ACOVE-2 Quality Indicators 2001

ACOVE-2 Quality Indicators

CONTINUITY AND COORDINATION OF CARE Identify source of care consultant, THEN the referring treatment (e.g., physical therapy or 1. ALL persons age 75 or older should be physician’s follow-up note should radiation oncology), THEN the able to identify a physician or a clinic document the consultant’s medical record should document that that they would call when in need of recommendations, or the medical the visit or treatment took place or that medical care or should know the phone record should include the consultant’s it was postponed or not needed. number or other mechanism by which note within 6 weeks or at the time of they can reach this source of care. the follow-up visit, whichever is later. Hospital follow-up within 6 weeks 10. IF a person age 75 or older is Medication follow-up Diagnostic test follow-up discharged from a hospital to home and 2. IF an outpatient, person age 75 or older 6. IF the outpatient medical record survives at least 4 weeks after is started on a new prescription documents that a diagnostic test was discharge, THEN he or she should medication, and he or she has a follow- ordered for a person age 75 or older, have a follow-up visit or documented up visit with the prescribing physician, THEN the medical record at the telephone contact within 6 weeks of THEN the medical record at the follow-up visit should document 1 of discharge; and the physician’s medical follow-up visit should document one of the following: result of the test, test was record documentation should the following: the medication is being not needed or reason why it will not be acknowledge the recent hospitalization. taken, the physician asked about the performed, or test is still pending. medication (e.g., side effects or Medical record transfer adherence or availability), or the Medication continuity after hospitalization 11. IF a person age 75 or older is medication was not started because it 7. IF a person age 75 or older is transferred between emergency rooms was not needed or because it was discharged from a hospital to home, or between acute care facilities, THEN changed. and he or she received a new the medical record at the receiving prescription medication or a change in facility should include medical records Medication continuity between physicians medication prior to discharge, THEN from the transferring facility, or should 3. IF a person age 75 or older is under the the outpatient medical record should acknowledge transfer of such medical outpatient care of ≥2 physicians, and document or acknowledge the records. one physician prescribed a new medication change within 6 weeks of prescription medication or a change in discharge. Discharge summary in chart medication, THEN subsequent medical 12. IF a person age 75 or older is record entries by the non-prescribing Pending test result discharged from a hospital to home or physician should acknowledge the 8. IF a person age 75 or older is to a nursing home, THEN there should medication change. discharged from a hospital to home or be a discharge summary in the to a nursing home, and the transfer outpatient physician or nursing home Reason for consultation form or discharge summary indicates medical record within 6 weeks. 4. IF an outpatient, person age 75 or older that a test result is pending, THEN the is referred to a consultant physician, outpatient or nursing home medical Interpreter THEN the reason for consultation record should include the test result 13. IF a person age 75 or older is deaf or should be documented in the within 6 weeks of hospital discharge. does not speak English, THEN an consultant’s note. interpreter or translated materials Post hospitalization follow-up appointment should be employed to facilitate Document consultant recommendations 9. IF a person age 75 or older is communication between the person age 5. IF an outpatient, person age 75 or older discharged from a hospital to home or 75 or older and the health care was referred to a consultant and to a nursing home, and the hospital provider. subsequently visited the referring medical record specifies a follow-up physician after the visit with the appointment for a physician visit or a

Related Quality Indicators for CONTINUITY AND COORDINATION OF CARE

Follow-up suicidal thoughts Hearing aid in hospital INR every 6 weeks for warfarin therapy (Depression #13) (Hearing #7) (Medication #6) Follow up of depression treatment Discharge planning in the hospital Lab tests after starting diuretic (Depression #15, 16, 17) (Hospital #2) (Medication #7) Continuity of care preferences Cardiac rehabilitation after MI or CABG Lab tests after starting ACE inhibitor (End of life #1, 3, 4, 6, 8, 9) (Ischemic heart disease #12) (Medication #12) Continuity of surrogate specification Up-to-date medication list across providers Follow-up response to pain treatment (End of life #2) (Medication #3) (Pain #7) Contact next of kin after death Follow-up response to medication Continuity of eye medications and glasses in (End of life #14) (Medication #4) the hospital (Vision #13, 15)

DEMENTIA disease, THEN the treating physician Cognitive and functional screening should discuss treatment with a 13. IF a person age 75 or older is 1-CH IF a person age 75 or older is admitted cholinesterase inhibitor with the patient physically restrained and the target to a hospital, THEN there should be and the primary caregiver (if available). behavioral disturbance requiring documentation of a multidimensional restraint is identified, THEN the health assessment of cognitive ability. Caregiver support and patient safety care team should include methods other 7. IF a person age 75 or older with than physical restraints in the care plan. 1-CO IF a person age 75 or older is new to a dementia has a caregiver (and, if physician practice, THEN there should capable, the patient assents), THEN the 14. IF a person age 75 or older is placed in be documentation of an assessment of physician should discuss or refer the physical restraints, THEN each of the memory. patient and caregiver for discussion following measures should be enacted: about patient safety, provide education • Consistent release from the 1-F. IF a person age 75 or older is admitted on how to deal with conflicts at home, restraints at least every 2 hours, to a hospital or is new to a physician and inform about community resources • Face-to-face reassessment by a practice, THEN there should be an for dementia. physician or nurse at least every 4 assessment of functional status. hours and before renewal of the Screening for depression restraint order, Medication review 9. IF a person age 75 or older has • Observation at least every 15 2. IF a person age 75 or older presents dementia, THEN he or she should be minutes, and more frequently if with dementia symptoms, THEN the screened for depression during the indicated by the patient's physician should review the patient’s initial evaluation period. condition, while the patient is in medication list for initiation of Depression treatment restraints, medications that might correspond • Interventions every 2 hours (or chronologically to the onset of 10. IF a person age 75 or older with dementia symptoms. dementia has depression, THEN he or as indicated by patient's she should be treated for the condition or needs) related to 3. IF a person age 75 or older presents depression. nutrition, hydration, personal with dementia symptoms that Driving privileges hygiene, toileting, and range- correspond in time with the initiation of of-motion exercises. new medication(s), THEN the 11. IF a person age 75 or older is newly

physician should discontinue or justify diagnosed with dementia, THEN the Memory loss the necessity of continuing these diagnosing physician should advise the 15. IF a person age 75 or over without a medications. patient not to drive a motor vehicle and/or request that the Department of previous diagnosis of dementia fails a Laboratory testing Motor Vehicles (or equivalent) re-test memory screen or presents with 4. IF a person age 75 or older is newly the patient's ability to drive, or refer the memory loss or forgetfulness, THEN diagnosed with dementia, THEN a patient to a drivers’ safety/education the physician should document an serum vitamin B12 and TSH should be course that includes assessment of assessment of memory, OR a diagnosis performed. driving ability consistent with state of or treatment for dementia (or laws. cognitive dysfunction or forgetfulness), Neuroimaging OR an explanation for the memory 5. IF a person age 75 or older has signs of Restraints loss, OR a referral to neurology, dementia and focal neurologic findings 12. IF a person age 75 or older with psychiatry, geriatrics, or a psychologist. suggestive of an intracranial process, dementia is to be physically restrained THEN the patient should be offered in the hospital, THEN the target neuroimaging (brain CT or MRI). behavioral disturbance or safety issue justifying use of restraints must be Cholinesterase inhibitors identified to the consenting person 6. IF a person age 75 or older is in a mild- (patient or legal guardian) and to-moderate stage of Alzheimer's documented in the chart.

