200/mL or a history of oropharyngeal candidiasis. (USPH/IDSA, 2002)

A higher score indicates better quality

Kaplan JE, Hanson DL, Navin TR, Jones JL. Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus--infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis. The Journal of Infectious Diseases. 1998;178:1126-32.

Personal communication. Michael Horberg, MD, Director, HIV/AIDS Policy, Quality Improvement, Research, The Permanente Federation. 2007 Nov 6.

Phair J, Munoz A, Detels R, Kaslow R, Rinaldo C, Saah A. The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Multicenter AIDS Cohort Study Group. NEJM. 1990 Jan 18;322:161-65.

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Denominator 1: The CD4 count below 200 cells/mm3 must occur during the first nine months of the year.

Denominator 2: The CD4 count below 500 cells/mm3 or the CD4 percentage below 15% must occur during the first nine months of the year.

Once all denominators and numerators are calculated, a total rate should be calculated using the sum of the three denominators and the sum of the three numerators.

TBD

Denominator 1: All patients aged 6 years and older with a diagnosis of HIV/AIDS and a CD4 count below 200 cells/mm3 who had at least two visits during the measurement year, with at least 90 days in between each visit

Denominator 2: All patients aged 1-5 years of age with a diagnosis of HIV/AIDS and a CD4 count below 500 cells/mm3 or a CD4 percentage below 15% who had at least two visits during the measurement year, with at least 90 days in between each visit

Denominator 3: All patients aged 6 weeks to 12 months with a diagnosis of HIV who had at least two visits during the measurement year, with at least 90 days in between each visit

Equals Initial Patient Population

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Numerator 1: Patients who were prescribed pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 200 cells/mm3

Numerator 2: Patients who were prescribed pneumocystic jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 500 cells/ mm3 or a CD4 percentage below 15%

Numerator 3: Patients who were prescribed Pneumocystic jiroveci pneumonia (PCP) prophylaxis at the time of diagnosis of HIV

Not Applicable

Numerator 1: Patient did not receive PCP prophylaxis because there was a CD4 count above 200 cells/mm3 during the three months after a CD4 count below 200 cells/mm3 

Numerator 2: Patient did not receive PCP prophylaxis because there was a CD4 count above 500 cells/mm3 or CD4 percentage above 15% during the three months after a CD4 count below 500 cells/mm3 or CD4 percentage below 15% 

Numerator 3: None

Not Applicable

Not Applicable

For every patient evaluated by this measure also identify payer, race, ethnicity, and sex.

      ------ Population Criteria 1 ------

• Initial Patient Population 1 =
  • AND: "Patient Characteristic Birthdate: birth date" >= 6 year(s) starts before start of "Measurement Period"
  • AND: "Diagnosis, Active: HIV" starts before or during "Measurement Period"
  • AND: "Occurrence A of Encounter, Performed: HIV Visit" during "Measurement Period"
  • AND: "Occurrence B of Encounter, Performed: HIV Visit" during "Measurement Period"
  • AND: "Occurrence A of Laboratory Test, Result: CD4+ Count (result < 200 per mm3)" < 9 month(s) ends after start of "Measurement Period"
  • AND: "Occurrence B of Encounter, Performed: HIV Visit" >= 90 day(s) starts after end of "Occurrence A of Encounter, Performed: HIV Visit"
• Denominator 1 =
  • AND: "Initial Patient Population 1"
• Denominator Exclusions 1=
  • None
• Numerator 1 =
  • AND:
    • OR: "Medication, Order: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis" <= 3 month(s) starts after end of "Occurrence A of Laboratory Test, Result: CD4+ Count"
    • OR:
      • AND: "Occurrence A of Medication, Order: Dapsone and pyrimethamine" <= 3 month(s) starts after end of "Occurrence A of Laboratory Test, Result: CD4+ Count"
      • AND: "Occurrence A of Medication, Order: Leucovorin" <= 3 month(s) starts after end of "Occurrence A of Laboratory Test, Result: CD4+ Count"
      • AND:
        • OR: "Occurrence A of Medication, Order: Leucovorin" concurrent with "Occurrence A of Medication, Order: Dapsone and pyrimethamine"
        • OR:
          • AND NOT: "Occurrence A of Medication, Order: Dapsone and pyrimethamine" ends before start of "Occurrence A of Medication, Order: Leucovorin"
          • AND: "Occurrence A of Medication, Order: Dapsone and pyrimethamine" < 1 day(s) starts before or during "Occurrence A of Medication, Order: Leucovorin"
        • OR:
          • AND NOT: "Occurrence A of Medication, Order: Leucovorin" ends before start of "Occurrence A of Medication, Order: Dapsone and pyrimethamine"
          • AND: "Occurrence A of Medication, Order: Leucovorin" < 1 day(s) starts before or during "Occurrence A of Medication, Order: Dapsone and pyrimethamine"
• Denominator Exceptions 1 =
  • AND: "Occurrence B of Laboratory Test, Result: CD4+ Count (result >= 200 per mm3)" <= 3 month(s) ends after end of "Occurrence A of Laboratory Test, Result: CD4+ Count"

