2020 MBHR Measure: Anxiety Screening

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Title Anxiety Screening
NQS Domain Community/Population Health
Measure ID MBHR1
NQF ID n/a
Measure Type Process
High Priority? No
Description The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, GAD-2, BAI) during measurement period.
Denominator Adult patients (18 years of age or older) with an anxiety disorder diagnosis (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder)

F40.1 Social phobias
F40.10 Social phobia, unspecified
F40.11 Social phobia, generalized
F41.0 Panic disorder without agoraphobia
F41.1 Generalized anxiety disorder
F41.3 other mixed anxiety disorders
F41.8 other specified anxiety disorders
F41.9 anxiety disorder unspecified
F43.1 Post-traumatic stress disorder (PTSD)
F43.10 Post-traumatic stress disorder, unspecified
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic

Denominator Exclusions Patients who die or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of schizophrenia or psychotic disorder.

F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.5 Residual schizophrenia
F20.81 Schizophreniform disorder
F20.89 Other schizophrenia
F20.9 Schizophrenia, unspecified
F23 Brief psychotic disorder
F25.0 Schizoaffective disorder, bipolar type
F25.1 Schizoaffective disorder, depressive type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
F28 Other psychotic disorder not due to a substance or known physiological condition

Numerator Adult patients (18 years of age or older) included in the denominator who have at least one GAD-7 tool administered and completed during a four-month measurement period. If positive (i.e., score equal to or greater than 10), this suggests a probable anxiety diagnosis which requires documentation of an appropriate follow-up plan such as further evaluation or referral to treatment.

Numerator Exclusions: None

Data Source Claims, EHR, Paper Medical Record, Registry
Meaningful Measure Area Prevention, Treatment, and Management of Mental Health
Meaningful Measure Rationale Utilization of the GAD-7 tool with individuals with anxiety disorders will improve the quality of care transitions and communications across care settings, and improve quality of life for patients with anxiety by identifying and addressing appropriate treatment needs. This provides a standardized way to communicate status which will improve both quality of treatment and efficient use of resources.
Inverse Measure? No
Proportional Measure? Yes
Continuous Variable Measure? No
Ratio Measure No
Number of Performance Rates 1
Risk Adjusted No
Preferred Specialty mental and behavioral health
Applicable Specialties Family Practice, Internal Medicine, Geriatric Medicine, Psychiatry, Mental/Behavioral Health

Measure Justification

Anxiety disorders are highly prevalent mental health problems, affecting approximately 18% of the adult population in the United States1. Although as common as depression, anxiety disorders have received less attention, leading to under-detection and lack of treatment, particularly in primary care settings2. Anxiety disorders can be disabling, having a substantial impact on patient functioning, work productivity, and health care utilization3. Moreover, anxiety disorders cost the United States an estimated $42 billion dollars per year4. Accordingly, a need to assess for anxiety symptoms rapidly in diverse treatment settings is essential to address the mental health needs of the public.
While originally developed to screen for generalized anxiety disorder, the GAD-7 is likely better characterized as an assessment of anxiety disorders generally rather than one of generalized anxiety disorder in particular. Studies have found that the GAD-7 is good at screening for panic disorder, social anxiety disorder and post-traumatic stress disorder3. Based on large and diverse sample (N=5223), a cut-off score of 8 was recommended for sensitivity to anxiety disorder diagnoses in general and generalized anxiety disorder5.

The psychometric properties of the GAD-7 have been examined in several different populations. Multiple studies have established internal consistency for the GAD-76,7,8, including finding that alpha reliability was consistent across all four diagnostic categories (generalized anxiety disorder, posttraumatic stress disorder, social anxiety disorder, and panic disorder)9. Good convergent validity with measures of depression, anxiety, general stress, and worry has also been established6,7,9,10.

Numerous guidelines have recommended assessing for anxiety in a variety of populations, including individuals who positively screen for depression11, patients who present for initial psychiatric evaluations12, individuals at risk for suicide13, and as part of a comprehensive pain assessment in older adults14. Specifically, a guideline from the American Society of Clinical Oncology15, recommends that Òall health care providers should routinely screen for the presence of emotional distress and specifically symptoms of anxietyÉuse(ing) the Generalized Anxiety Disorder (GAD)-7 scaleÓ in adults with cancer.