Related Quality Indicators for DEMENTIA

Evaluate patients with cognitive impairment Evaluate cognition at hospital admission Cognitive evaluation for weight loss for depression (Depression #1, 2) (Hospital #1) (Malnutrition #4) Evaluate patients for suicidal ideation and Check capacity before consent for surgery Avoid anticholinergic medication follow-up (Depression #4, 5, 13) (Hospital #6) (Medication #9) Decision making for patients with dementia Delirium evaluation and treatment (End of life #2, 3) (Hospital #9)

DEPRESSION Recognizing depression therapy should be offered within 2 1. IF a person age 75 or older presents weeks after diagnosis unless there is 12. IF a person age 75 or older is taking a with new onset of one of the following documentation within that period that MAOI, THEN he or she should not symptoms: sad mood, feeling down, the patient has improved, or unless the receive medications that interact with insomnia or difficulties with sleep, patient has substance abuse or MAOI for at least 2 weeks after apathy or loss of interest in pleasurable dependence, in which case treatment termination of the MAOI. activities, complaints of memory loss, may wait until 8 weeks after the patient Monitoring suicide risk unexplained weight loss of greater than is in a drug- or alcohol-free state. 13. IF a person age 75 or older is being 5% in the past month or 10% over 1 treated for depression, THEN at each Choice of antidepressant year, or unexplained fatigue or low treatment visit suicide risk should be energy, THEN the patient should be 7. IF a person age 75 or older is started on an antidepressant medication, THEN documented, if he or she had suicidal asked about or treated for depression, ideation during a previous visit. or referred to a mental health the following medications should not professional within 2 weeks of be used as first- or second-line therapy: Follow up of depression treatment presentation. tertiary amine tricyclics (amitriptyline, 14. IF a person age 75 or older is being imipramine, doxepin, clomipramine, treated for depression with trimipramine); monoamine oxidase antidepressants, THEN the Depression and co-morbid disease inhibitors (unless atypical depression is 2. IF a person age 75 or older presents antidepressants should be prescribed at present); benzodiazepines; or appropriate starting doses, and they with onset or discovery of one of the stimulants (except methylphenidate). following conditions: stroke, should have an appropriate titration schedule to a therapeutic dose, myocardial infarction, dementia, Psychotic or vegetative depression malignancy (excluding skin cancer), 8. IF a person age 75 or older has therapeutic blood level, or remission of chronic pain, alcohol or substance depression with psychotic features symptoms by 12 weeks. abuse or dependence, anxiety disorder, (e.g., auditory hallucinations, 15. IF a person age 75 or older has no or personality disorder, THEN the delusions), or has melancholic or meaningful symptom response after 6 patient should be asked about or treated vegetative depression with pervasive weeks of treatment, THEN one of the for depression, or referred to a mental anhedonia, unreactive mood, following treatment options should be health professional within 2 months of psychomotor disturbances, severe initiated by the 8th week of treatment: diagnosis of the condition. terminal insomnia, and weight and medication dose should be optimized or appetite loss, THEN he or she should changed, or the patient should be Documenting depression symptoms not be treated with psychotherapy 3. IF a person age 75 or older receives a referred to a psychiatrist (if initial alone, unless he or she is unable or treatment was medication); or diagnosis of a new depression episode, unwilling to take medication. THEN the medical record should medication should be initiated or referral to a psychiatrist should be document at least 3 of the 9 Diagnostic Referral for psychotic depression and Statistical Manual IV target 9. IF a person age 75 or older has offered (if initial treatment was symptoms for major depression within depression with psychotic features, psychotherapy alone). the first month of diagnosis. THEN he or she should be referred to a 16. IF a person age 75 or older responds psychiatrist and should receive Suicidality only partially after 12 weeks of treatment with a combination of an 4. IF a person age 75 or older receives a treatment, THEN one of the following antidepressant and an antipsychotic, or diagnosis of a new depression episode, treatment options should be instituted with electroconvulsive therapy. THEN the medical record should by the 16th week of treatment: switch to a different medication class or add a document on the day of diagnosis the Electrocardiogram with tricyclic use presence or absence of suicidal ideation 10. IF a person age 75 or older with a second medication to the first (if initial and psychosis (consisting of, at a history of cardiac disease is started on a treatment includes medication); add minimum, auditory hallucinations or tricyclic antidepressant, THEN a psychotherapy (if the initial treatment delusions). baseline electrocardiogram should be was medication); try medication (if performed prior to initiation of or initial treatment was psychotherapy 5. IF a person age 75 or older has within 3 months prior to treatment. without medication); consider thoughts of suicide, THEN the medical electroconvulsive therapy; or refer to a record should document, on the same Interactions with MAOI psychiatrist. date, that the patient either has no 11. IF a person age 75 or older is taking a immediate plan for suicide, or that the serotonin reuptake inhibitor (SRI), Continuing antidepressant therapy patient was referred for evaluation for THEN a monoamine oxidase inhibitor 17. IF a person age 75 or older has psychiatric hospitalization. (MAOI) should not be used for at least responded to antidepressant 2 weeks after termination of paroxetine, medication, THEN he or she should be Depression treatment sertraline, fluvoxamine and citalopram, continued on the drug at the same dose 6. IF a person age 75 or older is and for at least 5 weeks after for at least 6 months, and should make diagnosed with depression, THEN termination of fluoxetine. at least 1 clinician contact (office visit antidepressant treatment, or phone) during that time period. psychotherapy, or electroconvulsive

Related Quality Indicators for DEPRESSION

Screen and treat depression in patients with Depression evaluation for weight loss cognitive impairment (Dementia #9, 10) (Malnutrition #4)

DIABETES MELLITUS Glycated hemoglobin measurement 1. IF a person age 75 or older has Diabetic education Routine eye examination diabetes, THEN his or her glycated 6. IF a diabetic person age 75 or older has 10. IF a diabetic person age 75 or older is hemoglobin level should be measured a glycated hemoglobin level ≥ 10, not blind, THEN he or she should at least every 12 months. THEN he or she should be referred for receive a dilated eye examination diabetic education at least annually. performed by an ophthalmologist, Improving glycemic control optometrist, or diabetes specialist every 2. IF a person age 75 or older has an Blood pressure control 2 years. elevated glycated hemoglobin level, 7. IF a diabetic person age 75 or older has elevated blood pressure, THEN he or THEN he or she should be offered a Treatment of high risk she should be offered a therapeutic therapeutic intervention aimed at 11. IF a diabetic person age 75 or older has intervention to lower blood pressure: improving glycemic control within 3 one additional cardiac risk factor (i.e., • within 6 months if systolic blood months if the glycated hemoglobin smoker, hypertension, pressure 140-160 mm level is 9.0 to 10.9, and within 1 month hypercholesterolemia, or renal if the glycated hemoglobin level is ≥ • within 3 months if systolic blood insufficiency/microalbuminuria), THEN 11. pressure 161-180 mmHg he/she should be offered an ACE • within 1 month if systolic blood inhibitor or receptor blocker. Proteinuria screening pressure >180 mmHg 3. IF a diabetic person age 75 or older does not have established renal disease Aspirin therapy Foot examination and is not receiving an ACE inhibitor 8. ALL diabetic persons age 75 or older 12. IF a person aged 75 or over has or ACE receptor blocker, THEN he or not receiving other anticoagulation diabetes, THEN he or she should have she should receive an annual test for therapy should be offered daily aspirin an annual examination of his or her feet. therapy. proteinuria. Regular blood pressure measurement Lipid treatment 5. IF a person age 75 or older has diabetes, 9. IF a diabetic person age 75 or older has THEN his or her blood pressure should an LDL cholesterol > 130 mg/dl, THEN be checked at each outpatient visit. he or she should be offered an intervention to lower cholesterol.

