QCDR Name: MBHR Mental and Behavioral Health Registry
| Measure Title | Anxiety Response at 6-months |
| NQS Domain | Effective Clinical Care |
| Measure ID | MBHR2 |
| NQF ID | N/A |
| Measure Type | Patient Reported Outcome (PRO) |
| High Priority? | Yes |
| Description | The percentage of adult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, or panic disorder) who demonstrated a response to treatment at six months (+/- 60 days) after an index visit. To see additional details, please view the workflow diagram for this measure: View diagram |
| Denominator | Patients aged ≥ 18 years on date of encounter AND Diagnosis of anxiety disorder (generalized anxiety disorder, social anxiety disorder, or panic disorder) ICD-10-CM: F40.1, F40.10, F40.11, F41.0, F41.1, F41.3, F41.8, F41.9, F43.1AND CPT: 0362T, 0373T, 90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90875, 90876, 96110, 96112, 96113, 96116, 96121, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96159, 96164, 96165, 96167, 96170, 96171, 96178, 97129, 97130, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 98966, 98967, 98968, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215,99354, 99355, 99406, 99407, 99408, 99409, 99446, 99447, 99448, 99449, 99484, 99492, 99493, 99494, G2011, G2061, G2062, G2063, G0396, G0397, G0402, G0438, G0439AND Visit 6- months (+/- 60 days) with a GAD-7 Score after an Index Visit where the GAD-7 score >=8Denominator Exceptions: • Ongoing care not indicated (e.g., referred to another provider or facility, consultation only) OR INCLUDES TELEHEALTH? YES |
| Denominator Exclusions | • Patients who die OR • Are enrolled in hospice OR • Are unable to complete an anxiety measure due to cognitive deficit, visual deficit, motor deficit, language barrier, or low reading level, AND a suitable recorder (e.g., advocate) is not available OR • Are diagnosed with schizophrenia or psychotic spectrum disorder OR are diagnosed with a personality disorder (ICD-10-CM) 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 F22 – Delusional Disorder 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 Specified Schizophrenia Spectrum and Other Psychotic Disorder F29 – Unspecified Schizophrenia Spectrum and Other Psychotic Disorder F21 – Schizotypal Personality Disorder F60.0 – Paranoid Personality Disorder F60.1 – Schizoid Personality Disorder F60.2 – Antisocial Personality Disorder F60.3 – Borderline Personality Disorder F60.4 – Histrionic Personality Disorder F60.5 – Obsessive-Compulsive Personality Disorder F60.6 – Avoidant Personality Disorder F60.7 – Dependent Personality Disorder F60.81 – Narcissistic Personality Disorder F60.89 – Other Specified Personality Disorder F60.9 – Unspecified Personality Disorder |
| Numerator | The number of patients in the denominator who demonstrated a response to treatment, with a GAD-7 result that is reduced by 25% or greater from the index GAD-7 score, six months (+/- 60 days) after an index visit
Numerator Exclusions: None |
| Data Source | Claims, EHR, Paper Medical Record, Registry |
| Meaningful Measure Area | Prevention, Treatment, and Management of Mental Health |
| Meaningful Measure Rationale | Anxiety disorders are highly prevalent mental health problems, affecting approximately 18% of the adult population in the United States. Although more common than mood disorders, anxiety disorders have received less attention, leading to under-detection and lack of treatment, particularly in primary care and palliative care settings. Anxiety disorders can be disabling, having a substantial impact on patient functioning, work productivity, and health care utilization. Moreover, anxiety disorders cost the United States an estimated $42 billion dollars per year. Accordingly, a need to assess for anxiety symptoms rapidly in diverse treatment settings is essential to address the mental health needs of the public. Anxiety disorders are also highly treatable conditions]; a number of psychological and medication-based interventions have demonstrated effectiveness in treating the spectrum of anxiety disorders. Evaluating outcomes of treatment is critical to ensuring the most effective treatment approach is being utilized. Measuring anxiety response in treatment will promote interventions and best practices that are effective at reducing symptoms and improve functional status and quality of life. |
| Inverse Measure? | No |
| Proportional Measure? | Yes |
| Continuous Variable Measure? | No |
| Ratio Measure | No |
| Number of Performance Rates | 1 |
| Risk Adjusted | Yes – This measure is risk adjusted based on severity band of the GAD-7 which is based on the initial GAD-7 score. Severity bands are defined as 5-9 mild anxiety, 10-14 moderate anxiety and 15-21 severe anxiety. The measure is also risk adjusted for insurance product type (commercial, Medicare, and Medicaid/state government programs/self-insured) and age bands (18-25, 26-50, 51-65 and 66+) |
| Preferred Specialty | mental and behavioral health |
| Applicable Specialties | Family Practice, Internal Medicine, Geriatric Medicine, Psychiatry, Behavioral Health |
| Care Settings | Ambulatory Care: Hospital; Inpatient; Rehabilitation Facility; Nursing Home; Outpatient Services; Long Term Care |
Measure Justification
Anxiety disorders are highly prevalent mental health problems, affecting approximately 18% of the adult population in the United States (Kessler et al., 2005). Although more common than mood disorders, anxiety disorders have received less attention, leading to under-detection and lack of treatment, particularly in primary care settings (Goldberg et al., 2007; Kessler et al., 1999) and palliative care (Atkin, Vickerstaff, & Candy, 2017). Anxiety disorders can be disabling, having a substantial impact on patient functioning, work productivity, and health care utilization (Dark et al., 2017; Kroenke et al., 2007). Moreover, anxiety disorders cost the United States an estimated $42 billion dollars per year (Bui et al., 2017; Greenberg et al., 1999). Accordingly, a need to assess for anxiety symptoms rapidly in diverse treatment settings is essential to address the mental health needs of the public (Gregory et al., 2020).
