This is a table showing HEDIS – Healthcare Effectiveness Data and Information Set – concepts.
| Category | Concept | Numerator | Denominator | Plain English Description | Use Case | Keywords |
|---|---|---|---|---|---|---|
| Effectiveness of Care – Prevention | Childhood Immunization Status (CIS) | Children who received all recommended vaccines by their second birthday | All children who turned 2 years old during the measurement year | Measures whether young children received all NCQA-recommended vaccinations including DTaP, IPV, MMR, HiB, Hepatitis B, VZV, and pneumococcal conjugate by age 2. Combination rates track multiple vaccines together. | Use to evaluate pediatric preventive care quality and identify gaps in childhood vaccination rates. Critical for Stars ratings and public health outcomes. Helps practices target outreach for overdue immunizations. | childhood immunization, vaccines, CIS, DTaP, MMR, preventive care, pediatric quality |
| Effectiveness of Care – Prevention | Breast Cancer Screening (BCS) | Women aged 50-74 who had a mammogram during the measurement year or year prior | All women aged 50-74 years enrolled in health plan | Tracks compliance with breast cancer screening guidelines requiring mammography every 2 years for women in target age range. Focuses on early detection to improve cancer outcomes and reduce mortality. | Use to monitor cancer screening rates and identify women overdue for mammograms. Essential for preventive care outreach campaigns and HEDIS/Stars performance. Supports population health management for women’s health. | breast cancer, mammogram, BCS, cancer screening, women’s health, preventive screening |
| Effectiveness of Care – Prevention | Colorectal Cancer Screening (COL) | Adults aged 45-75 who had appropriate colorectal cancer screening (colonoscopy, FIT, Cologuard, sigmoidoscopy) | All adults aged 45-75 years enrolled in health plan | Measures whether adults received recommended colorectal cancer screening through various methods including colonoscopy (10 years), FIT test (annual), Cologuard (3 years), or flexible sigmoidoscopy (5 years). Multiple testing options allow member choice. | Use to track CRC screening compliance across different testing modalities. Critical for identifying screening gaps and supporting outreach for age-eligible members. Important Stars measure with significant weight. | colorectal cancer, colonoscopy, FIT, COL, cancer screening, preventive care, Cologuard |
| Effectiveness of Care – Prevention | Cervical Cancer Screening (CCS) | Women aged 21-64 who received appropriate cervical cancer screening (Pap test or HPV test) | All women aged 21-64 years enrolled in health plan | Tracks cervical cancer screening compliance using either Pap smear (every 3 years for ages 21-64) or HPV testing (every 5 years for ages 30-64). Age-specific screening intervals differ based on test type and risk factors. | Use to monitor cervical cancer screening rates and identify overdue women. Important for women’s preventive health programs and quality reporting. Helps target outreach based on last screening date and age. | cervical cancer, Pap smear, CCS, HPV test, women’s health, cancer screening |
| Effectiveness of Care – Diabetes | Comprehensive Diabetes Care (CDC) | Diabetic members meeting specific clinical targets or receiving recommended tests | All members aged 18-75 with diabetes (Type 1 or Type 2) | Multi-component measure tracking diabetes management including HbA1c testing, HbA1c control (<8% or <9%), eye exams, kidney monitoring (medical attention for nephropathy), and BP control. Each component has separate numerator/denominator calculations. | Use to evaluate comprehensive diabetes management across multiple clinical dimensions. Essential for chronic disease management programs and identifying gaps in diabetic care. Critical Stars measure with multiple reporting components. | diabetes, HbA1c, CDC, eye exam, nephropathy, blood pressure, chronic disease management |
| Effectiveness of Care – Diabetes | Hemoglobin A1c Control (<8%) | Diabetic members with most recent HbA1c level <8% | All members aged 18-75 with diabetes who had at least one HbA1c test during measurement year | Measures percentage of diabetic patients achieving good glycemic control defined as HbA1c less than 8%. Focuses on the most recent HbA1c value during the measurement year. Lower HbA1c reduces risk of complications. | Use to assess diabetes control quality and identify patients needing intervention for high blood sugar. Supports care management outreach for poorly controlled diabetics. Key quality indicator for diabetic population health. | HbA1c, glycemic control, diabetes management, blood sugar, A1c testing |