Related Quality Indicators for DIABETES MELLITUS

Chlorpropramide use (Medication #8) Retinal examination (Vision #7, 8)

END-OF-LIFE CARE Advance directives, surrogates, and preferences Advance directive continuity Mechanical ventilator withdrawal 1. ALL persons age 75 or older should 6. IF a person age 75 or older has an 10. IF a noncomatose person age 75 or have in their outpatient charts (1) an advance directive in the outpatient, older is not expected to survive and a advance directive indicating the inpatient or nursing home medical mechanical ventilator is withdrawn or patient's surrogate decision maker//life- record or the patient reports the intubation is withheld, THEN the sustaining treatment preferences, or (2) existence of an advance directive in an patient should receive (or have orders documentation of a discussion about interview, and the patient receives care available for) an opiate or who would be a surrogate decision in a second venue, THEN (1) the benzodiazepine or barbiturate infusion maker or a search for a advance directive should be present in to reduce dyspnea and the chart should surrogate/preferences, or (3) indication the medical record at the second venue, document whether the patient has that there is no identified or (2) documentation should dyspnea. surrogate/preference. acknowledge its existence, its contents, and the reason that it is not in the 2. IF a person age 75 or older with medical record. Care of the Dying Patient dementia, coma or altered mental status Mechanical ventilation preferences Dyspnea treatment is admitted to the hospital, THEN 11. IF a person age 75 or older who was within 48 hours of admission the 7. IF a person age 75 or older requires mechanical ventilation during a having difficulty with dyspnea in the last medical record should (1) contain an 7 days of life died an expected death, advance directive indicating the hospitalization (except short-term and post-operative mechanical ventilation), THEN there should be chart patient's surrogate decision maker, or documentation of how the dyspnea was (2) document a discussion about who THEN the medical record should document within 48 hours of the treated and there should be follow-up would be a surrogate decision maker or documentation about the dyspnea. a search for a surrogate, or (3) indicate initiation of mechanical ventilation the that there is no identified surrogate. goals of care and the patient's preference Pain treatment for mechanical ventilation or why this 12. IF a person age 75 or older who was Documentation of care preferences information is unavailable. conscious during the last 3 days of life 3. IF a person age 75 or older carries a Life-sustaining care decisions died an expected death, THEN the diagnosis of severe dementia, and is medical record should contain admitted to the hospital, and survives 8. IF a person age 75 or older with decision making capacity has orders documentation about pain or lack of 48 hours, THEN within 48 hours of pain during the last 3 days of life. admission, the medical record should written in the hospital or the nursing document consideration of the patient's home to withhold or withdraw a Search for next of kin prior preferences for care or that these particular treatment modality (e.g., DNR 14. IF a person age 75 or older without could not be elicited or are unknown. order or an order not to initiate dialysis), nown family or next of kin died in the THEN the medical record should hospital, THEN the chart should 4. IF a person age 75 or older is admitted document (1) patient participation in the document a search for next of kin. directly to the intensive care unit (from decision, or (2) why the patient chose the outpatient setting or emergency not to participate in the decision. room) and survives 48 hours, THEN within 48 hours of admission, the Care consistency with preferences medical record should document 9. IF a person age 75 or older has specific consideration of the patient's treatment preferences (e.g., DNR, no preferences for care or that these could tube feeding, no hospital transfer) not be elicited or are unknown. documented in a medical record, THEN these treatment preferences should be followed.

Related Quality Indicators for END-OF-LIFE CARE Caregiver support (Dementia #7) Permanent urinary catheter (UI #10)

FALLS AND MOBILITY PROBLEMS Asking about falls 1. ALL persons age 75 or older should Basic fall examination Exercise and assistive device prescription have documentation that they were 3-E. IF a person age 75 or older reported 2 5. IF a person age 75 or older asked at least annually about the or more falls in the past year, or a demonstrates decreased balance and/or occurrence of recent falls. single fall with injury requiring proprioception or increased postural treatment, THEN there should be sway, THEN an appropriate exercise Detecting balance and gait disturbances documentation of a basic fall program should be offered and an 2. ALL persons age 75 or older should examination that resulted in specific evaluation for an assistive device have documentation that they were diagnostic and therapeutic performed. asked about or examined for the recommendations. presence of balance and/or gait 6. IF a person age 75 or older is found to disturbances at least once. Gait/mobility and balance evaluation have problems with strength (e.g., 4/5 4. IF a person age 75 or older reports or is or less on manual muscle testing or Basic fall history found to have new or worsening needs arms to rise from a chair) or 3-H. IF a person age 75 or older reported 2 difficulty with ambulation, balance endurance (e.g., dyspnea on mild or more falls in the past year, or a and/or mobility, THEN there should be exertion), THEN an exercise program single fall with injury requiring documentation that a basic gait, or physical therapy should be offered. treatment, THEN there should be mobility, and balance evaluation was documentation of a basic fall history. performed within 3 months that resulted in specific diagnostic and therapeutic recommendations.

Related Quality Indicators for FALLS AND MOBILITY PROBLEMS Avoid tricyclic antidepressants Annual medication review (Medication #5) Strengthening program for patients with (Depression #7) Avoid anticholinergic medication osteoarthritis (Osteoarthritis #3) New medications should have clearly defined (Medication #9) Vision evaluation every 2 years (Vision #1) indications (Medication #1) Annual evaluation of function and pain for Corrective lenses for correctable refractive Educate concerning side effects of new osteoarthritis (Osteoarthritis #1) error (Vision #14) medications (Medication #2) Corrective lenses in the hospital (Vision #15)

HEARING LOSS Screening for hearing loss 1. ALL persons age 75 or older should Referral to audiologist Conductive hearing loss have a hearing screen as part of the 4. IF a person age 75 or older is a 6. IF a person age 75 or older has initial evaluation. hearing aid candidate, THEN he or conductive hearing loss, THEN he she should be offered referral to an or she should be offered a referral to Formal audiologic evaluation audiologist within 3 months after an otolaryngologist. 2. IF a person age 75 or older fails a audiologic exam. hearing screening, THEN he or she Inpatient access to hearing aid should be offered a formal Hearing rehabilitation 7. IF a person age 75 or older who uses audiologic evaluation within 3 5. IF a person age 75 or older is a a hearing aid for any activities of months. hearing aid candidate, THEN he or daily living is hospitalized (or is in a she should be offered hearing nursing home), THEN the hearing Ear examination 3. IF a person age 75 or older has a rehabilitation. impairment should be recognized hearing problem or fails an and accommodated. audiologic screening, THEN he or she should have an ear examination within 3 months.

