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  1. eCQM Issue Tracker
  2. CQM-283

Screen patients for tobacco use and to intervene if the patient is a tobacco user.

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    • Howard Bregman
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      I agree this is much simpler and probably makes sense. Given the amount of existing prior discussions on the definition of tobacco user and the controversy on the subject we need to investigate and determine if there is not consensus whether that makes sense for all measures and implement in the annual update.

      UPDATE POSTED 2/9/15:
      This CQM Issue was discussed at the Pilot Change Review Process (CRP) Meeting on 2/4/2015. We have identified a possible solution to address the issues described here, and are looking for feedback on a proposed revised numerator under consideration for the upcoming annual update cycle.

      Proposed Numerator =
      AND:
      • Most recent: Occurrence A of “Risk Category Assessment: Tobacco Screening (result)” <= 24 months starts before end of “Measurement Period”
      AND
      • OR: Occurrence A of “Risk Category Assessment: Tobacco Screening (result: Tobacco Non-User)”
      • OR:
      o AND: Occurrence A of “Risk Category Assessment: Tobacco Screening (result: Tobacco User)”
      o AND: Union of:
       "Intervention, Performed: Tobacco Use Cessation Counseling"
       "Medication, Active: Tobacco Use Cessation Pharmacotherapy"
       "Medication, Order: Tobacco Use Cessation Pharmacotherapy"
       Starts After Or Concurrent with Start of Occurrence A of “Risk Category Assessment: Tobacco Screening (result: Tobacco User)”

      We are specifically looking for comment and reactions from implementers on the following:
      1. We believe the revision explicitly states that we’re looking for the most recent screening result in the measurement period or year prior.
      2. Allows removal of complex logic (AND/AND NOT of tobacco user/non-user)
      3. Removes ambiguity of multiple tobacco statuses that may not have appropriate cessation.
      4. Measures whether the cessation was provided after (or concurrent w/start) of screening result.
      5. Uses same value sets currently included in the measure; but tobacco user and tobacco non-user would be classified as a QDM Attribute rather than “Patient Characteristic” in current version. Is this type of change an issue for implementers? What is the level of effort involved in making the change from a QDM classification of patient characteristic to QDM classification of “Attribute”?


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      I agree this is much simpler and probably makes sense. Given the amount of existing prior discussions on the definition of tobacco user and the controversy on the subject we need to investigate and determine if there is not consensus whether that makes sense for all measures and implement in the annual update. UPDATE POSTED 2/9/15: This CQM Issue was discussed at the Pilot Change Review Process (CRP) Meeting on 2/4/2015. We have identified a possible solution to address the issues described here, and are looking for feedback on a proposed revised numerator under consideration for the upcoming annual update cycle. Proposed Numerator = AND: • Most recent: Occurrence A of “Risk Category Assessment: Tobacco Screening (result)” <= 24 months starts before end of “Measurement Period” AND • OR: Occurrence A of “Risk Category Assessment: Tobacco Screening (result: Tobacco Non-User)” • OR: o AND: Occurrence A of “Risk Category Assessment: Tobacco Screening (result: Tobacco User)” o AND: Union of:  "Intervention, Performed: Tobacco Use Cessation Counseling"  "Medication, Active: Tobacco Use Cessation Pharmacotherapy"  "Medication, Order: Tobacco Use Cessation Pharmacotherapy"  Starts After Or Concurrent with Start of Occurrence A of “Risk Category Assessment: Tobacco Screening (result: Tobacco User)” We are specifically looking for comment and reactions from implementers on the following: 1. We believe the revision explicitly states that we’re looking for the most recent screening result in the measurement period or year prior. 2. Allows removal of complex logic (AND/AND NOT of tobacco user/non-user) 3. Removes ambiguity of multiple tobacco statuses that may not have appropriate cessation. 4. Measures whether the cessation was provided after (or concurrent w/start) of screening result. 5. Uses same value sets currently included in the measure; but tobacco user and tobacco non-user would be classified as a QDM Attribute rather than “Patient Characteristic” in current version. Is this type of change an issue for implementers? What is the level of effort involved in making the change from a QDM classification of patient characteristic to QDM classification of “Attribute”?

      The numerator definition of this measure categorizes the patient as user or non-user. But rather than this simple definition of a user:
      “Patient Characteristic: Tobacco User" <= 24 month(s) starts before or during "Measurement End Date”
      The specification uses this definition of non-user:
       AND NOT: "Patient Characteristic: Tobacco User" starts after end of "Occurrence A of Patient Characteristic: Tobacco Non-User"
       AND: "Occurrence A of Patient Characteristic: Tobacco Non-User" <= 24 month(s) starts before or during "Measurement End Date
      And this one for a user:
       AND NOT: "Patient Characteristic: Tobacco Non-User" starts after end of "Occurrence A of Patient Characteristic: Tobacco User"
       AND: "Occurrence A of Patient Characteristic: Tobacco User" <= 24 month(s) starts before or during "Measurement End Date"
      Which means only the last recording of tobacco status defines the final status. A patient who was last recorded as a non-user is a non-user, and one who was last recorded as a user is a user, no matter what was recorded in the past. A patient could have been designated as a smoker 8-9 times, as long as the last record is as a non-user, the patient is in the numerator without any intervention. But the patient who is a non-smoker until the very last recording and then is marked as a smoker fails if no intervention is given.
      Given the measure logic, the following outcomes are defined:
      1. A patient who is recorded as a non-smoker 23 months ago and never has status recorded again, despite multiple visits, is counted in the numerator.
      2. A patient who has multiple recordings as a smoker and is given no intervention, but in the last visit is marked as a non-smoker, is in counted in the numerator.
      3. A patient who is a heavy smoker with multiple visits can be counseled once in a two year period, never counseled again, and is in the numerator. A patient who is marked as a non-smoker in multiple visits for two years, and is marked as a smoker in the last visit and not counseled, is not.
      4. A patient who is recorded as having a reason for not recording tobacco status once is excluded from the denominator no matter what happened at any other visit.
      5. A patient who is recorded as having a reason for not receiving pharmacotherapy is excluded from the denominator, even if they were never counseled to quit.

        1. 2015-0204 CMS 138-Tobacco Measure CRP Presentation.pdf
          243 kB

            julia.skapik Julia Skapik (Inactive)
            hbregman Howard Bregman
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