Anxiety disorders are treatable conditions (Hofmann et al., 2012); a number of psychological and medication-based interventions have demonstrated effectiveness in treating the spectrum of anxiety disorders (Yulish et al., 2017). Evaluating outcomes of treatment is critical to ensuring the most effective treatment approach is being utilized.
The GAD-7 (Spitzer et al., 2006) is comprised of seven self-report items covering anxiety symptoms of general nervousness, difficulty controlling worry, worry about diverse topics, difficulty relaxing, restlessness, restlessness to the point of trouble sitting still, irritability, and a general sense of dread. Each item is rated from “not at all” to “nearly every day.” There is a total score range of 0 – 21. Following the aforementioned seven items, there is a general question included to rate the difficulty the problem areas have had on functioning (work, home, and/or social functioning) in four levels: not difficult at all; somewhat difficult; very difficult; and extremely difficult. Most respondents complete the measure in less than five minutes. The psychometric properties of the GAD-7 have been examined in several different populations.
Available literature suggests that the GAD-7 is an internally consistent measure (Beard & Bjorgvinsson, 2014; Kertz et al., 2013; Ryan et al., 2013; Schalet et al., 2014) with good convergent validity (Ruiz et al., 2011; Rutter & Brown, 2017). Findings generally support using a single score from the measure to represent anxiety severity (Beard and Bjorgvinsson, 2014; Kertz et al., 2013; Jordan et al., 2017). Research also supports psychometric and performance generalizability across different subpopulations, including low potential for gender bias (Jordan et al., 2017; Lowe et al., 2008; Moreno et al., 2019).
Available research suggests that cut-off scores may be used that are suggestive of any anxiety disorder (sensitivity). A cut-off score of 10 has been supported in some studies (Beard & Bjorgvinsson, 2014; Kertz et al., 2013). Notably, Plummer et al. (2016) reported on the diagnostic accuracy of the GAD-7 from multiple samples (total N = 5223) with varied diagnostic characteristics and treatment settings. A cut-off score of 8 was recommended for sensitivity to anxiety disorder diagnoses in general. Findings from Parkerson et al. (2015) suggested that a cut-off score of 10 may under identify anxiety disorders in African-American participants. Additional studies have reported optimally sensitive cut-offs in specifically subpopulations between a score of 7 (Micoulaud-Franchi et al. 2016; Zhong et al., 2015) and 9 (Delgadillo et al., 2012).
The GAD-7 also appears to be sensitive to change (Beard & Bjorgvinsson, 2014; Kertz et al., 2013; Newby et al., 2017). In studies that have calculated change score metrics, change scores of between 2 and 4 points have been suggested (Kertz et al., 2013; Toussaint et al., 2020). In a large naturalistic sample of patients who had attended at least two sessions of psychotherapy (N = 19,395), the mean change on the GAD-7 for patients initially classed as “mild” on the measure was 2.16 (SD = 4.32), in comparison to 6.77 (SD = 6.27) for patients classed as “severe” (Gyani et al., 2013).
- Atkin, N., Vickerstaff, V., & Candy, B. (2017). Worried to death: The assessment and management of anxiety in patients with advanced life-limiting disease, a national survey of palliative medicine physicians. BMC Palliative Care, 16:69. doi 10.1186/s12904-017-0245-5
- 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.
- Bui, A. L.,Dieleman, J. L.,Hamavid,H., Birger,M., Chapin, A., Duber, H. C.,… Murray, C. J. (2017). Spending on children’s personal health care in the United States, 1996–2013. JAMA Pediatrics, 171(2), 181–189.
- Dark, T., Flynn, H. A., Rust, G., Kinsell, H., & Harman, J. S. (2017). Epidemiology of emergency department visits for anxiety in the United States: 2009–2011. Psychiatric Services, 68(3), 238–244.
- Delgadillo, J., Payne, S., Gilbody, S., Godfrey, C., Gore, S., Jessop, D., & Dale, V. (2012). Brief case finding tools for anxiety disorders: Validation of GAD-7 and GAD-2 in addictions treatment. Drug and Alcohol Dependence, 125, 37-42.
- Goldberg, D.P., Reed, G.M., Robles, R., Minhas, F., Razzaque, B., Fortes, S., et al., 2017. Screening for anxiety, depression, and anxious depression in primary care: a field study for ICD-11 PHC. Journal of Affective Disorders, 213, 199–206. https://doi.org/10. 1016/j.jad.2017.02.025.