Related Quality Indicators for HEARING LOSS Interpreter for hearing impaired patient (Continuity #13)

HEART FAILURE ACE Inhibitor use 1. IF a person age 75 or older has heart Diagnostic testing Beta blocker use failure with a left ventricular ejection 5. IF a person age 75 or older is newly 9. IF a person age 75 or older has heart fraction <40%, THEN he or she should diagnosed with heart failure, THEN he failure, has left ventricular ejection be offered an ACE inhibitor. or she should undergo the following fraction ≤ 40%, and is New York Heart studies within 1 month of the diagnosis Association Class I to III, THEN he or Medical history (unless they have already been she should be offered a beta blocker, 3. IF a person age 75 or older is newly performed within the prior 3 months): unless a contraindication (e.g, diagnosed with heart failure, THEN he chest x-ray, electrocardiogram, CBC, uncompensated heart failure) has been or she should have a history taken at serum sodium and potassium, serum documented. the time of diagnosis and creatinine, and TSH in patients with hospitalization that documents the atrial fibrillation or heart failure with Calcium channel blocker use presence or absence of prior no obvious etiology. 10. IF a person age 75 or older has heart myocardial infarction, documented failure, has left ventricular ejection coronary artery disease, Patient education fraction < 40%, and does not have revascularization, current symptoms of 6. IF a person age 75 or older is newly atrial fibrillation, THEN from among chest pain or angina, history of diagnosed with heart failure, THEN the three generations of calcium hypertension, history of diabetes, education about disease management channel blocker medications, he or she history of hypercholesterolemia, history should be provided and documented. should not be treated with a first or second generation calcium channel of valvular heart disease, history of Evaluation of ejection fraction blocker. thyroid disease, smoking, current 7. IF a person age 75 or older is newly medications, and a description of diagnosed with heart failure, THEN he Antiarrhythmic agents functional capacity (e.g., New York or she should be offered an evaluation 11. IF a person age 75 or older has heart Heart Association functional status). of left ventricular ejection fraction failure and left ventricular ejection within 1 month. Physical examination fraction < 40%, THEN he or she should not be treated with a type I 4. IF a person age 75 or older is newly Biochemical monitoring antiarrhythmic agent unless an diagnosed with heart failure, THEN he 8. IF a person age 75 or older is implantable cardioverter defibrillator is or she should have the following hospitalized with heart failure, THEN in place. elements of the physical examination he or she should have serum documented at the time of presentation: electrolytes, creatinine, and blood urea Digoxin monitoring weight, blood pressure and heart rate, nitrogen performed within 1 day of 12. IF a person age 75 or older with heart lung examination, cardiac examination, hospitalization. failure has been treated with digoxin, and abdominal and/or lower extremity THEN a digoxin level should be examination. checked within 1 week if signs of toxicity develop.

Related Quality Indicators for HEART FAILURE Hospital follow-up (Continuity #7) Electrolyte check for diuretic (Medication Beta blocker after myocardial infarction INR check for warfarin use (Medication #6) #7) (IHD #13) Electrolyte and renal check after starting ACEI (Medication #12)

HOSPITAL CARE Admission evaluation aneurysm repair, THEN a cardiac 1-H. IF a person age 75 or older is admitted Deep vein thrombosis prevention stress test should be performed, if not to the hospital for any acute or chronic 4. IF a hospitalized person age 75 or older performed in the prior year. illness or any surgical procedure, is at very high risk for venous THEN the evaluation should include thrombosis, THEN the patient should Fever evaluation within 24 hours: (1) diagnoses, and (2) have venous thromboembolism 8. IF a hospitalized person age 75 or older pre-hospital and current medications. prophylaxis. has a new fever (temperature >38.5°C), THEN there should be documentation Stress ulcer prevention that a physician examination was 1-C. IF a person age 75 or older is admitted 5. IF a hospitalized person age 75 or older to the hospital for any acute or chronic performed within 4 hours (or fever has peptic stress ulcer risk factors, evaluation performed in the last 48 illness or any surgical procedure, THEN the patient should receive THEN documentation of cognitive hours or an alternative explanation for prophylaxis with either an H2-blocker, the fever documented in the chart). status should be performed within 24 sucralfate, or a proton pump inhibitor. hours. Delirium evaluation and treatment Capacity for informed consent 9-D. IF a hospitalized person age 75 or older 6. IF a person age 75 or older is to have Discharge planning has a definite or suspected diagnosis of an inpatient or outpatient elective 2. IF a person age 75 or older enters the delirium, THEN an evaluation for surgery, THEN there should be hospital, THEN discharge planning potentially precipitating factors must be medical record documentation of the should begin within 48 hours. undertaken. patient’s ability to understand risks,

Endocarditis prevention benefits and consequences of the 9-T. IF a hospitalized person age 75 or 3. IF a person age 75 or older has valvular proposed surgical operation before the older has a definite or suspected or congenital heart disease, intracardiac operative consent form is presented for diagnosis of delirium, THEN identified valvular prosthesis, hypertrophic signature. cardiomyopathy, mitral valve prolapse potential causes should be treated. with regurgitation or previous episode Cardiac evaluation before vascular of endocarditis and a high risk surgery procedure is planned, THEN 7. IF a person age 75 or older enters the endocarditis prophylaxis should be hospital for non-emergent peripheral given. revascularization or aortic abdominal

Related Quality Indicators for HOSPITAL CARE Hospital follow-up (Continuity #10) Decision making participation Medication list in medical record Follow-up medications, tests and (End of life #8) (Medication #3) appointments after discharge Palliative care (End of life #10 - 12) Avoid meperidine use (Medication #11) (Continuity #7, 8, 9) In-hospital death (End of life #14) Preventive immunization (Pneumonia #3) Medical record transfer between hospitals Hearing aid in hospital (Hearing #7) Pneumonia care (Pneumonia #7 - 11) (Continuity #11) Lab tests for hospitalized patients with heart Pressure ulcer risk assessment, prevention Discharge summary in chart failure (Heart failure #8) and treatment (Pressure ulcers #1 - 11) (Continuity #12) Myocardial infarction treatment Stroke treatment (Stroke #5 - 10) Admission cognitive and functional (IHD #1-7, 12, 13) assessments (Dementia #1) Eye medications and glasses in the hospital Alimentation for patient who cannot eat (Vision #13, 15) Use of restraints (Dementia #12 - 14) (Malnutrition #6) Advance directive and preference continuity Nutritional supplementation for malnourished (End of life #2, 3, 4, 6, 9) hip fracture patient (Malnutrition #7) Mechanical ventilation (End of life #7, 10)

HYPERTENSION

Electrocardiogram for new hypertension Nonpharmacologic management 7. IF a person age 75 or older has 1. IF a person age 75 or older is newly 4. IF a person age 75 or older is hypertension and has renal diagnosed with hypertension, THEN diagnosed with hypertension, THEN parenchymal disease with a serum within 4 weeks of the diagnosis an nonpharmacologic therapy with creatinine >1.5 mg/dL or > 1 gram of electrocardiogram should be lifestyle modification for treatment of protein/24 hours of collected urine, performed. hypertension should be recommended, THEN therapy with an ACE inhibitor including: dietary sodium restriction or ACE RB should be offered. Cardiovascular risk documentation and weight loss if patient is > 10% over 2. IF a person age 75 or older is newly ideal body weight. 8. IF a person age 75 or older has diagnosed with hypertension, THEN hypertension and asthma, THEN beta there should be documentation Pharmacologic management blocker therapy for hypertension should regarding the presence or absence of 5. IF a person age 75 or older remains not be used. other cardiovascular risk factors. hypertensive after non-pharmacologic intervention, THEN pharmacologic 9. IF a person age 75 or older remains hypertensive, THEN he/she should be Hypertension diagnosis antihypertensive treatment should be 3. IF a person age 75 or older is initiated. offered a therapeutic intervention to diagnosed with hypertension and the lower blood pressure: blood pressure is below 170/90, THEN 6. IF a person age 75 or older requires • within 3 months if systolic blood there should be evidence that 3 or more pharmacotherapy for treatment of pressure 161-180 mmHg hypertension in the outpatient setting, blood pressure measures of ≥140/90 • within 1 month if systolic blood THEN a once- or twice-daily were obtained prior to the diagnosis. pressure >180 mmHg medication should be used unless there

is documentation regarding the need for agents that require more frequent dosing.

