What is a HEDIS® measure?

Healthcare Effectiveness Data and Information Set (HEDIS®) is a standardized set of performance measures maintained by the National Committee for Quality Assurance (NCQA) used by >90% of health plans.^10,11 CMS works with NCQA to collect HEDIS® measures (HM) from Medicare Special Need Plans, using this to assess quality of care delivered by health plans, track improvement, and focus efforts on identifying performance gaps to improve health care.¹⁰ HEDIS® includes >90 measures across 6 domains of care: (i) effectiveness of care, (ii) access/availability of care, (iii) experience of care, (iv) utilization and risk-adjusted utilization, v) health plan descriptive information, and (vi) measures reported using electronic clinical data systems.¹¹ CMS offers “pay-for-performance incentives” or “value-based reimbursement” when insurers and providers aim to achieve compliance in all 6 domains.^10–12

HM were first developed as a mechanism to compare managed care organization plan quality.^{Reference McIntyre, Rogers and Overview13} HM create service accountability among health plans, providers, and medical institutions to justify the quality or value of healthcare plans, particularly when quality concerns related to underuse, overuse, or misuse of healthcare services and their associated patient harm arose during the late 1990s.^{Reference McIntyre, Rogers and Overview13} Table 1 outlines the current HM developed for ID conditions, or three targeted clinical diagnoses that account for >30% of all outpatient antibiotic prescriptions: bronchitis, upper respiratory infections (URIs), and pharyngitis,^{Reference Melville, Musser, Fishman, Rainis and Byron14} along with additional CMS quality measures (QM). HM are reported in three age stratifications, where the total rate is the sum of the age stratifications: pediatrics (ie, 3 months–17 years), 18–64 years, and ≥65 years.

Table 1.

A summary of quality measures, descriptions, and the antimicrobial stewardship target for performance measures

* This measure is designed to capture the frequency of antibiotic utilization for respiratory conditions and is meant to be used for internal evaluation only.

HM are calculated using outpatient and ED patient-level data through International Classification of Diseases, 10^th edition (ICD-10) for disease state diagnosis with an eligible denominator during the evaluation period, as derived from the affiliated health system. HM competency and assessment of progress can be challenging to interpret and rely on competitor payor and national data to set thresholds. Ambulatory ASPs should develop a strong relationship with the affiliated health system’s payor relations leadership for an individualized approach to HM progress and goals.

Measure #1—avoidance of antibiotic treatment for acute bronchitis/bronchiolitis (AAB)

The AAB measure evaluates the percentage of patients ≥3 months of age with an outpatient or ED visit diagnosed as having acute bronchitis/bronchiolitis (ICD-10 J20.0–J20.9) without select comorbid conditions who did not receive an antibiotic prescription within 3 days of the encounter.^{Reference Melville, Musser, Fishman, Rainis and Byron14} Patients with documented medical reasons for prescribing or dispensing antibiotics, or who used hospice services during the evaluation period, are excluded. Higher percentages indicate better care and adherence to evidence-based guidelines. The goal is to avoid unnecessary antibiotic use to minimize patient medication ADEs, reduce health expenditure, and combat antibiotic resistance.

Acute bronchitis is a top ten reason for outpatient visits in the United States,^{Reference Oeffinger, Snell, Foster, Panico and Archer15,Reference Stenehjem, Wallin and Willis16} with 70% resulting in unnecessary antibiotic prescriptions due to viral etiology.^{Reference Al-Hasan, Winders, Bookstaver and Justo9} Thus, it is a major stewardship target for independent and federal agencies.^{1,Reference Morley, Firgens and Vanderbilt17} Multiple national associations have published best practice recommendations to avoid antibiotics in URI, suggesting supportive care and symptom management as the mainstay of treatment.^{Reference Kinkade and Long18}

