eMeasure Title

Gap In HIV Medical Visits

eMeasure Identifier (Measure Authoring Tool) 312 eMeasure Version number 0.0.004
NQF Number None GUID 667cad46-09e0-4e84-b8c9-32eee76fb7ef
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward Health Resources & Services Administration
Measure Developer Health Resources & Services Administration
Endorsed By None
Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period within 24 months with a minimum of 60 days between medical visits.
Measure specifications are in the Public Domain.
This material contains CPT(R) copyright 2004-2016 American Medical Association, LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc., SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2015 International Health Terminology Standards Development Organisation, and ICD-10 copyright 2015 World Health 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].
These 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 without warranty.

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.
Measure Scoring Proportion
Measure Type Process
Risk Adjustment
Rate Aggregation
Human immunodeficiency virus (HIV) is a communicable infection that leads to a progressive disease. Without treatment, most persons develop acquired immunodeficiency syndrome (AIDS) within 10 years of HIV infection. Antiretroviral therapy delays this progression, increases the length of survival, and prevents sexual transmission of HIV. Early linkage to, and long-term retention in HIV care leads to better health outcomes. Linkage to HIV medical care shortly after HIV diagnosis and continuous care thereafter provide opportunities for risk reduction counseling, initiation of treatment, and other strategies that improve individual health and prevent onward transmission of infection. Delayed linkage and poor retention in care are associated with delayed receipt of antiretroviral treatment, higher rate of virologic failure, and increased morbidity and mortality. Early retention in HIV care has been found to be associated with time to viral load suppression and 2-year cumulative viral load burden among patients newly initiating HIV medical care.

Retention in medical care among people living with HIV is associated with a significantly greater mean increase in baseline CD4 count. Conversely, mortality is higher among those with suboptimal retention. While prompt linkage to, and sustained retention in, HIV medical care have been clearly shown to maximize patient outcomes, defining and measuring "optimal retention" is not necessarily straightforward, as the most appropriate or useful measure varies according to where the patient is in his/her treatment trajectory (newly diagnosed, recently re-engaged in care after some lapse in treatment, or long-time care recipients), who will use the measure (e.g., providers, administrators, or payors), and how the information yielded by the measure will be used. It is envisioned that this measure will have a significant impact on patient retention because the patients listed in the numerator are those who require a medical visit. In other words, no additional work needs to be done to generate a list of patients in need of follow-up. A list of the patients in the numerator can be generated, and the medical provider staff can immediately begin follow-up with the patient to schedule an appointment for a medical visit.
Clinical Recommendation Statement
HHS Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents:
Frequency of CD4 Count Monitoring. In general, CD4 counts should be monitored every 3-4 months to determine when to start ART in untreated patients, assess immunologic response to ART, and assess the need for initiation or discontinuation of prophylaxis for opportunistic infections.
At Initiation or Change in Therapy. Plasma viral load should be measured before initiation of therapy and preferably within 2-4 weeks, and not more than 8 weeks, after treatment initiation or after treatment modification. Repeat viral load measurement should be performed at 4-8-week intervals until the level falls below the assay's limit of detection. 
- In Patients Who Have Viral Suppression but Therapy Was Modified Due to Drug Toxicity or Regimen Simplification. Viral load measurement should be performed within 2-8 weeks after changing therapy. The purpose of viral load monitoring at this point is to confirm potency of the new regimen.
- In Patients on a Stable ARV Regimen. Viral load should be repeated every 3-4 months or as clinically indicated. Some clinicians may extend the interval to every 6 months for adherent patients who have suppressed viral loads for more than 2-3 years and whose clinical and immunologic status is stable.

Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection:
Consequently, CD4 values should be obtained as soon as possible after a child has a positive test for HIV and every 3 to 4 months thereafter. More frequent evaluation may be needed for children with suspected clinical, immunologic, or virologic deterioration; to confirm an abnormal value; or when initiating or changing therapy. Because young infants with HIV infection may have rapid disease progression, some experts monitor CD4 percentage more frequently (e.g., every 1-2 months) in untreated infants younger than 6-12 months of age. HIV RNA copy number should be assessed as soon as possible after a child has a positive virologic test for HIV and every 3 to 4 months thereafter; more frequent evaluation may be necessary for children experiencing virologic, immunologic, or clinical deterioration or to confirm an abnormal value.
Improvement Notation
A lower score indicates better quality
Giordano TP, Gifford AL, White AC Jr, Suarez-Almazor ME, Rabeneck L, Hartman C, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007; 44:1493-9. 
Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011; 365:493-505. 
Giordano TP, White AC Jr, Sajja P, Graviss EA, Arduino RC, Adu-Oppong A, et al. Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic. J Acquir Immune Defic Syndr. 2003; 32:399- 405. 
Lucas GM, Chaisson RE, Moore RD. Highly active antiretroviral therapy in a large urban clinic: risk factors for virologic failure and adverse drug reactions. Ann Intern Med. 1999; 131:81-7. 
Metsch LR, Pereyra M, Messinger S, Del Rio C, Strathdee SA, Anderson-Mahoney P, et al; Antiretroviral Treatment and Access Study (ARTAS) Study Group. HIV transmission risk behaviors among HIV-infected persons who are successfully linked to care. Clin Infect Dis. 2008; 47:577-84. 
Montaner JS, Lima VD, Barrios R, Yip B, Wood E, Kerr T, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010; 376:532- 9. 
Ulett KB, Willig JH, Lin HY, Routman JS, Abroms S, Allison J, Chatham A, Raper JL, Saag MS, Mugavero MJ. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS. 2009 Jan; 23(1):41-9. 
Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, Dombrowski JC, Norton WE, Raper JL, Kitahata MM, Saag MS. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr. 2012 Jan 1; 59(1):86-93. 
Mugavero MJ, Lin HY, Willig JH, Westfall AO, Ulett KB, Routman JS, Abroms S, Raper JL, Saag MS, Allison JJ. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009 Jan 15;48(2):248-56. 
Tripathi A, Youmans E, Gibson JJ, Duffus WA. The impact of retention in early HIV medical care on viro-immunological parameters and survival: a statewide study. AIDS Res Hum Retroviruses. 2011; 27:751-8. 
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed 11/25/2016.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed 11/25/2016.
Transmission Format
Initial Population
Patients, regardless of age, diagnosed with HIV during the first 3 months of the measurement period or prior to the measurement period who had at least one medical visit in the first 6 months of the measurement period.
Equals Initial Patient Population
Denominator Exclusions
Patients who died at any time during the measurement period.
Patients who did not have a medical visit in the last 6 months of the measurement period.
Numerator Exclusions
Denominator Exceptions
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 Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables

Measure Set