eMeasure Title Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
eMeasure Identifier
(Measure Authoring Tool)
2 eMeasure Version number 2
NQF Number 0418 GUID 9a031e24-3d9b-11e1-8634-00237d5bf174
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Centers for Medicare & Medicaid Services
Measure Developer Quality Insights of Pennsylvania
Endorsed By National Quality Forum
Description
Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
Copyright
Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications.

CPT (R) contained in the Measure specifications is copyright 2007-2011 American Medical Association. 

LOINC (R) copyright 2004-2011 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2011 International Health Terminology Standards Development Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Disclaimer
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
The World Health Organization, as seen in Pratt & Brody (2008), found that major depression was the leading cause of disability worldwide. Depression causes suffering, decreases quality of life, and causes impairment in social and occupational functioning. It is associated with increased health care costs as well as with higher rates of many chronic medical conditions. Studies have shown that a higher number of depression symptoms are associated with poor health and impaired functioning, whether or not the criteria for a diagnosis of major depression are met. Persons 40-59 years of age had higher rates of depression than any other age group. Persons 12-17, 18-39 and 60 years of age and older had similar rates of depression. Depression was more common in females than in males. Non-Hispanic black persons had higher rates of depression than non-Hispanic white persons. In the 18-39 and 40-59 age groups, those with income below the federal poverty level had higher rates of depression than those with higher income. Among persons 12-17 and 60 years of age and older, rates of depression did not vary significantly by poverty status. Overall, approximately 80% of persons with depression reported some level of difficulty in functioning because of their depressive symptoms. In addition 35% of males and 22% of females with depression reported that their depressive symptoms make it very or extremely difficult for them to work, get things done at home, or get along with other people. More than one-half of all persons with mild depressive symptoms also reported some difficulty in daily functioning attributable to their symptoms. 

The negative outcomes associated with early onset depression, make it crucial to identify and treat depression in its early stages. As reported in Borner et al. (2010), a study conducted by the World Health Organization (WHO) reported that in North America, primary care and family physicians are likely to provide the first line of treatment for depressive disorders. Others consistently report a 10% prevalence rate of depression in primary care patients. But studies have shown that primary care physicians fail to recognize up to 50% of depressed patients, purportedly because of time constraints and a lack of brief, sensitive, easy-to administer psychiatric screening instruments. Coyle et al. (2003), suggested that the picture is more grim for adolescents, and that more than 70% of children and adolescents suffering from serious mood disorders go unrecognized or inadequately treated. In 2000, Healthy People 2010 recommended routine screening for mental health problems as a part of primary care for both children and adults.   
  
Major depressive disorder (MDD) is a debilitating condition that has been increasingly recognized among youth, particularly adolescents. The prevalence of current or recent depression among children is 3% and among adolescents is 6%. The lifetime prevalence of MDD among adolescents may be as high as 20%. Adolescent-onset MDD is associated with an increased risk of death by suicide, suicide attempts, and recurrence of major depression by young adulthood. MDD is also associated with early pregnancy, decreased school performance, and impaired work, social, and family functioning during young adulthood (Williams et al., 2009). Every fifth adolescent may have a history of depression by age 18. The increase in the onset of depression occurs around puberty. According to Zalsman et al. (2006), as reported in Borner et al. (2010), depression ranks among the most commonly reported mental health problems in adolescent girls. 

The economic burden of depression is substantial for individuals as well as society. Costs to an individual may include suffering, possible side effects from treatment, fees for mental health and medical visits and medications, time away from work and lost wages, transportation, and reduced quality of personal relationships. Costs to society may include loss of life, reduced productivity (because of both diminished capacity while at work and absenteeism from work), and increased costs of mental health and medical care. In 2000, the United States spent an estimated $83.1 billion in direct and indirect costs of depression (USPSTF, 2009).
Clinical Recommendation Statement
Adolescent Recommendation (12-18 years) 
The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up (2009).