Related Quality Indicators for HYPERTENSION

Check blood pressure at each outpatient visit Orthostatic blood pressure check for fall Electrolyte monitoring for diuretics for patients with diabetes (Diabetes #5) (Falls #3) (Medication #7) Control blood pressure for patients with Education for initiation of new medication Electrolyte and renal check after starting diabetes (Diabetes #7) (Medication #2) ACEI (Medication #12) Follow-up on therapeutic effect of new medication (Medication #4)

ISCHEMIC HEART DISEASE Assess left ventricular function 1. IF a person age 75 or older is Early coronary catheterization Cholesterol-lowering intervention hospitalized with an acute myocardial 6. IF a person age 75 or older without 9. IF a person age 75 or older has infarction, THEN he or she should be contraindications to revascularization established CHD and LDL cholesterol offered assessment of left ventricular has an acute myocardial infarction or >130 mg/dl, THEN he or she should be function before discharge or within 3 unstable angina with one or more of the offered an intervention to lower days after hospital discharge. following: cholesterol. pain refractory to medical therapy Non-invasive stress testing (>1 hour on aggressive medical Antiplatelet therapy 2. IF a person age 75 or older has an therapy) 10. IF a person age 75 or older has acute myocardial infarction or unstable recurrent angina/ischemia at rest or established CHD and is not on angina, did not undergo angiography, with low-level activities warfarin, THEN he or she should be and does not have contraindications to ischemia accompanied by symptoms offered antiplatelet therapy. revascularization, THEN he or she of heart failure, Smoking cessation should be offered non-invasive stress THEN he or she should be offered 11. IF a person age 75 or older with testing 4-21 days after the infarction or urgent catheterization. established CHD smokes, THEN he or anginal event. she should be offered counseling for Coronary artery bypass surgery Early aspirin therapy 7. IF a person age 75 or older has smoking cessation at least annually and 3. IF a person age 75 or older has an significant left main or significant 3- have this documented in the medical acute myocardial infarction or unstable vessel coronary artery disease with left record. angina, THEN he or she should be ventricular ejection fraction < 50%, Coronary rehabilitation given aspirin therapy within 1 hour of THEN he or she should be offered 12. IF a person age 75 or older has had a presentation. coronary artery bypass graft surgery. recent myocardial infarction or recent Early beta blocker therapy Cholesterol evaluation coronary bypass graft surgery, THEN 4. IF a person age 75 or older has 8. IF a person age 75 or older has he or she should be offered cardiac unstable angina or an acute myocardial established CAD and his or her rehabilitation. infarction, THEN he or she should be cholesterol level is not known, THEN Beta blocker therapy offered beta blocker therapy within 12 he or she should undergo a fasting 13. IF a person age 75 or older has had a hours of presentation. cholesterol evaluation including total myocardial infarction, THEN he or she LDL and HDL cholesterol. Reperfusion therapy should be offered a beta blocker. 5. IF a person age 75 or older has an acute myocardial infarction by electrocardiography and does not have contraindications to reperfusion therapy, THEN he or she should be offered treatment with reperfusion therapy.

Related Quality Indicators for ISCHEMIC HEART DISEASE

Hospital follow-up (Continuity #10) Daily aspirin for patient with diabetes Cardiac evaluation before vascular procedure (Diabetes #8) (Hospital #7) Evaluate patients s/p myocardial infarction for depression (Depression #2) Treat hypercholesterolemia in patient with Document cardiovascular risk factors for new diabetes (Diabetes #9) hypertension (Hypertension #3) ECG before tricyclic antidepressant in patient with cardiac disease (Depression #10) Document CAD history for patient with new Follow-up on therapeutic effect of new heart failure (Heart failure #3) medication (Medication #4)

MALNUTRITION Weight measurement 1. ALL persons age 75 or older should be Evaluate comorbid conditions Supplement hip fracture patient weighed at each physician office visit 4. IF a person age 75 or older has 7. IF a person age 75 or older who was and these weights should be documented documented involuntary weight loss or hospitalized for a hip fracture has in the medical record. hypoalbuminemia (< 3.5 g/dL), THEN evidence of nutritional deficiency (thin he or she should receive an evaluation body habitus or low serum albumin or Document weight loss for potentially relevant comorbid prealbumin), THEN oral or enteral 2. IF a person age 75 or older has conditions including: nutritional protein-energy involuntary weight loss of > 10% of medications that might be supplementation should be initiated body weight over 1 year or less, THEN associated with decreased appetite post-operatively. weight loss (or a related disorder) should (e.g., digoxin, fluoxetine, be documented in the medical record as anticholinergics) Gastrostomy feeding in stroke patient an indication that the physician depressive symptoms, and 8. IF a stroke patient has persistent recognized malnutrition as a potential cognitive impairment. dysphagia at 14 days, THEN a problem. gastrostomy or jejunostomy tube should Alternative alimentation be considered for enteral feeding. Evaluate weight loss/hypoalbuminemia 6. IF a hospitalized person age 75 or older 3. IF a person age 75 or older has Is unable to take foods orally for more documented involuntary weight loss or than 72 hours, THEN alternative hypoalbuminemia (< 3.5 g/dL), THEN alimentation (e.g., enteral or parenteral) she or he should receive an evaluation should be offered. for potentially reversible causes of poor nutritional intake.

Related Quality Indicators for MALNUTRITION

Evaluate patients with weight loss for Nutritional intervention for patient at depression (Depression #1) pressure ulcer risk (Pressure ulcer #3)

MEDICATION USE Drug indication 1. IF a person age 75 or older is Monitoring warfarin Barbiturates prescribed a new drug, THEN the 6-I. IF a person age 75 or older is 10. IF a person age 75 or older does not prescribed drug should have a clearly prescribed warfarin, THEN an need control of seizures, THEN defined indication documented in the international normalized ratio (INR) barbiturates should not be used. record. should be determined within 4 days after initiation of therapy. Opioid analgesic 11. IF Patient education a person age 75 or older requires 2. IF a person age 75 or older is 6-C. IF a person age 75 or older is analgesia, THEN meperidine should prescribed a new drug, THEN the prescribed warfarin, THEN an not be used. patient (or, if incapable, a caregiver) internationalized normalized ratio Monitoring for new ACE inhibitor should receive education about the (INR) should be done at least every 6 12. IF a person age 75 or older is newly purpose of the drug, how to take it, and weeks. started on an ACE inhibitor, THEN expected side effects or important serum potassium and creatinine levels adverse reactions. Monitoring electrolytes for diuretic 7-I. IF a person age 75 or older is should be checked within 1 month of the initiation of therapy. Medication list prescribed a thiazide or loop diuretic, 3. For ALL persons age 75 or older there THEN electrolytes should be checked should be an up-to-date medication list within 1 month after initiation of NSAIDs in the outpatient medical record of therapy. 13A. IF a person age 75 or over is treated every physician and in the hospital with a non-selective nonsteroidal anti- medical record. 7-C. IF a person age 75 or older is inflammatory drug (NSAID), THEN prescribed a thiazide or loop diuretic, the patient should be advised of the Response to therapy THEN he or she should have risks associated with the drug. 4. EVERY new drug that is prescribed to electrolytes checked at least yearly. a person age 75 or older on an ongoing 13B. IF a person age 75 or over is treated basis for a chronic medical condition Oral hypoglycemic medication with a COX-2 nonsteroidal, anti- should have a documentation of 8. IF a person age 75 or older is inflammatory drug (NSAID), THEN response to therapy within 6 months. prescribed an oral hypoglycemic drug, the patient should be advised of the THEN chlorpropamide should not be risks associated with the drug. Drug regimen review used. 5. ALL persons age 75 or older should have a drug regimen review at least Anticholinergic medications 14. IF a person age 75 or over is treated annually. 9. ALL persons age 75 or older should with a COX non-selective NSAID, not be prescribed a medication with THEN he or she should be offered strong anticholinergic effects if concomitant treatment with either alternatives are available. misoprostol or a proton pump inhibitor.