- 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.
- Gregory KD et al. (2020). Screening for anxiety in adolescent and adult women: A recommendation from the Women’s Preventive Services Initiative. Annals of Internal Medicine, 173 (1), 48-56. https://doi.org/10.7326/M20-0580
- Gyani, A., Shafran, R., Layard, R., Clark, D.M. (2013). Enhancing recovery rates: lessons from year one of IAPT. Behaviour Research and Therapy, 51, 597–606.
- Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research. 2012; 36:427–440.
- Jordan, P., Shedden-Mora, M.C., & Lowe, B. (2017). Psychometric analysis of Generalized Anxiety Disorder Scale (GAD-7) in primary care using modern item response theory. PLoS ONE 12 (8) e0182162. https://doi.org/10.1371/journal.pone.0182162
- Kertz, S., Bidga-Peyton, J., & Bjorgvinsson, T. (2013). Validity of the Generalized Anxiety Disorder-7 Scale in an acute psychiatric sample. Clinical Psychology & Psychotherapy, 20, 456-464.
- 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.
- 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.
- 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.Lowe, B., Decker, O., Muller, S., Brahler, E., Schellberg, D., Herzog, W., & Herzberg, P.Y. (2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care, 46, 266-274.
- Micoulaud-Franchi, J.A., Lagarde, S., Barkate, G., Dufournet, B., Besancon, C., Fonseca, A.T., Gavaret, M. … , & McGonigal, A. (2016). Rapid detection of generalized anxiety disorder and major depression in epilepsy: Validation of the GAD-7 as a complementary tool to the NDDI-E in a French sample. Epilepsy & Behavior, 57, 211-216., 252, 114-121.
- Moreno, E., Munoz-Navarro, R., Medrano, L.A., Gonzalez-Blanch, C., Ruiz-Rodriguez, P., Limonero, J.T. , et al. (2019). Factorial invariance of a computerized version of the GAD-7 across various demographic groups and over time in primary care patients. Journal of Affective Disorders, 252, 114-121.
- Newby, J.M., Mewton, L., & Andrews, G. (2017). Transdiagnostic versus disorder-specific internet-delivered cognitive behavior therapy for anxiety and depression in primary care. Journal of Anxiety Disorders, 46, 25-34.
- Parkerson, H.A., Thibodeau, M.A., Brandt, C.P., Zvolensky, M.J., & Asmundson, G.J.G. (2015). Cultural-based biases of the GAD-7. Journal of Anxiety Disorders, 31, 38-42
- 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.
- 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.
- Ruiz, M.A., Zamorano, E., Garcia-Campayo, J., Pardo, A., Freire, O., & Rejas, J. (2011). Validity of the GAD-7 scale as an outcome measure of disability in patients with generalized anxiety disorders in primary care. Journal of Affective Disorders, 128, 277-286.
- 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.
- 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.
- Spitzer, R.L., Kroenke, K., Williams, J.B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092-1097.
- Toussaint, A., Husing, P., Gumz, A., Wingenfeld, K., Harter, M., Schramm, E., & Lowe, B. (2020). Sensitivity to change and minimal clinically significant difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of Affective Disorders, 265, 395-401.
- Yulish, N. E., Goldberg, S. B., Frost, N. D., Abbas, M., Oleen-Junk, N., Kring, M., . . . Wampold, B. E. (2017). The importance of problem-focused treatments: A meta-analysis of anxiety treatments. Psychotherapy, 54, 321-338.
- Zhong, Q.Y., Gelaye, B., Zaslavsky, A.M., Fann, J.R., Rondon, M.B., Sanchez, S.E., & Williams, M.A. (2015). Diagnostic validity of the Generalized Anxiety Disorder – 7 (GAD-7) among pregnant women. PLoS One, 10, e0125096..
Numerous guidelines have recommended assessing anxiety in a variety of populations, including individuals who positively screen for depression [1], patients who present for initial psychiatric evaluations [2], individuals at risk for suicide [3], and as part of a comprehensive pain assessment in older adults [4]. Specifically, a guideline from the American Society of Clinical Oncology [5], recommends that “all health care providers should routinely screen for the presence of emotional distress and specifically symptoms of anxiety…use(ing) the Generalized Anxiety Disorder (GAD)-7 scale” in adults with cancer. In addition, the Women’s Preventive Services Initiative [6] recommends assessing anxiety in women and adolescent girls, including pregnant and postpartum women.
- 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].
- American Psychiatric Association (APA). Practice guidelines for the psychiatric evaluation of adults, third edition. Arlington (VA): American Psychiatric Association (APA); 2015. 164 p.
- 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.
- 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])
- 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;32(15):1605-19.
- Gregory KD, Chelmow D, Nelson HD, Van Niel MS, Conry JA, Garcia F, et al. Screening for anxiety in adolescent and adult women: A recommendation from the Women’s Preventive Services Initiative. Annals of Internal Medicine, 2020; 173 (1): 48-56. https://doi.org/10.7326/M20-0580