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  1. eCQM Issue Tracker
  2. CQM-1193

PN6 Denominator 2 appears to need an OR rather than an AND

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Resolved
    • Icon: Critical Critical
    • Guidance
    • None
    • CMS188v4NQF0147
    • Hide
      Thank you for your question. After careful review of the logic as it is currently written, we propose the following logic to replace it during the next annual update. Feedback on this proposal is appreciated.

      o OR:
         AND:
         AND: ""Diagnosis, Active: Hospital Measures-Pneumonia""
         AND: ""Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')""
         <= 24 hour(s) starts after start of "" Occurrence A of Encounter, Performed: Encounter Inpatient""
         AND NOT: "" Occurrence A of Encounter, Performed: Emergency Department Visit"" <= 1 hour(s) ends before start of "" Occurrence A of Encounter, Performed: Encounter Inpatient""
         AND NOT: "" Occurrence A of Encounter, Performed: ICU Admission or Transfer"" <= 24 hour(s) starts after start of "" Occurrence A of Encounter, Performed: Encounter Inpatient""
      o OR:
         AND NOT: "" Occurrence A of Encounter, Performed: ICU Admission or Transfer"" <= 24 hour(s) starts after start of ""Occurrence A of Encounter, Performed: Emergency Department Visit""
         AND:
         AND: ""Diagnosis, Active: Hospital Measures-Pneumonia""
         AND: ""Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')""
         <= 24 hour(s) starts after start of ""Occurrence A of Encounter, Performed: Emergency Department Visit""

      This logic will meet the intent of this non-ICU population, meeting 2 scenarios. One is a direct inpatient admission with a diagnosis of pneumonia and antibiotics started within 24 hours of admission. The other represents a patient seen in the ED and meeting the same criteria within 24 hours of admission to the ED.
      Show
      Thank you for your question. After careful review of the logic as it is currently written, we propose the following logic to replace it during the next annual update. Feedback on this proposal is appreciated. o OR:    AND:    AND: ""Diagnosis, Active: Hospital Measures-Pneumonia""    AND: ""Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')""    <= 24 hour(s) starts after start of "" Occurrence A of Encounter, Performed: Encounter Inpatient""    AND NOT: "" Occurrence A of Encounter, Performed: Emergency Department Visit"" <= 1 hour(s) ends before start of "" Occurrence A of Encounter, Performed: Encounter Inpatient""    AND NOT: "" Occurrence A of Encounter, Performed: ICU Admission or Transfer"" <= 24 hour(s) starts after start of "" Occurrence A of Encounter, Performed: Encounter Inpatient"" o OR:    AND NOT: "" Occurrence A of Encounter, Performed: ICU Admission or Transfer"" <= 24 hour(s) starts after start of ""Occurrence A of Encounter, Performed: Emergency Department Visit""    AND:    AND: ""Diagnosis, Active: Hospital Measures-Pneumonia""    AND: ""Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')""    <= 24 hour(s) starts after start of ""Occurrence A of Encounter, Performed: Emergency Department Visit"" This logic will meet the intent of this non-ICU population, meeting 2 scenarios. One is a direct inpatient admission with a diagnosis of pneumonia and antibiotics started within 24 hours of admission. The other represents a patient seen in the ED and meeting the same criteria within 24 hours of admission to the ED.
    • CMS188v1/NQF0147
    • Cannot implement measure without guidance

      The logic from the denominator for the non-ICU population (population 2) is not clear and it appears that it should be connected with an OR rather than an AND operator:

      In the denominator we have the following two statements:

      ◾AND: "Diagnosis, Active: Hospital Measures-Pneumonia"
      ◾AND: "Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')"

      They are listed twice and each one is attached to a different time statement as shown below:

      time statement 1:

      <= 24 hour(s) starts after start of "Encounter, Performed: Encounter Inpatient"

      time statement 2:

      ◾AND: "Occurrence B of Encounter, Performed: Encounter Inpatient"
      ◾ <= 24 hour(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"

      Unless I don't understand (legitimate possibility) It would appear that the antimicrobial med and the diagnosis active of pneumonia must be <= 24 hours before the inpatient visit AND <= 24 hours before the emergency department.

      Additionally the denominator also includes the following statement:

      ◾AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Encounter, Performed: Encounter Inpatient"

      I believe the two statements (see screenshot 1 section in red and the other in blue) should be separated by an OR.

      Can you please confirm if this was the intent of the measure.

        1. PN6_Denominator2_Logic2.PNG
          42 kB
          Gregory Magazu

            JLeflore Joelencia Leflore
            gmagazu Gregory Magazu (Inactive)
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