A 2023 study evaluated an effective ambulatory ASP intervention in urgent care, targeting reduced antibiotic prescribing for respiratory illnesses, including bronchitis.^{Reference Stenehjem, Wallin and Willis16} The stewardship intervention included clinician and patient education, electronic health record (EHR) tools, clinician benchmarking dashboard, incentivized performance with financial support, and media.^{Reference Stenehjem, Wallin and Willis16} Three-month post-intervention, there was a 47% reduction in antibiotic prescribing (OR, 0.53; 95%CI, 0.44–0.63; P <0.001).^{Reference Stenehjem, Wallin and Willis16} A multifaceted approach which focused on active clinician- and patient-focused educational materials was successful in reducing prescribing rates for bronchitis by 10.1% in the intervention period.^{Reference Chung, Nailon and Ashraf19} Another study included various outpatient settings who implemented a passive, prescriber-directed best practice advisory, and optional education regarding acute bronchitis treatment; antibiotic prescribing rates decreased by 9.4% (P <0.001) post-intervention.^{Reference Sanchez, Roberts, Albert, Johnson and Hicks20}

Measure #2 - appropriate treatment for URI

The URI measure evaluates the percentage of patients aged ≥3 months with an outpatient or ED visit with a non-bronchitis URI diagnosis (ICD-10 J00, J06.0, J06.9) who did not receive an antibiotic prescription <3 days of the encounter.¹¹ Encounters with competing diagnosis are excluded from the measure. Like the AAB measure, the URI measure aims to maximize the percentage of episodes managed without antibiotics.¹¹

Although mostly viral, URIs lead to antibiotic prescriptions in up to 32% of cases.^{Reference Chandra Deb, McGrath and Schlosser21} As such, national efforts have been designed to target inappropriate antibiotic prescribing for URI. National societies have disseminated strategies for treatment,^{Reference Harris, Hicks and Qaseem22} with recommendations based on the meta-analysis of 15 randomized controlled trials reporting increased patient ADEs when treated with antibiotics, thus supporting the recommendation against antibiotic therapy.^{Reference Smith, Fahey, Smucny and Becker23} Promoting over-the-counter symptomatic relief is a first-line recommendation, with low minor ADEs and proven to shorten illness duration.^{Reference Chang, Cheng and Chang24} Effective and impactful strategies to curb inappropriate antibiotic prescribing in URIs have been published, including a multifaceted intervention that reduced inappropriate URI prescriptions in outpatient pediatric and adult patients.^{Reference Davidson, Gentry, Priem, Kowalkowski and Spencer25} Patient and provider educational materials along with a computer-based dashboard for provider URI prescribing reduced antibiotic prescriptions from 41% pre-intervention to 33% during the intervention.^{Reference Davidson, Gentry, Priem, Kowalkowski and Spencer25} Another successful ASP intervention was conducted in rural China, reducing antibiotic prescribing in URIs for pediatric outpatients though provider training, guidelines, peer-review meetings, and caregiver education over 6 months.^{Reference Wei, Zhang and Walley26} The authors concluded a 29% absolute risk reduction in antibiotic prescribing due to the intervention (95%CI, –42 to –16; P = 0.002).^{Reference Wei, Zhang and Walley26} Despite these positive findings,^{Reference Davidson, Gentry, Priem, Kowalkowski and Spencer25–Reference Ilges, Jensen and Draper27} studies evaluating education, training, or tools used for patient or provider-directed URI interventions have shown heterogenous results.^{Reference Thompson and McCormack28} Separate studies highlight inconsistencies in antibiotic prescribing when comparing the use of educational materials to control groups.^{Reference Thompson and McCormack28,Reference Mortazhejri, Hong and Yu29}

A potentially underutilized method to reduce antibiotic use is delayed antibiotic prescription-filling interventions with various approaches: delayed prescriptions, patient-led prescriptions, post-dated prescriptions, delayed collection, and delayed re-contact.^{Reference Thompson and McCormack28} Literature on delayed antibiotic prescribing (ie, “wait and watch”) showed efficacy as a stewardship intervention, as patients who received delayed antibiotics were less likely to use antibiotics compared to the group who received a prescription at the encounter.^{Reference Thompson and McCormack28} Delayed antibiotic interventions resulted in similar patient satisfaction and fewer antibiotic ADEs (specifically, a lower rate of diarrhea) between groups.^{Reference Thompson and McCormack28}

Measure #3—appropriate testing for pharyngitis (CWP)

CWP assesses the percentage of patients aged ≥3 years with an outpatient or ED visit diagnosis of pharyngitis (ICD-10 J02.8, J02.9, J02.0) who had an appropriate antibiotic ordered and received a group A streptococcus (GAS) diagnostic test within 3 days of the encounter.¹¹ Patients receiving hospice services during the encounter or who received antibiotics <30 days of the encounter are excluded. The purpose of this measure is to reduce unnecessary antibiotic use by confirming GAS diagnosis via testing prior to antibiotic prescription.