Related Quality Indicators for MEDICATION USE Medication follow up (Continuity #2) Dosing and titration of antidepressants Evaluate medications if patient presents with Continuity between providers (Depression #14) weight loss (Malnutrition #4) (Continuity #3) Calcium channel blocker use in heart failure Acetaminophen use for osteoarthritis Continuity after hospital discharge (Heart failure #10) (Osteoarthritis #7) (Continuity #7) Antiarhythmic use in heart failure Calcium and vitamin D if taking steroids Causing cognitive impairment (Heart failure #11) (Osteoporosis #7) (Dementia #2, 3) Evaluate medications on hospital admission Bowel regimen for opioid use (Pain #5) Choice of antidepressant medication (Hospital #1) Follow up therapeutic effect of pain (Depression #7) Assess medications if delirium present treatment. (Pain #7) ECG before tricyclic antidepressant in patient (Hospital #9) Anticoagulation for atrial fibrillation with cardiac disease (Depression #10) Long-acting medications for hypertension (Stroke #4) MAOI interactions (Depression #11, 12) (Hypertension #6) Stroke prophylaxis (Stroke #11)

OSTEOARTHRITIS Assess functional status/pain 1. IF a person age 75 or older is Exercise therapy First-line pharmacologic therapy diagnosed with symptomatic 3. IF an ambulatory person age 75 or 7. IF oral pharmacologic therapy is osteoarthritis, THEN functional status older has had a diagnosis of initiated to treat osteoarthritis, THEN and degree of pain should be assessed symptomatic osteoarthritis of the knee acetaminophen should be the first drug annually. for >3 months and has no used, unless there is a documented contraindications to exercise and is contraindication to use. Aspirate hot joints physically and mentally able to 2. IF a person age 75 or older has exercise THEN a directed or Total joint replacement monoarticular joint pain associated supervised strengthening or aerobic 11. IF a person age 75 or older with severe with redness, warmth and/or swelling exercise program should have been symptomatic osteoarthritis of the knee and the patient also has an oral prescribed at least once or hip has failed to respond to non- temperature > 38.0°C, and does not pharmacologic and pharmacologic Patient education have a previously established diagnosis therapy, THEN the patient should be 5. IF an ambulatory person age 75 or of pseudogout or gout, THEN a offered referral to an orthopedic older has had a diagnosis of diagnostic aspiration of the painfully surgeon to be evaluated for total joint symptomatic osteoarthritis for >6 swollen red joint should be performed replacement within 6 months unless a months THEN there should be that day. contraindication to surgery is evidence that education regarding the documented. natural history, treatment and self- management of the disease was offered at lease once

Related Quality Indicators for OSTEOARTHRITIS Follow up therapeutic effect of pain treatment. (Pain #7)

OSTEOPOROSIS

Prevention Identifying secondary osteoporosis Calcium/vitamin D with corticosteroid use 1A. ALL female persons age 75 or older 4. IF a person age 75 or older has a new 7. IF a person age 75 or older is taking should be counseled at least once diagnosis of osteoporosis, THEN corticosteroids for more than 1 month, regarding intake of dietary calcium and during the initial evaluation period an THEN the patient should be offered vitamin D. underlying cause of osteoporosis calcium and vitamin D. should be sought by checking 1B. ALL female persons age 75 or older medication use and current alcohol use. Treatment of osteoporosis should be counseled at least once 8. IF a person age 75 or older is newly regarding weight-bearing exercises. Calcium/vitamin D for osteoporosis diagnosed with osteoporosis, THEN 6. IF a person age 75 or older has the patient should be offered treatment Smoking cessation osteoporosis, THEN calcium and with hormone replacement therapy, 2. ALL female persons age 75 or older vitamin D supplements should be SERMs, bisphosphonates, or calcitonin who smoke should be counseled recommended at least once. within 3 months of diagnosis. annually about smoking cessation. Pharmacologic preventive therapy 3. EVERY female person age 75 or older should be counseled about her risk for osteoporosis and the potential need for pharmacologic prevention of osteoporosis at least once.

Related Quality Indicators for OSTEOPOROSIS Evaluate for falls or gait imbalance (Falls Smoking history and counseling #1, 2) (S&P #4, 5) Alcohol screening (S&P #3) Exercise counseling (S&P #6)

PAIN MANAGEMENT Screening for pain 1. ALL persons age 75 or older should be 3-E. IF a person age 75 or older has a newly Treating pain screened for chronic pain during the reported chronic painful condition, 6. IF a person age 75 or older has a newly initial evaluation period. THEN a physical exam should be reported chronic painful condition, performed within 1 month. THEN treatment should be offered. 2. ALL persons age 75 or older should be screened for chronic pain every 2 years. Constipation with opioid use Reassessment of pain control 5. IF a person age 75 or older with 7. IF a person age 75 or older is treated Targeted history/physical chronic pain is treated with opioids, for a chronic painful condition, THEN 3-H. IF a person age 75 or older has a THEN he or she should be offered a he or she should be assessed for a newly reported chronic painful bowel regimen, or the medical record response within 6 months. condition, THEN a targeted history should document the potential for should be performed within 1 month. constipation or explain why bowel treatment is not needed.