| Effectiveness of Care – Diabetes | Eye Exam for Patients with Diabetes | Diabetic members who received a retinal or dilated eye exam during measurement year or year prior | All members aged 18-75 with diabetes | Tracks whether diabetic patients received appropriate diabetic retinopathy screening through dilated eye exam or retinal photography. Biennial screening acceptable. Prevents blindness through early detection of diabetic eye disease. | Use to monitor diabetic eye exam compliance and prevent vision loss complications. Essential for diabetic care management programs and closing gaps in preventive services. Supports coordination between PCPs and ophthalmologists/optometrists. | diabetic retinopathy, eye exam, dilated exam, retinal photography, diabetes complications |
| Effectiveness of Care – Cardiovascular | Controlling High Blood Pressure (CBP) | Members with hypertension whose BP was adequately controlled (<140/90 mmHg) during measurement year | All members aged 18-85 with hypertension diagnosis | Measures percentage of hypertensive patients maintaining blood pressure below 140/90 mmHg. Uses most recent BP reading during measurement year. Adequate BP control reduces cardiovascular events, stroke, and kidney disease. | Use to evaluate hypertension management effectiveness and identify patients with uncontrolled BP needing intervention. Critical Stars measure heavily weighted in overall ratings. Supports cardiovascular risk reduction programs. | hypertension, blood pressure, CBP, cardiovascular disease, BP control, chronic disease |
| Effectiveness of Care – Cardiovascular | Statin Therapy for Patients with Cardiovascular Disease (SPC) | Members with clinical atherosclerotic cardiovascular disease who received statin therapy during measurement year | All members aged 21-75 with history of CVD including MI, CABG, PCI, stroke, or other atherosclerotic conditions | Tracks whether patients with established cardiovascular disease are prescribed and fill statins for secondary prevention. Focuses on medication adherence and appropriate prescribing for high-risk patients. | Use to ensure appropriate statin therapy for CVD patients to prevent recurrent events. Important for medication adherence programs and identifying gaps in evidence-based therapy. Supports pharmacy intervention initiatives. | statin therapy, cardiovascular disease, SPC, cholesterol, secondary prevention, medication adherence |
| Effectiveness of Care – Cardiovascular | Statin Therapy for Patients with Diabetes (SPD) | Diabetic members aged 40-75 who received statin therapy during measurement year | All members aged 40-75 with diabetes | Measures statin use in diabetic patients aged 40-75 for primary prevention of cardiovascular disease. Diabetes significantly increases CVD risk, making statin therapy evidence-based preventive treatment regardless of cholesterol levels. | Use to promote cardiovascular risk reduction in diabetic population through appropriate statin prescribing. Supports preventive cardiology initiatives and medication therapy management. Links diabetes and CVD prevention strategies. | statin therapy, diabetes, SPD, cardiovascular prevention, cholesterol, primary prevention |
| Effectiveness of Care – Respiratory | Medication Management for People with Asthma (MMA) | Asthmatic members who remained on controller medication for at least 75% of treatment period | All members aged 5-64 with persistent asthma who were prescribed controller medication | Tracks medication adherence for asthma controller medications (ICS, ICS/LABA, leukotriene modifiers) measuring whether patients filled enough medication to cover at least 75% of days (PDC ≥75%). Separate rates for different age groups. | Use to identify asthmatic patients with poor medication adherence needing intervention. Critical for reducing asthma exacerbations and ED visits. Supports pharmacy outreach and medication therapy management programs. | asthma, controller medication, MMA, medication adherence, PDC, respiratory disease |
| Effectiveness of Care – Respiratory | Pharmacotherapy Management of COPD Exacerbation (PCE) | COPD patients who received systemic corticosteroid and bronchodilator within 14 days of exacerbation | All members aged 40+ with COPD who had acute exacerbation (ED visit or inpatient stay) | Measures appropriate pharmacologic treatment of COPD exacerbations with both systemic corticosteroid and bronchodilator dispensed within 14 days of acute event. Two separate components for each medication class. | Use to evaluate quality of COPD exacerbation management and ensure evidence-based treatment. Helps identify gaps in post-exacerbation care and supports care transitions. Important for reducing COPD readmissions. | COPD, exacerbation, PCE, corticosteroid, bronchodilator, respiratory disease |
| Effectiveness of Care – Behavioral Health | Antidepressant Medication Management (AMM) | Members with depression who remained on antidepressant for acute phase (12 weeks) and continuation phase (6 months) | All members aged 18+ with new depression episode and antidepressant prescription | Two-part measure tracking antidepressant adherence for newly diagnosed depression: Acute Phase (84+ days in 114-day period) and Continuation Phase (180+ days in 231-day period). Focuses on appropriate treatment duration. | Use to promote adequate antidepressant treatment duration and reduce premature discontinuation. Critical for behavioral health quality and preventing depression relapse. Supports medication therapy management and behavioral health integration. | depression, antidepressant, AMM, medication adherence, behavioral health, mental health |