Pharyngitis, with either viral or bacterial etiologies, is another leading cause of outpatient visits. Unlike other URIs, rapid antigen detection tests (RADT) distinguish between viral and GAS pharyngitis within minutes, therefore optimizing antibiotics through a test-and-treat method. Patients who undergo RADT also demonstrate a higher level of adherence to the test-and-treat approach.¹¹ Despite the CWP measure and the high sensitivity of RADT for GAS pharyngitis, appropriate testing rates have declined nationwide across all insurance plans recently.¹¹ One study found that antibiotics are prescribed in 70% of pediatric primary care visits with unconfirmed pharyngitis.^{Reference Cohen, Cohen and Levy30}

When differentiating between bacterial and viral pharyngitis, “clinical diagnosis cannot be made with certainty even by the most experienced physicians.”^{Reference Cohen, Cohen and Bidet31,Reference Shulman, Bisno and Clegg32} Bacterial pharyngitis causes an estimated 30% and 15% of pharyngitis episodes in children and adults, respectively,³³ and viruses are the most common cause of pharyngitis across all age groups. Prediction tools for identifying GAS pharyngitis based on clinical features have been published, but fail to demonstrate diagnostic accuracy, particularly in children.^{Reference Cohen, Cohen and Levy30} This underscores the critical importance of conducting diagnostic tests prior to prescribing antibiotics. The reluctance to not prescribe antibiotics for pharyngitis may stem from the potential risks of untreated disease complications,^{Reference Shulman, Bisno and Clegg32} but adherence of this measure can mitigate antibiotic overuse.

With high specificity of RADT and cultures, why do physicians still rely more on their clinical judgment when it has been described as faulty?^{Reference Avent, Cosgrove, Price-Haywood and van Driel34} Avent et al discussed the need for a sustainable “top-down strategy” in the ambulatory setting.^{Reference Avent, Cosgrove, Price-Haywood and van Driel34} HAPPY AUDIT was a multinational, pre-post-study evaluating a multifaceted intervention targeting general practitioners’ treatment of patients with respiratory infections, including GAS pharyngitis, and was effective for reducing the number of antibiotic prescriptions in six countries with a sustainable intervention after a 6-year audit.^{Reference Bjerrum, Munck and Gahrn-Hansen35–Reference Molero, Cordoba, López-Valcárcel, Moragas, Losa and Llor37} Molero et al evaluated the practitioners who participated in the HAPPY AUDIT intervention in Spain, inviting them to participate in another pre- post-intervention and 6-year audit with a focus on acute pharyngitis RADT and antibiotic prescribing.^{Reference Molero, Cordoba, López-Valcárcel, Moragas, Losa and Llor37} Regrettably, the intervention’s sustainability was suboptimal: RADTs were utilized less (51.7% to 49.4%), and increased antibiotic prescriptions (21.3%–36.1%, P <0.001) resulted in over 2-fold increase in antibiotics prescribed after 6 years (odds ratio: 2.24, 95% confidence interval: 1.73–2.89).^{Reference Molero, Cordoba, López-Valcárcel, Moragas, Losa and Llor37}

Measure #4—antibiotic utilization for respiratory conditions (AXR)

Of the four measures, the most recently published HM was AXR in 2022. The purpose of this measure is to summarize data on the percentage of outpatient episodes (i.e., telephone encounter, ED visit, e-visit, virtual check-in) for members > 3 months of age with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event.¹¹ This measure coincides with the three previously discussed measures, but with less variability in diagnosis and coding practices for health plans to compare prescribing more accurately for these respiratory conditions.³⁸ Since NCQA does not view higher or lower service counts as indicative of better or worse performance for this measure, organizations can only leverage this measure for internal benchmarks and evaluation.