While screening for anxiety disorders might be considered a standard of care, it is unclear whether routine screening is occurring. In a sample of practicing psychologists, only 39% reported routinely using outcome assessments to monitor progress (Wright et al., 2017). In addition, only a minority of patients (15% to 36%) with anxiety are recognized in primary care (Kessler et al., 1999; Lowe et al., 2003). Further, Kroenke et al. (2007) found that in a sample of individuals with at least one anxiety disorder, 41% were receiving no treatment for their disorder. These findings suggest that while anxiety disorders are quite common, they continue to be underrecognized and undertreated, thus warranting the inclusion of a process measure to ensure that adequate screening is occurring.

1. Kessler, R.C., Chiu, W.T., Dernier, O., & Walters, E.E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62, 617-627.
2. Kessler, D., Lloyd, Lewis, G., & Gray, D. P. (1999). Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ, 318, 436-439.
3. Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., & Lowe, B. (2007). Anxiety disorders in primary care: Prevalence, impairment, Comorbidity, and detection. Annals of Internal Medicine, 146, 317-325.
4. Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S.N., Berndt, E. R., Davidson, J. R., et al. (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 60, 427-435.
5. Plummer, F., Manea, L., Trapel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis. General Hospital Psychiatry, 39, 1-29.
6. Ryan, T.A., Bailey, A., Fearon, P., & King, J. (2013). Factorial invariance of the Patient Health Questionnaire and Generalized Anxiety Disorder Questionnaire. British Journal of Clinical Psychology, 52, 438-449.
7. Kertz, S., Bidga-Peyton, J., & Bjorgvinsson, T. (2013). Validity of the Generalized Anxiety Disorder-7 Scale in an acult psychiatric sample. Clinical Psychology & Psychotherapy, 20, 456-464.
8. Schalet, B.D., Cook, K.F., Choi, S.W., & Cella, D. (2014). Establishing a common metric for self-reported anxiety: Linking the MASQ, PANAS, and GAD-7 to PROMIS Anxiety. Journal of Anxiety Disorders, 28, 88-96.
9. Beard, C., & Bjorgvinnson, T. (2014). Beyond generalized anxiety disorder: Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. Journal of Anxiety Disorders, 28, 547-552.
10. Rutter, L.A., & Brown, T.A. (2017). Psychometric properties of the Generalized Anxiety Disorder Scale-7 (GAD-7) in outpatients with anxiety and mood disorders. Journal of Psychopathology and Behavioral Assessment, 39, 140-146.
11. U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(11):784-792. Updated 2016 Jan [8 p].
12. American Psychiatric Association (APA). Practice guidelines for the psychiatric evaluation of adults, third edition. Arlington (VA): American Psychiatric Association (APA); 2015. 164 p.
13. Assessment and Management of Risk for Suicide Working Group. VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. Washington (DC): Department of Veterans Affairs, Department of Defense; 2013 Jun. 190 p.
14. Comprehensive Pain Assessment (American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons, 009 [Level I]; Herr et al., “Pain assessment,” 2006 [Level I]; Pasero & McCaffery, 2011 [Level VI])
15. Andersen BL, DeRubeis RJ, Berman BS, Gruman J, Champion VL, Massie MJ, Holland JC, Partridge AH, Bak K, Somerfield MR, Rowland JH, American Society of Clinical Oncology. Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation. J Clin Oncol. 2014 May 20;32(15):1605-19.
Lowe B, Grafe K, Zipfel S, Spitzer RL, Herrmann-Lingen C, Witte S, et al. (2003). Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physiciansÕ diagnosis. J Psychosom Res, 55, 515-9.

Wright, C. V., Beattie, S. G., Galper, D. I., Church, A. S., Bufka, L. F., Brabender, V. M., & Smith, B. L. (2017). Assessment practices of professional psychologists: Results of a national survey. Professional Psychology: Research and Practice, 48, 73-78.