CMS22 measure is a preventative care and screening measure that requires screening for high blood pressure and if elevated or high readings are identified an appropriate follow-up plan is documented. CMS22 has been updated in accordance with the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. The new guideline has impacted the following measure criteria including: the measure description, rationale, references, clinical recommendation statements, definitions, guidance, numerator, exceptions, numerator logic, exceptions logic, and value sets. The initial population, denominator and denominator exclusions were not impacted by the guideline update. The updated draft version of the measure specification is provided as an attachment for review and comment. Description with minor language change: Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented as indicated- added. Rationale/ References: Literature review findings were incorporated into the rationale from the following references: Centers for Disease Control and Prevention (CDC) and National Center for Health Statistics. (2017). Health, United States, 2016 with Chartbook on Long-term Trends in Health, 223. Retrieved from https://www.cdc.gov/nchs/data/hus/hus16.pdf Luehr, D., Woolley, T., Burke, R., Dohmen, F., Hayes, R., Johnson, M., Kerandi, H., Margolis, K., Marshall, M., O'Connor, P., Pereira, C., Reddy, G., Schlichte, A. & Schoenleber, M. (2012). Hypertension diagnosis and treatment; Institute for Clinical Systems Improvement health care guideline. Updated November, 2012. Muntner, P., Carey, R.M., Gidding, S., Jones, D.W., Taler, S.J., Wright J.T. Jr., Whelton, P.K. (2017). Potential U.S. Population Impact of the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline, 2, 113, 117. https://doi.org/10.1161/CIRCULATIONAHA.117.032582 Whelton, P.K., Carey, R.M., Aronow, W.S., Casey, D.E. Jr, Collins, K.J., Dennison Himmelfarb C., DePalma, S.M., Gidding S., Jamerson, K.A., Jones, D.W., MacLaughlin, E.J., Muntner, P., Ovbiagele, B., Smith, S.C. Jr, Spencer, C.C., Stafford, R.S., Taler, S.J., Thomas, R.J., Williams, K.A. Sr, Williamson, J.D., Wright, J.T. Jr. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. (2017), 22, 29, 33-34, 45, 70, 72, 74, 89, 100, 153. doi:10.1016/j.jacc.2017.11.006 Winter, K., H., Tuttle, L., A., Viera, A., J. (2013). Hypertension. Prim Care Clin Office Pract, 1, 40, 179-194 Clinical Recommendations: Blood Pressure classifications: Normal, Hypertensive, First Hypertensive and Second Hypertensive Readings were replaced by Blood Pressure Categories: Normal, Elevated or Stage 1 or 2 Hypertension. Stage 1 also includes clinical ASCVD/10-y CVD risk score < and > 10%. Within each category of Blood Pressure are non-pharmacological interventions and reassessment periods. Additionally, Stage 1 and 2 assesses goal attainment with intervention and follow-up. Definitions: Reflect the new blood pressure categories and ranges within each category. Optimal lifestyle habits, non-pharmacological therapy and ASCVD are defined. This area also includes an explanation of treatment of hypertension in pregnancy, older persons and race and ethnicity based on new guideline recommendations. Guidance: Updated to provide direction as it applies to the pooled cohort, averaged blood pressure (BP) readings and consideration given to race, diagnosis, and or older persons when determining appropriate pharmacological therapy. Also added is the 2017 High Blood Pressure Clinical Practice Guideline that recommends using clinical judgment, shared decision making involving the team and patient, when determining the risks, benefits and approach to BP reduction and the use of antihypertensive medications for adults greater or equal to 65 years old diagnosed with hypertension and comorbid conditions limiting life expectancy. Denominator Exceptions: Added: Applies to either BP measurement or follow-up interventions. Numerator: Revised with the removal of blood pressure classifications and replaced with blood pressure categories. Numerator/ Exceptions Logic: Revised to incorporate all measure header updates as listed below: Numerator logic: · Index BP reading will be average of all documented systolic and diastolic readings from most recent encounter where BP was documented · Logic update will reflect current hypertension guidelines as follows: Ø Normal SBP <120 mm Hg and DBP <80 mm Hg Ø Elevated SBP 120-129 mm Hg and DBP <80 mm Hg o Follow- up plan updated to require non-pharmacological therapy and reassessment in 3-6 months § If patient is age 65 or older this is treated as normal Ø Stage 1 BP 130-139 mm Hg or 80-89 mm Hg without ASCVD* o Follow- up plan updated to require non-pharmacological therapy and reassessment in 3-6 months Ø Stage 1 with ASCVD* o Follow- up plan updated to include non-pharmacological therapy and BP Lowering medications and reassess in 1 month Ø Stage 2 BP > = 140 mm Hg or > = 90 mm Hg o Follow- up plan updated to include non-pharmacological therapy and BP Lowering medications and reassess in 1 month *Clinical Atherosclerotic Cardiovascular Disease (ASCVD) diagnosis or procedure or estimated 10yr CVD risk >10%. The Cardiovascular disease 10Y risk [Likelihood] ACC-AHA Pooled Cohort by Goff 2013 equation has also been added to the numerator logic.   Exception Logic: · Logic: Updated denominator exception to include a medical reason for no follow up interventions.   Value Sets: Updates reflect the following as being consistent with the guideline recommendations: · Creation of a new grouping OID, Non-pharmacological Intervention for HTN (Non-pharmacological Intervention for HTN (OID: 2.16.840.1.113762.1.4.1047.503) incorporated the following value sets: Lifestyle Recommendation" using "Lifestyle Recommendation (OID:2.16.840.1.113883.3.600.1508); Moderation of ETOH Consumption Recommendation" using "Moderation of ETOH Consumption Recommendation (OID:2.16.840.1.113883.3.600.823); Physical Activity Recommendation" using "Physical Activity Recommendation (OID: 2.16.840.1.113883.3.600.1518). · Potassium and sodium recommendations were added to the dietary value set (OID: 2.16.840.1.113883.3.600.1515). · Medications recommended within the guidelines were added to the Anti-Hypertensive Pharmacologic Therapy value set (OID: 2.16.840.1.113883.3.600.1476).

Final Recommendation: Based on the CRP comments received, we will include the following in the guidance section: Refer to Table 8. Checklist for Accurate Measurement of BP for guidance regarding accurate blood pressure measurement (Whelton PK, et al., 2017 High Blood Pressure Clinical Practice Guideline, p. 28) Patients with documented medical reason(s), such as older patients with frailty, limited life expectancy, known symptoms of orthostasis and other clinical risk factors should be clinically assessed as stated above to determine the risks and benefits of hypertensive treatment interventions. Additionally, we will include all of the other changes and review the final specification with the EWG and will include all changes for review by CMS.