Related Quality Indicators for PAIN MANAGEMENT Evaluate depression in patients with chronic Avoid meperidine (Medication #11) Acetaminophen use for osteoarthritis pain (Depression #2) Assess pain and function annually for (Osteoarthritis #7) Palliative care (End of life #12) osteoarthritis (Osteoarthritis #1) NSAID use (Medication #13, 14) Educate concerning side effects of new medication (Medication #2)

PNEUMONIA Pneumococcal vaccination 1. IF a person age 75 or older with no Vaccination rates Oxygen therapy history of allergy to the pneumococcal 4. IF pneumococcal and/or influenza 8. IF a person age 75 or older is admitted vaccine is not known to have already vaccination rates among patients of a to the hospital with community-acquired received a pneumococcal vaccine or if health delivery organization are low pneumonia with hypoxia, THEN the the patient received it more than 5 (i.e., < 60% of persons at risk for patient should receive oxygen therapy. years ago (if prior to age 65), THEN a pneumococcal and influenza disease and pneumococcal vaccine should be < 90% of institutionalized elderly), Empyema offered. THEN methods to increase the rate of 9. IF a person age 75 or older has an vaccination should be employed. empyema, THEN drainage is required. Influenza vaccination 2. IF a person age 75 or older has no Vaccinate health care workers Changing parenteral to oral antibiotics history of anaphylactic hypersensitivity 5. IF a health care organization cares for 10. IF a person age 75 or older with to eggs or to other components of the elderly patients, THEN it should have community-acquired pneumonia is to influenza vaccine, THEN the patient a formal plan to offer and encourage be switched from parenteral to oral should be offered an annual influenza influenza vaccination among its antimicrobial therapy, THEN the vaccination. employees. patient must meet all of the following criteria: Smoking cessation Vaccination of inpatients • clinically improving condition 6. IF a smoker develops pneumonia, 3. IF a person age 75 or older is • hemodynamically stable hospitalized and he or she is eligible for THEN the smoker should be advised to quit smoking. • tolerating oral medication and/or vaccination (i.e., is not up-to-date with food and fluids. pneumococcal or influenza Antibiotics vaccination), THEN the patient should 7. IF a person age 75 or older is admitted Stability at discharge be offered vaccination against to the hospital with pneumonia, THEN 11. IF a person age 75 or older with pneumococcus and influenza (during antibiotics should be administered community-acquired pneumonia is to flu season). within 8 hours of hospital arrival. be discharged home, THEN the patient should not be unstable on the day prior to or the day of discharge.

Related Quality Indicators for PNEUMONIA

Hospital follow-up (Continuity #7) Mechanical ventilator (End of life #7, 10)

PRESSURE ULCERS

Risk assessment Management Systemic infection 1. IF a person age 75 or older is admitted 5. IF a person age 75 or older presents 9. IF a person age 75 or older with a full- to an intensive care unit or a with a clean full-thickness pressure thickness pressure ulcer presents with medical/surgical unit of a hospital and is ulcer and has no improvement at 4 systemic signs and symptoms of unable to reposition himself or herself or weeks post-treatment, THEN (1) the infection such as elevated temperature, has limited ability to do so, THEN risk appropriateness of the treatment plan leukocytosis, confusion and agitation, assessment for pressure ulcers should be and (2) the presence of cellulitis or and these signs and symptoms are not performed on admission. osteomyelitis should be assessed. due to another identified cause, THEN the ulcer should be debrided of necrotic Preventive intervention 6. IF a person age 75 or older presents tissue within 12 hours. 2. IF a person age 75 or older is identified with a partial-thickness pressure ulcer as "at risk" for pressure ulcer and has no improvement at 2 weeks 10. IF a person age 75 or older with a full- development or a pressure ulcer risk post-treatment, THEN the thickness pressure ulcer presents with assessment score indicates that the appropriateness of the treatment plan systemic signs and symptoms of person is "at risk,” THEN preventive should be assessed. infection such as elevated temperature, intervention must be instituted within leukocytosis, or confusion and 12 hours, addressing repositioning Debridement agitation, and these signs and needs and pressure reduction (or 7. IF a person age 75 or older presents symptoms are not due to another management of tissue loads). with a full-thickness sacral or identified cause, THEN a tissue biopsy trochanteric pressure ulcer covered or a needle aspiration should be Nutritional intervention with necrotic debris or eschar, THEN obtained and sent for culture and 3. IF a person age 75 or older is identified debridement interventions using sharp, sensitivity within 12 hours. as "at risk" for pressure ulcer mechanical, enzymatic or autolytic development and has malnutrition procedures should be instituted within Topical dressings (involuntary weight loss of >10% over 3 days of diagnosis. 11. IF a person age 75 or older presents 1 year or low albumin or prealbumin), with a clean full-thickness or a partial- THEN nutritional intervention or Cleansing thickness pressure ulcer, THEN a dietary consultation should be 8. IF a person age 75 or older has a stage moist wound healing environment instituted. 2 or greater pressure ulcer, THEN a should be provided with topical topical antiseptic should not be used on dressings. Evaluation the wound. 4. IF a person age 75 or older presents with a pressure ulcer, THEN the pressure ulcer should be assessed for: (1) location, (2) depth and stage, (3) size and (4) presence of necrotic tissue.

SCREENING AND PREVENTION

Alcohol screening 5. IF a person age 75 or older uses Colorectal cancer screening 3. ALL persons age 75 or older should be tobacco regularly, THEN he or she 7. ALL persons age 75 or older should be screened to detect problem drinking should be offered counseling and/or offered screening for colorectal cancer and hazardous drinking with a history pharmacologic therapy to stop tobacco at least once with fecal occult blood of alcohol use or the use of use at least once. testing or should have had standardized screening questionnaires sigmoidoscopy in the last 5 years or (e.g., CAGE, AUDIT) at least once. Physical activity screening colonoscopy in the last 10 years. 6. ALL persons age 75 or older should Tobacco screening and counseling receive an assessment of their activity 4. ALL persons age 75 or older should level, and be provided with counseling receive screening for tobacco use and to promote regular physical activity at nicotine dependence. least once.

Related Quality Indicators for SCREENING AND PREVENTION Cognitive and functional evaluation Weigh patient each outpatient visit Smoking screen and counsel (IHD #11; (Dementia #1) (Malnutrition #1) Osteoporosis #2; Pneumonia #6; Stroke Advance directives/preferences Calcium, vitamin D and exercise counseling #8) (End of life #1) (Osteoporosis #1) Screen for pain (Pain #1, 2) Screen for falls and imbalance (Falls #1, 2) Pharmacologic prevention of osteoporosis Pneumococcal vaccine (Pneumonia #1, 3, 4) Hearing screening (Hearing #1) (Osteoporosis #3) Influenza vaccine (Pneumonia #2, 3, 4, 5) Cognitive evaluation at hospital admission Calcium/Vitamin D with corticosteroid use Urinary incontinence screening (UI #1, 2) (Osteoporosis #7) (Hospital #1) Vision evaluation (Vision #1)

