Major Depressive Disorder (MDD): Suicide Risk Assessment (NQF 0104)

eMeasure Name Major Depressive Disorder (MDD): Suicide Risk Assessment eMeasure Id BBD7B8F2-A69A-46FA-A302-1494C26A57D9
Version number 1 eMeasure Set Id A8F1CA32-93E3-4C0A-811B-86EEF019D547
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward American Medical Association - Physician Consortium for Performance Improvement
Endorsed by National Quality Forum
Description Percentage of patients who had a suicide risk assessment completed at each visit.
Copyright
© 2010 American Medical Association. All Rights Reserved
Measure scoring Proportion
Measure type Process
Stratification
None
Risk Adjustment
None
Data Aggregation
Rationale
Research has shown that patients with major depressive disorder are at a high risk for suicide, which makes this assessment an important aspect of care that should be assessed at each visit.
Clinical Recommendation Statement
A careful assessment of the patient's risk for suicide is crucial. An assessment of the presence of suicidal ideation is essential, including the degree to which the patient intends to act on any suicidal ideation and the extent to which the patient has made plans for or begun to prepare for suicide. (APA)
The components of an evaluation for suicide risk [include an assessment of the following]:
1) Presence of suicidal or homicidal ideation, intent, or plans
2) Access to means for suicide and the lethality of those means
3) Presence of psychotic symptoms, command hallucinations, or severe anxiety
4) Presence of alcohol or substance abuse
5) History and seriousness of previous attempts
6) Family history or recent exposure to suicide (APA)
Improvement notation
Higher score indicates better quality
Measurement duration
12 month(s)
Reference
American Psychiatric Association (APA). Practice guidelines for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(suppl 4): 1-45.
Definition
Assessment may include: Documentation of current medications, continue same medications, change in medication dose, documentation indicating that the patient was asked about OTC medication use
Definition
Initial Patient Population(s): Patients aged 18 years and older at the beginning of the measurement period.
Diagnosis Active:  Patient has a documented diagnosis of Major Depressive Disorder (MDD), new or recurrent episode
Encounter:  At least two visits with the physician, physician's assistant, or nurse practitioner during the measurement period.
Definition
Denominator(s): All patients aged 18 years and older with a new diagnosis or recurrent episode of MDD.
Definition
Denominator Exclusion(s): N/A
Definition
Numerator(s): Patients who had suicide risk assessment completed at each visit
Definition
Denominator Exception(s): N/A
Guidance
A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period. For patients with multiple encounters, each encounter should count separately in the denominator.
Supplemental Data Elements
Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)".

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Supplemental Data Elements




Measure set CLINICAL QUALITY MEASURE SET 2011-2012