Preventive Care and Wellness (Composite)

Measure Specification

With rising rates of certain chronic conditions in the general population, wellness and preventive care have become increasingly important to improve outcomes and reduce costs. Research shows that performing the preventive services identified in the measure leads to identification of disease earlier in the care process (screenings) or prevention of disease (immunizations), which enables treatment to begin earlier, potentially improving patient outcomes.

The composite measure can provide an opportunity for providers and patients to identify and manage a patient’s health risks for many preventable conditions. This measure assigns a single performance score reflecting overall eligible clinician delivery of age- and sex-appropriate preventive screenings and wellness services to their patients. The seven services in this measure are (1) influenza vaccination, (2) pneumococcal vaccination, (3) breast cancer screening, (4) colorectal- cancer screening, (5) body mass index screening and follow-up, (6) tobacco use screening and intervention, and (7) screening for high blood pressure and follow-up.

The services contained in the measure are recommended by USPSTF, ACIP, and AACE/ACE and apply to the general population (rather than a specific age group with specific risks, for example, older adults with cardiovascular risk). Although increased use of preventive care services may cause a short- term increase in health care costs, it may result in better quality of life and care.

A study of preventive services covered under the Affordable Care Act examined the extent to which lives could be saved if adults over 18 received them, including some addressed by this measure. The article states that preventive services ameliorate 9 of the 10 leading causes of death in America and could save at least 100,000 lives. Among the services referenced are screening for breast cancer, colon cancer, blood pressure, diabetes, and tobacco cessation, as well as influenza and pneumococcal vaccination.

Higher rates of patient compliance with the appropriate and recommended preventive services could save additional lives and ensure better health outcomes. Composites can overcome statistical challenges such as small sample sizes while reducing data burden for interpretability. Due to the condensed nature of the composite’s information, it is more feasible to track a broader, more comprehensive range of metrics than otherwise possible, making composites well suited for pay-for-performance incentives or consumer decisions about clinicians.

Composite measures are an important strategy to maintain data fidelity as they are more likely to be stable over time, making incentives less sensitive to individual measure performance. Potential implementation of this composite measure not only provides a more comprehensive assessment of a clinician’s performance of preventive care than any single measure, but also provides CMS an opportunity to replace the individual measures in the program with a more robust measure, which aligns with the meaningful measure framework’s goal to include fewer, more robust measures in the program overall.

Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. For each recipient, a licensed and age-appropriate vaccine should be used. Advisory Committee on Immunization Practices (ACIP) makes no preferential recommendation for a specific vaccine when more than one licensed, recommended, and age-appropriate vaccine is available.

During the 2022–23 influenza season, the following types of vaccines are expected to be available quadrivalent, containing hemagglutinin (HA) derived from one influenza A(H1N1)pdm09 virus, one influenza A(H3N2) virus, one influenza B/Victoria lineage virus, and one influenza B/Yamagata lineage virus. Inactivated influenza vaccines (IIV4s), recombinant influenza vaccine (RIV4), and live attenuated influenza vaccine (LAIV4) are expected to be available.

(CDC/Advisory Committee on Immunization Practices [ACIP], 2022). Adults aged ≥ 65 years who have not previously received pneumococcal conjugate vaccine (PCV) or whose previous vaccination history is unknown should receive 1 dose of PCV (either PCV20 or PCV15). Adults aged 19–64 years with certain underlying medical conditions or other risk factors who have not previously received PCV or whose previous vaccination history is unknown should receive 1 dose of PCV (either PCV20 or PCV15).

Dosing schedule for PCV15: When PCV15 is used, it should be followed by a dose of PPSV23. The recommended interval between administration of PCV15 and PPSV23 is ≥1 year. A minimum interval of 8 weeks can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk for IPD caused by serotypes unique to PPSV23 in these vulnerable groups.

Adults with previous PPSV23 only: Adults who have only received PPSV23 may receive a PCV (either PCV20 or PCV15) ≥1 year after their last PPSV23 dose. When PCV15 is used in those with history of PPSV23 receipt, it need not be followed by another dose of PPSV23. Adults with previous PCV13: The incremental public health benefits of providing PCV15 or PCV20 to adults who have received PCV13 only or both PCV13 and PPSV23 have not been evaluated.