STROKE AND ATRIAL FIBRILLATION

Carotid entarterectomy Anticoagulation for atrial fibrillation Thrombolytic therapy 1. IF a male person age 75 or older has 4. IF a person age 75 or older has atrial 9. IF a person age 75 or older is started on carotid artery symptoms, and is fibrillation (AF) > 48-hour duration and thrombolytic therapy for a stroke, diagnosed with a TIA or nondisabling has any "high risk" condition: THEN all of the following should be stroke, and has had carotid imaging • impaired LV function true: documenting > 70% carotid stenosis on • female gender • a head CT or MRI should precede the side ipsilateral to the hemisphere • hypertension or systolic blood initiation of thrombolytic therapy; producing the symptoms, and the pressure >160 mmHg • sulcal effacement, mass effect, medical record does not document that • prior ischemic stroke, TIA, or edema, or possible hemorrhage no facility is available with < 6% 30- systemic embolism should not be present on day morbidity and mortality, THEN he THEN he or she should be offered oral neuroimage; should receive referral for evaluation anticoagulation therapy, or antiplatelet • time from symptom onset to for carotid endarterectomy (CEA) therapy if the medical record initiation of thrombolytic therapy within 4 weeks of the diagnostic study documents a reason not to give should be documented in the or event, whichever is later. anticoagulant therapy. medical record and should not Carotid artery imaging exceed 3 hours; Stroke imaging before anticoagulation • absence of absolute 2. IF a male person age 75 or older has 5. IF a person age 75 or older has a carotid artery symptoms and is contraindications to thrombolysis presumed stroke, THEN a CT or MRI should be documented in the diagnosed with TIA or nondisabling of the head should be obtained prior to stroke, and the medical record does not medical record; initiation or continuation of • tPA should be used; AND document that the patient is not a thrombolytic treatment, anticoagulant • National Institute of Neurological candidate for carotid surgery, THEN a therapy, or antiplatelet therapy. carotid artery imaging study should be Disorders and Stroke exclusion performed within 4 weeks. Antiplatelet therapy for acute stroke/TIA criteria should not be present. 7. IF a person age 75 or older is Admission to stroke unit Contraindications to CEA diagnosed with acute atherothrombotic 10. IF a person age 75 or older is admitted 3. IF for a person age 75 or older the ischemic stroke or with a TIA, THEN to the hospital with a diagnosis of acute combined risk of surgery (patient antiplatelet treatment should be offered ischemic or hemorrhagic stroke, characteristics and hospital or surgeon within 48 hours following the stroke or THEN he or she should be admitted to experience) is 10% or greater, THEN TIA, unless the patient is already a specialized acute or combined acute CEA should not be performed. receiving anticoagulant treatment. and rehabilitative stroke unit, or Smoking cessation transferred to a specialized stroke unit 8. IF a person age 75 or older has a TIA if such a unit is available in the or stroke, THEN the medical record hospital. should document that smoking status was assessed, and that smokers were Stroke prophylaxis counseled to stop smoking. 11. IF a person age 75 or over has cerebrovascular disease, THEN the patient should be offered appropriate stroke prophylaxis with antiplatelet agents or warfarin.

Related Quality Indicators for STROKE AND ATRIAL FIBRILLATION Evaluate patients with stroke for depression Antiplatelet therapy for patients with IHD Feeding for persistent dysphagia after stroke (Depression #2) (IHD #10) (Malnutrition #8) Aspirin for diabetic patients (Diabetes #8) Follow INR for warfarin use (Medication #6)

URINARY INCONTINENCE targeted physical exam should be Initial evaluation performed that documents (1) a rectal Urodynamic testing pre-procedure 1. ALL persons age 75 or older should exam and (2) a genital system exam 8. IF a person age 75 or older undergoes have documentation of the presence or (including a pelvic exam for women). surgery or periurethral injections for absence of urinary incontinence (UI) UI, THEN subtracted cystometry during the initial evaluation. Diagnostic tests should be performed prior to the 5. IF a person age 75 or older has new UI procedure. Annual evaluation that persists for over 1 month or UI at 2. ALL persons age 75 or older should the time of a new evaluation, THEN a Incontinence surgery annually have documentation of the dipstick urinalysis and post-void 9. IF a female person age 75 or older has presence or absence of UI. residual should be obtained. documented stress UI caused by isolated intrinsic sphincter deficiency Targeted history Discussion of treatment options (ISD) or ISD with coexistent 3. IF a person age 75 or older has new UI 6. IF a person age 75 or older has new UI hypermobility and she undergoes that persists for over 1 month or UI at or UI at the time of a new evaluation, surgical correction, THEN a sling or the time of a new evaluation, THEN a THEN treatment options should be artificial sphincter procedure should be targeted history should be obtained that discussed. used. documents each of the following: (1) characteristics of voiding, (2) ability to Behavioral therapy Chronic indwelling catheter use get to the toilet, (3) prior treatment for 7. IF a cognitively intact person age 75 or 10. IF a person age 75 or older has urinary incontinence, (4) importance of older who is capable of independent clinically significant, newly discovered the problem to the patient, and (5) toileting has documented stress, urge, overflow UI, and indwelling urethral mental status. or mixed incontinence without catheterization is used, THEN there evidence of hematuria or high post- should be documentation that the Targeted physical examination void residual, THEN behavioral patient is not a candidate for alternative 4. IF a person age 75 or older has new UI treatment should be offered. interventions as a result of severe that persists for over 1 month or UI at physical or mental impairments or does the time of a new evaluation, THEN a not want alternative interventions.

VISION CARE Comprehensive eye examination of each eye should include the essential nerve damage on visual field tests or 1. ALL persons age 75 or older should be components of a comprehensive eye optic nerve examination, THEN offered an eye evaluation every 2 years exam AND documentation of the optic treatment should be reassessed and/or that includes the essential components nerve appearance, visual field testing advanced at least every 3 months until of a comprehensive eye exam. and determination of an initial target the intra-ocular pressure is lowered by pressure. at least 20% or there is documentation Urgent signs and symptoms that the vision loss has stabilized. 2. IF a person age 75 or older has sudden- Diabetic retinopathy onset visual changes, eye pain, corneal 7. IF a person age 75 or older with Ocular therapy opacity, or severe purulent discharge, diabetes has a retinal exam, THEN the 13. IF a person age 75 or older who has THEN the patient should be examined presence and/or degree of diabetic been prescribed an ocular therapeutic within 72 hours by an ophthalmologist. retinopathy should be documented. regimen becomes hospitalized, THEN the regimen should be administered in Chronic signs and symptoms 8. IF a person age 75 or older is the hospital unless discontinued by an 3. IF a person age 75 or older develops diagnosed with proliferative diabetic ophthalmological consultant. progression of a chronic visual deficit retinopathy, THEN a dilated eye exam that now interferes with his or her should be performed at least every 4 Refraction correction ability to carry out needed or desired months. 14. IF a person age 75 or older with activities, THEN he or she should have functional visual deficits has subjective an ophthalmic examination by a person Macular edema improvement on refraction, THEN he skilled at ophthalmic examination 9. IF a person age 75 or older with or she should receive a primary or within 2 months. diabetes is diagnosed with macular updated prescription for corrective edema, THEN a dilated eye exam lenses. Function evaluation for cataract should be performed at least every 6 4. IF a person age 75 or older is months. Inpatient access to corrective lenses diagnosed with a cataract, THEN 15. IF a person age 75 or older who uses assessment of visual function with Cataract extraction corrective lenses for any activities of respect to his or her ability to carry out 10. IF a person age 75 or older is daily living is hospitalized (or in a needed or desired activities should be diagnosed with a cataract that limits the nursing home) and his or her corrective performed every 12 months. patient's ability to carry out needed or lenses are at the hospital (or nursing desired activities, THEN cataract home), THEN the corrective lenses Macular degeneration evaluation extraction should be offered. should be readily accessible to the 5. IF a person age 75 or older with age- person age 75 or older. related macular degeneration has a Cataract surgery follow up

new-onset change in vision, THEN he 11. IF a person age 75 or older undergoes Monitoring of glaucoma or she should have a dilated retinal cataract surgery, THEN a follow-up ocular exam should occur within 48 16. IF a person age 75 or over has examination of the affected eye within glaucoma, THEN documentation of 3 days. hours and re-examination should occur within 3 months. follow-up examinations of the eye Initial glaucoma evaluation should include the status of the optic 6. IF a person age 75 or older has a new Glaucoma follow up nerve. diagnosis of primary open-angle 12. IF a person age 75 or older with glaucoma, THEN the initial evaluation glaucoma experiences progressive optic

Related Quality Indicators for VISION CARE Dilated eye examination for patient with diabetes every 2 years (Diabetes #10)