| Effectiveness of Care – Behavioral Health | Follow-Up After Emergency Department Visit for Mental Illness (FUM) | Members who had outpatient follow-up visit within 7 days and 30 days after ED visit for mental illness | All members aged 6+ who had ED visit with mental health primary diagnosis | Two rates measuring timely follow-up after mental health ED visits: within 7 days and within 30 days. Tracks outpatient, intensive outpatient, partial hospitalization, or telehealth follow-up to ensure care continuity. | Use to reduce readmissions and ensure appropriate care transitions after mental health crises. Critical for behavioral health integration and care coordination. Helps identify patients lost to follow-up after ED visits. | mental health, FUM, ED visit, follow-up care, behavioral health, care transitions |
| Effectiveness of Care – Behavioral Health | Follow-Up After Hospitalization for Mental Illness (FUH) | Members who had outpatient follow-up visit within 7 days and 30 days after psychiatric hospitalization discharge | All members aged 6+ who were hospitalized for mental illness | Two rates measuring timely outpatient follow-up after inpatient psychiatric discharge: within 7 days and within 30 days. Emphasizes care transitions and preventing readmissions through early engagement. | Use to improve care coordination after psychiatric hospitalization and reduce readmission risk. Essential for behavioral health care management and transitional care programs. Supports high-risk patient outreach. | mental health, FUH, hospitalization, discharge, follow-up, behavioral health |
| Access/Availability of Care | Adults’ Access to Preventive/Ambulatory Health Services (AAP) | Members who had at least one ambulatory or preventive care visit during measurement year | All members aged 20+ enrolled in health plan | Measures whether adult members engaged with healthcare system through ambulatory or preventive visits. Separate age stratifications (20-44, 45-64, 65-74, 75-85). Broad definition includes office visits, preventive visits, online assessments. | Use to track healthcare engagement and identify members who haven’t accessed care. Important for population health outreach and preventing care gaps. Indicates overall plan accessibility and member utilization patterns. | access to care, AAP, preventive care, ambulatory visit, primary care, engagement |
| Access/Availability of Care | Children and Adolescents’ Access to Primary Care Practitioners (CAP) | Children/adolescents who had at least one visit with PCP or OB/GYN during measurement year | All children and adolescents enrolled in health plan, stratified by age groups | Four age-stratified rates (12-24 months, 25 months-6 years, 7-11 years, 12-19 years) measuring whether children accessed primary care. Ensures appropriate well-child and preventive care utilization across developmental stages. | Use to monitor pediatric and adolescent healthcare access and identify children without PCP engagement. Essential for preventive care and developmental screening. Supports pediatric quality initiatives and medical home models. | pediatric access, CAP, primary care, children, adolescents, well-child visit |
| Utilization | Ambulatory Care (Emergency Department Visits) | Number of ED visits per 1,000 member months | All members enrolled in health plan | Tracks ED utilization rate, reported per 1,000 member months to normalize for enrollment fluctuations. Lower rates indicate better primary care access and chronic disease management. Separate reporting for different service categories. | Use to identify high ED utilization patterns and opportunities for care redirection to appropriate settings. Important cost and quality indicator. Supports case management for high utilizers and urgent care alternatives. | emergency department, ED visits, utilization, ambulatory care, avoidable ED use |
| Utilization | Inpatient Utilization (General Hospital/Acute Care) | Number of acute inpatient stays and days per 1,000 member months | All members enrolled in health plan | Measures hospital admission rates and total inpatient days, reported per 1,000 member months. Includes total inpatient stays, maternity stays, surgery stays, and medicine stays as separate components. Lower rates suggest better outpatient management. | Use to monitor hospital utilization trends and identify opportunities for admission prevention. Critical for care management targeting and cost containment. Supports population health strategies for reducing preventable admissions. | hospital admission, inpatient utilization, acute care, length of stay, admission rate |