Additional QM

CMS has also developed QM with a goal to deliver safe, efficient, and equitable patient-centered care. QM are important for public reporting and pay-for-reporting programs.³⁹ As of 2024, two ASP-related QM fall under the merit-based incentive payment systems, including avoiding overuse of antibiotic prescribing in adult sinusitis and prescribing appropriate antibiotics for acute bacterial sinusitis.^40,41 Measures are met when antibiotic prescribing occurs <10 days after sinusitis symptoms onset, and when amoxicillin (with/without clavulanate) was prescribed as the first-line antibiotic at diagnosis. A systematic review found no clear benefits of antibiotics over placebo (or no treatment) for rapid recovery in adults with acute rhinosinusitis in the ambulatory setting but noted an increase in side effects.^{Reference Lemiengre, van Driel, Merenstein, Liira, Mäkelä and De Sutter42} Like other QM, bundled stewardship interventions were associated with guideline-concordant antibiotic use for sinusitis including telemedicine visits.^{Reference Wasylyshyn, Kaye and Chen43} These additional measures are outlined in Table 1.

Notably, there are additional QM tied to patient immunizations among the general population and people living with HIV that may be worth considering based on the ASP’s capacity.⁴⁴ Focusing on preventative measures, including vaccinations for pneumococcal disease, SARS-CoV-2, and influenza, can serve as a proactive stewardship strategy that can reduce the incidence of respiratory illnesses. This, in turn, could decrease the number of healthcare episodes for such conditions, thereby minimizing the likelihood of unnecessary antibiotic prescriptions.

How should the ASP leverage HEDIS® and other performance measures?

Newly established ambulatory ASPs may lack strategic direction or struggle to identify high-value targets for intervention. The ASP’s initial stewardship targets should include HM given their implications on value-based reimbursement, pay-for-performance metrics, patient satisfaction, and incentivization to participate in other performance measures or rewards. The ambulatory ASP should gather baseline and trended HEDIS® data to identify pragmatic interventions and use these insights to strengthen provider relationships for future initiatives beyond HEDIS®. Methods to disseminate constructive feedback to prescribers related to HM performance could include e-mail, through the EHR public dashboard display, or through routine presentation at stakeholder meetings. Figure 1 proposes a stepwise approach. Each institution should formalize specific goals with stakeholders (ie, organizational leadership) based on HEDIS benchmarks as key performance indicators for ambulatory practices and providers that can be tied to financial incentives and disincentives, as well as performance reviews. Ideally, this information should be presented to end users and leadership through easy-to-interpret displays and in other data-sharing avenues (ie, personalized report cards, dashboards).

Figure 1.

A stepwise approach for the ambulatory steward to leverage the performance measures.

Source: https://www.canva.com/design/DAGRspmkee0/8wJiv1McJECYl2EayQYL6w/edit

A review of literature describing barriers and challenges

Enablers and opportunities

Legislative change, comparative scorecards, and multi-institutional efforts

Advocacy is essential to informing policy around ambulatory infectious syndromes and translate it into actionable change and quantifiable results.⁶ Health systems should collaborate with other hospitals on quality initiatives to improve the delivery of quality patient care. For example, the Michigan Hospital Medicine Safety Consortium (HMS) unites hospitals statewide to collect and analyze data, implement improvement strategies, and evaluate change over time.⁶² Although HMS currently focuses on hospitalized patients, the development of validated measures of inappropriate diagnosis for UTI and community acquired pneumonia has reduced antibiotic use, including for ASB.^{Reference Vaughn, Gupta and Petty63,Reference White, Vaughn and Petty64} These measures are now endorsed by the National Quality Forum. Sharing data between institutions can also create comparative scorecards whereby ambulatory ASP can select which measures are top priority to focus efforts to incentivize and generate buy-in with the C-suite (Figure 2).

Figure 2.

Example of a HEDIS® measure scorecard to inform opportunities for improvement. In this example, the institution is scoring significantly lower than both the Physician Group Incentive Program (PGIP) average and the 90^th percentile in the measure of appropriate testing for pharyngitis. For the antimicrobial steward reviewing this scorecard, it would be important to prioritize that measure over avoiding antibiotics for bronchitis and appropriate treatment for upper respiratory infections, where the program is scoring better than the average.