Level II Child Preventive Services should be assessed and offered to each patient; as such services have been shown to be effective. Such Level II services include: Screening adolescents ages 12-18 for major depressive disorder when systems are in place for accurate diagnosis, treatment, and follow-up (ICSI, 2010).

Adult Recommendation (18 years and older) 
The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up (2009). 

Routine depression screening should be performed for adult patients (including older adults) but only if the practice has staff-assisted "systems in place to ensure that positive results are followed by accurate diagnosis, effective treatment, and careful follow-up" (ICSI, 2010).
Improvement Notation
Higher score indicates better quality.
Reference
Pratt L.A. & Brody DJ, NCHS Data Brief (2008). Sep;(7):1-8. Depression in the United States household population, 2005-2006.
Reference
Borner, I., Braunstein, J. W., St. Victor, R., & Pollack, J. (2010). Evaluation of a 2-Question Screening Tool for Detecting Depression in Adolescents in Primary Care, Clinical Pediatrics 49(10) 947–9532010
Reference
Coyle, J.T., Pine, D. S., Charney, D. S., Lewis, L, Nemeroff, C. B., et al. (2003). Depression and Bipolar Support Alliance Consensus Statement on the Unmet Needs in Diagnosis and Treatment of Mood Disorders in Children and Adolescents , Journal of the American Academy of Child & Adolescent Psychiatry Volume 42, Issue 12, December, 1494–1503
Reference
US Department of Health & Human Services, (n.d.) Healthy People 2010 Leading Health Indicators. Retrieved from http://www.healthypeople.gov/2010/LHI
Reference
Williams S.B., O’Connor, E.A., Eder, M., & Whitlock, E.P. (2009). Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventive Services Task Force. Pediatrics, 2009;123;e716-e735, DOI: 10.1542/peds.2008-2415
Reference
Zalsman, G., Brent, D.A. & Weersing, V.R.( 2006). Depressive disorders in childhood and adolescence: an overview: epidemiology, clinical manifestation and risk factors. Child Adolesc Psychiatr Clin N Am. 2006;15:827-841
Reference
U.S. Preventive Services Task Force (2009). The Guide to Clinical Preventive Services – 2009. Recommendations of the Screening for Depression in Adults.124-126
Reference
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT (ICSI) (2010). Preventive Services for Children and Adolescents. Retrieved from  http://www.icsi.org/preventive_services_ for_children __guideline_/ preventive_services_for_children_and_adolescents_2531.html
Definition
Screening: 
Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.  

Standardized Depression Screening Tool – A normalized and validated depression screening tool developed  for the patient population in which it is being utilized

Examples of depression screening tools include but are not limited to: 
•  Adolescent Screening Tools (12-17 years) 
Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire, Center for Epidemiologic Studies Depression Scale (CES-D) and PRIME MD-PHQ2 
•  Adult Screening Tools (18 years and older) 
Patient Health Questionnaire (PHQ9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (SDS), Cornell Scale Screening and PRIME MD-PHQ2 

Follow-Up Plan: 
Proposed outline of treatment to be conducted as a result of positive clinical depression screening. Follow-up for a positive depression screening must include one (1) or more of the following: additional evaluation, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, other interventions or follow-up for the diagnosis or treatment of depression.
Guidance
A clinical depression screen is complete on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. The documented follow up plan must be related to positive depression screening, example: “Patient referred for psychiatric evaluation due to positive depression screening.”

Standardized Depression Screening Tools should be normalized and validated for the age appropriate patient population in which they are used.
Transmission Format
TBD
Initial Patient Population
All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period.
Denominator
Equals Initial Patient Population
Denominator Exclusions
Patients with an active diagnosis for Depression or Bipolar Disorder
Numerator
Patients screened for clinical depression on the date of the encounter  using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screen
Numerator Exclusions
Not Applicable
Denominator Exceptions
Patient Reason(s)
Patient refuses to participate 

OR

Medical Reason(s)	
Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status 

OR

Situations where the patient’s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools.  For example: certain court appointed cases or cases of delirium
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
Preventive Care and Screening