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  2. CQM-1281

Logic error in CMS171 Numerator

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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      Thank you for your question. The data element in the paper based measure specifications 'surgical incision time' is the basis for the timing of antibiotic administration prior to surgery. This logic was an attempt to account for the possibility of multiple surgical procedures during a surgical episode. The antibiotic timing must be based on the incision time of the first procedure, whether it is the principal procedure or not. Since the value set for the anesthesia does not contain surgical procedures, in order to accommodate the timing, these phrases will be changed to use the start date and time of the anesthesia episode. This is an acceptable alternative according to the paper specifications. This will be changed during the next annual update.
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      Thank you for your question. The data element in the paper based measure specifications 'surgical incision time' is the basis for the timing of antibiotic administration prior to surgery. This logic was an attempt to account for the possibility of multiple surgical procedures during a surgical episode. The antibiotic timing must be based on the incision time of the first procedure, whether it is the principal procedure or not. Since the value set for the anesthesia does not contain surgical procedures, in order to accommodate the timing, these phrases will be changed to use the start date and time of the anesthesia episode. This is an acceptable alternative according to the paper specifications. This will be changed during the next annual update.
    • CMS171v1/NQF0527, CMS172v1/NQF0528
    • Numerator for CMS171 may not be achievable

      The SCIP-INF-1 measure contains the following (or similar) in all numerators:

      OR: "Medication, Administered: IV quinolones (route: 'Hospital measures-Route IV')" <= 120 minute(s) starts before start of "Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)"
      OR: "Medication, Administered: Hospital measures-IV Vancomycin (route: 'Hospital measures-Route IV')" <= 120 minute(s) starts before start of "Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)"
      OR: "Medication, Administered: IV Antimicrobial medication (route: 'Hospital measures-Route IV')" <= 60 minute(s) starts before start of "Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)"

      The issue here is that the codes in the General or Neuraxial Anesthesia valueset (unsurprisingly) do not refer to a procedure which involves an incision, it refers to the anesthesia. Instead, the valueset used here should be the actual surgery being performed - CABG, or other Cardiac, etc.

      It is clear what the intent of the measure author is in this case; that the incision time of the principal surgical procedure be used. However, that is not what the logic formally suggests. With a literal reading of the logic, patients cannot pass the measure in this fashion, as there should not be an incision time associated with the anesthesia event, only with the surgery.

            JLeflore Joelencia Leflore
            jkratz Jason Kratz (Inactive)
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