These adults should complete the previously recommended PPSV23 series (Kobayashi et al., 2022). The CDC further clarifies that the previous pneumococcal recommendations remain in effect pending further evaluation and recommends using the following information for guidance on the number of and interval between any remaining recommended doses of PPSV23 following previous receipt of PCV13 (CDC, 2022).

- For adults 65 years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, CDC recommends 1 dose of PPSV23 at age 65 years or older. Administer a single dose of PPSV23 at least 1 year after PCV13 was received. Their pneumococcal vaccinations are complete. - For adults 19 years or older with a cerebrospinal fluid leak or cochlear implant, CDC recommends 1 dose of PPSV23 before age 65 years and 1 dose of PPSV23 at age 65 years or older.

Administer a single dose of PPSV23 at least 8 weeks after PCV13 was received. If the adult is 65 years or older, their pneumococcal vaccinations are complete. If the adult was younger than 65 years old when the first dose of PPSV23 was given, then administer a final dose of PPSV23 once they turn 65 years old and at least 5 years have passed since PPSV23 was first given.

Their pneumococcal vaccinations are complete. - Adults 19 years or older with an immunocompromising condition, CDC recommends 2 doses of PPSV23 before age 65 years and 1 dose of PPSV23 at age 65 years or older. Administer a single dose of PPSV23 at least 8 weeks after PCV13 was received. If the patient was younger than 65 years old when the first dose of PPSV23 was given and has not turned 65 years old yet, administer a second dose of PPSV23 at least 5 years after the first dose of PPSV23.

This is the last dose of PPSV23 that should be given prior to 65 years of age. Once the patient turns 65 years old and at least 5 years have passed since PPSV23 was last given, administer a final dose of PPSV23 to complete their pneumococcal vaccinations. - For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available.

If PCV20 is used, their pneumococcal vaccinations are complete. The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 40-74 years (B recommendation) (USPSTF, 2023). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older (I statement) (USPSTF, 2023).

The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer (I Statement) (USPSTF, 2016). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, in women identified to have dense breasts on an otherwise negative screening mammogram (I statement) (USPSTF, 2023).

The National Comprehensive Cancer Network (NCCN) and the American College of Radiology (ACR) recommend using conventional mammography or DBT for screening women at low, intermediate or high risk for breast cancer (NCCN, 2021) (ACR, 2017). The U.S. Preventive Services Task Force (2021) recommends screening for colorectal cancer in adults aged 45 to 49 years.

This is a Grade B recommendation (U.S. Preventive Services Task Force 2021). The U.S. Preventive Services Task Force (2021) recommends screening for colorectal cancer in adults aged 50 to 75 years. This is a Grade A recommendation (U.S. Preventive Services Task Force, 2021). Appropriate screenings are defined by any one of the following: -Colonoscopy (every 10 years) -Flexible sigmoidoscopy (every 5 years) -Fecal occult blood test (annually) -Stool DNA (sDNA) with FIT test (every 3 years) -Computed tomographic colonography (every 5 years) All adults should be screened annually using a BMI measurement.

BMI measurements >25kg/m2 should be used to initiate further evaluation of overweight or obesity after taking into account age, gender, ethnicity, fluid status, and muscularity; therefore, clinical evaluation and judgment must be used when BMI is employed as the anthropometric indicator of excess adiposity, particularly in athletes and those with sarcopenia (Garvey, et al.

, 2016 AACE/ACE Guidelines, 2016. pp. 12-13) (Grade A). Overweight and Underweight Categories: Underweight <18.5; Normal weight 18.5-24.9; Overweight 25-29.9; Obese class I 30-34.9; Obese class II 35-39.9; Obese class III >40 (Garvey, et al., 2016 AACE/ACE Guidelines, 2016. p. 15). BMI cutoff point value of ≥23 kg/m2 should be used in the screening and confirmation of excess adiposity in Asian adults (Garvey, et al.

, 2016 AACE/ACE Guidelines, 2016,. p. 13) (Grade B). Lifestyle/Behavioral Therapy for Overweight and Obesity should include behavioral interventions that enhance adherence to prescriptions for a reduced-calorie meal plan and increased physical activity (behavioral interventions can include: self-monitoring of weight, food intake, and physical activity; clear and reasonable goal-setting; education pertaining to obesity, nutrition, and physical activity; face-to-face and group meetings; stimulus control; systematic approaches for problem solving; stress reduction; cognitive restructuring [i.

e., cognitive behavioral therapy], motivational interviewing; behavioral contracting; psychological counseling; and mobilization of social support structures) (Garvey, et al., 2016 AACE/ACE Guidelines, 2016. p. 22) (Grade A). Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural, socioeconomic, and educational background (Garvey, et al.