      ------ Population Criteria 2 ------

• Initial Patient Population 2 =
  • AND: "Patient Characteristic Birthdate: birth date" >= 1 year(s) starts before start of "Measurement Period"
  • AND: "Patient Characteristic Birthdate: birth date" < 6 year(s) starts before start of "Measurement Period"
  • AND: "Diagnosis, Active: HIV" starts before or during "Measurement Period"
  • AND: "Occurrence A of Encounter, Performed: HIV Visit" during "Measurement Period"
  • AND: "Occurrence B of Encounter, Performed: HIV Visit" during "Measurement Period"
  • AND: "Occurrence B of Encounter, Performed: HIV Visit" >= 90 day(s) starts after end of "Occurrence A of Encounter, Performed: HIV Visit"
  • AND:
    • OR: "Occurrence A of Laboratory Test, Result: CD4+ Count (result < 500 per mm3)" < 9 month(s) ends after start of "Measurement Period"
    • OR: "Occurrence A of Laboratory Test, Result: CD4+ Percentage (result < 15 %)" < 9 month(s) ends after start of "Measurement Period"
• Denominator 2 =
  • AND: "Initial Patient Population 2"
• Denominator Exclusions 2=
  • None
• Numerator 2 =
  • AND:
    • OR: "Medication, Order: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis" <= 3 month(s) starts after end of "Occurrence A of Laboratory Test, Result: CD4+ Count"
    • OR: "Medication, Order: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis" <= 3 month(s) starts after end of "Occurrence A of Laboratory Test, Result: CD4+ Percentage"
• Denominator Exceptions 2 =
  • AND:
    • OR: "Occurrence B of Laboratory Test, Result: CD4+ Count (result >= 500 per mm3)" <= 3 month(s) ends after end of "Occurrence A of Laboratory Test, Result: CD4+ Count"
    • OR: "Occurrence B of Laboratory Test, Result: CD4+ Percentage (result >= 15 %)" <= 3 month(s) ends after end of "Occurrence A of Laboratory Test, Result: CD4+ Percentage"

      ------ Population Criteria 3 ------

• Initial Patient Population 3 =
  • AND: FIRST: "Occurrence A of Diagnosis, Active: HIV" starts before or during "Measurement Period"
  • AND: "Patient Characteristic Birthdate: birth date" >= 6 week(s) starts before start of "Measurement Period"
  • AND: "Patient Characteristic Birthdate: birth date" < 1 year(s) starts before start of "Measurement Period"
  • AND: "Occurrence A of Encounter, Performed: HIV Visit" during "Measurement Period"
  • AND: "Occurrence B of Encounter, Performed: HIV Visit" during "Measurement Period"
  • AND: "Occurrence B of Encounter, Performed: HIV Visit" >= 90 day(s) starts after end of "Occurrence A of Encounter, Performed: HIV Visit"
• Denominator 3 =
  • AND: "Initial Patient Population 3"
• Denominator Exclusions 3=
  • None
• Numerator 3 =
  • AND: "Medication, Order: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis" starts during "Occurrence A of Diagnosis, Active: HIV"
• Denominator Exceptions 3=
  • None

• "Diagnosis, Active: HIV" using "HIV Grouping Value Set (2.16.840.1.113883.3.464.1003.120.12.1003)"
• "Encounter, Performed: HIV Visit" using "HIV Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1047)"
• "Laboratory Test, Result: CD4+ Count" using "CD4+ Count Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1004)"
• "Laboratory Test, Result: CD4+ Percentage" using "CD4+ Percentage Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1005)"
• "Medication, Order: Dapsone and pyrimethamine" using "Dapsone and pyrimethamine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1202)"
• "Medication, Order: Leucovorin" using "Leucovorin Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1205)"
• "Medication, Order: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis" using "Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1076)"
• "Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"

• None

• "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"
• "Patient Characteristic Payer: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.114222.4.11.3591)"
• "Patient Characteristic Race: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"
• "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex Administrative Sex Value Set (2.16.840.1.113762.1.4.1)"