| Risk Adjustment | Hierarchical Condition Categories (HCC) | Not applicable – risk scoring methodology | All Medicare Advantage members | CMS risk adjustment model using diagnosis codes to predict healthcare costs and adjust capitation payments. Higher risk scores reflect sicker populations. Requires complete annual diagnosis capture through claims and encounters. | Use to ensure accurate risk adjustment and appropriate capitation payments. Critical for Medicare Advantage plans to document chronic conditions. Supports annual wellness visits and comprehensive health assessments for diagnosis capture. | HCC, risk adjustment, Medicare Advantage, risk score, diagnosis capture, chronic conditions |
| Stars Ratings | Overall Star Rating | Not applicable – composite performance measure | All Medicare Advantage and Part D plans | CMS five-star quality rating system combining multiple HEDIS measures, CAHPS scores, and Part D metrics. Weighted average across domains (outcomes, process, patient experience, complaints). Determines quality bonus payments and marketing advantages. | Use to evaluate overall plan performance and qualify for quality bonus payments. Drives strategic quality improvement initiatives. Critical for plan competitiveness and member acquisition in Medicare market. | Stars ratings, CMS Stars, quality rating, Medicare Advantage, performance measures, quality bonus |
| Medication Adherence | Adherence to Diabetes Medications | Diabetic members with PDC ≥80% for diabetes medications (oral or non-insulin injectables) | All members aged 18+ with diabetes on oral medications or non-insulin injectables for at least 91 days | Measures medication adherence using Proportion of Days Covered (PDC) methodology requiring 80% coverage threshold. Includes metformin, sulfonylureas, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists. Does not include insulin. | Use to identify diabetic patients with poor medication adherence needing intervention. Important Stars measure and predictor of clinical outcomes. Supports pharmacy MTM programs and refill reminder initiatives. | medication adherence, diabetes, PDC, oral diabetes medications, pharmacy quality, Stars measure |
| Medication Adherence | Adherence to Hypertension (RAS Antagonists) Medications | Members with hypertension diagnosis who have PDC ≥80% for RAS antagonist medications | All members aged 18+ with hypertension on RAS antagonists (ACE inhibitors or ARBs) for at least 91 days | Tracks adherence to renin-angiotensin system antagonist medications (ACE inhibitors and ARBs) using 80% PDC threshold. Focuses on single drug class commonly prescribed for hypertension and cardiovascular protection. | Use to improve hypertension medication adherence and blood pressure control. Critical Stars measure linked to cardiovascular outcomes. Supports pharmacy outreach for patients missing refills. | medication adherence, hypertension, ACE inhibitor, ARB, PDC, RAS antagonist, pharmacy quality |
| Medication Adherence | Adherence to Cholesterol (Statins) Medications | Members with cardiovascular disease or diabetes on statin therapy who have PDC ≥80% | All members aged 18+ with CVD or diabetes on statin medications for at least 91 days | Measures statin adherence for high-risk patients using 80% PDC threshold. Targets patients most likely to benefit from cholesterol-lowering therapy due to CVD history or diabetes diagnosis. | Use to ensure appropriate statin adherence in high-risk populations to prevent cardiovascular events. Important Stars measure supporting secondary and primary prevention. Links to other cardiovascular quality measures. | medication adherence, statin, cholesterol, PDC, cardiovascular disease, diabetes, pharmacy quality |
| Overuse/Appropriateness | Non-Recommended Cervical Cancer Screening in Adolescent Females | Adolescent females aged 16-20 who received cervical cancer screening | All females aged 16-20 enrolled in health plan | Inverse measure where lower rates are better – tracks inappropriate cervical cancer screening in adolescents younger than recommended age 21. Overscreening causes unnecessary anxiety, procedures, and potential harm without clinical benefit. | Use to reduce inappropriate screening and follow evidence-based guidelines. Educational measure highlighting overuse of services. Supports provider education on age-appropriate preventive care guidelines. | cervical cancer screening, overuse, adolescents, inappropriate screening, guideline adherence |
| Overuse/Appropriateness | Use of Imaging Studies for Low Back Pain | Patients with new low back pain episode who had imaging study within 28 days | All members aged 18-50 with new primary low back pain diagnosis without red flag conditions | Inverse measure tracking overuse of imaging (X-ray, CT, MRI) for uncomplicated low back pain. Lower rates indicate appropriate conservative management. Excludes patients with red flag symptoms requiring imaging. | Use to reduce unnecessary imaging costs and radiation exposure for low back pain. Educational measure promoting evidence-based conservative care. Supports provider education on Choosing Wisely recommendations. | low back pain, imaging overuse, inappropriate imaging, conservative care, evidence-based medicine |