, 2016 AACE/ACE Guidelines, 2016. p. 22) (Grade B). The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer or refer adults with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. Interventions: Effective intensive behavioral interventions were designed to help participants achieve or maintain a weight loss of at least five percent through a combination of dietary changes and increased physical activity Most interventions lasted for one to two years, and the majority had at least 12 sessions in the first year Most behavioral interventions focused on problem solving to identify barriers, self-monitoring of weight, peer support, and relapse prevention Interventions also provided tools to support weight loss or weight loss maintenance (e.

g., pedometers, food scales, or exercise videos) (Grade B) (USPSTF, 2018). Nutritional safety for the elderly should be considered when recommending weight reduction. “A clinical decision to forego obesity treatment in older adults should be guided by an evaluation of the potential benefits of weight reduction for day-to-day functioning and reduction of the risk of future cardiovascular events, as well as the patient’s motivation for weight reduction.

Care must be taken to ensure that any weight reduction program minimizes the likelihood of adverse effects on bone health or other aspects of nutritional status” (NHLBI Obesity Education Initiative, 1998, p. 91) (Evidence Category D). In addition, weight reduction prescriptions in older persons should be accompanied by proper nutritional counseling and regular body weight monitoring (NHLBI Obesity Education Initiative, 1998, p.

91). The possibility that a standard approach to weight loss will work differently in diverse patient populations must be considered when setting expectations about treatment outcomes (NHLBI Obesity Education Initiative, 1998, p. 97) (Evidence Category B). The US Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.

S. Food and Drug Administration (FDA)- approved pharmacotherapy for cessation to nonpregnant adults who use tobacco (Grade A Recommendation) (U.S. Preventive Services Task Force, 2021). The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco (Grade A Recommendation) (U.

S. Preventive Services Task Force, 2021) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women (Grade I Statement) (U.S. Preventive Services Task Force, 2021). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of electronic cigarettes (e-cigarettes) for tobacco cessation in adults, including pregnant persons.

The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety (Grade I Statement) (U.S. Preventive Services Task Force, 2021). The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents (Grade B Statement) (U.

S. Preventive Services Task Force, 2020). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care--feasible interventions for the cessation of tobacco use among school-aged children and adolescents (Grade I Statement) (U.S. Preventive Services Task Force, 2020). All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis.

Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008).

All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008). Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.

Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008). The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone.

Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008). The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 years and older.

This is a grade A recommendation (2021).

This measure contains seven strata defined by seven submission criteria. This measure produces seven performance rates which are used for a weighted average. There are 7 Submission Criteria for this measure: 1) All patients who were screened for influenza vaccination AND 2) All patients who were screened for pneumococcal vaccination status for older adults AND 3) All patients who were screened for breast cancer AND 4) All patients who were screened for colorectal cancer screening AND 5) All patients who were screened for body mass index (BMI): screening and follow-up plan AND 6) All patients who were screened for tobacco use: screening and cessation interventions AND 7) All patients who were screened for high blood pressure and follow-up documented This measure will be calculated with 7 performance rates: 1) Percentage of patients who received an influenza immunization or who reported previous receipt of an influenza immunization 2) Percentage of patients 65 years of age or older who received a pneumococcal vaccination on or after their 19th birthday 3) Percentage of patients with a mammogram during the 27 months prior to the end of the measurement period 4) Percentage of patients with one or more appropriate colorectal cancer screenings 5) Percentage of patients with a documented Body Mass Index (BMI), with follow-up plan if applicable, during the encounter or during the previous 12 months 6) Percentage of patients screened for tobacco use and, if identified as a tobacco user, received cessation intervention during the encounter or within the previous six months 7) Percentage of visits where patients were screened for high blood pressure with a documented follow-up plan, as indicated For accountability reporting in the CMS MIPS program, all seven performance rates must be submitted, and a weighted average will be used for performance.

For the purposes of MIPS implementation, this visit measure is submitted each time a patient has a denominator eligible encounter during the performance period. However, the individual performance rates have different submission frequencies.