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  1. eCQM Issue Tracker
  2. CQM-4817

Replace denominator exceptions with denominator exclusions

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    • EP/EC eCQMs
    • Status: Open
    • Moderate
    • Resolution: Unresolved
    • None

    Description

      Brief Description of Measure:

      CMS138: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
      Percentage of patients aged 18 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention if identified as a tobacco user
      Three rates are reported:
      a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times during the measurement period
      b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention
      c. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention if identified as a tobacco user

      Description of Issue:
      ​Currently, the measure allows for medical reason exceptions for not screening for tobacco use or for not providing a tobacco cessation intervention. The measure developer plans to specify particular medical reasons (hospice and advanced illness and frailty) a patient should be excluded from the measure, in order to align with the approach in other NCQA-stewarded measures.

      However, there are no plans to add a denomintor exclusion for patients receiving palliative care because there is strong evidence of the harms of tobacco and the benefits of screening and tobacco cessation interventions for this patient population. Given that brief counseling counts toward the numerator for this measure, we are not excluding patients receiving palliative care.

      Proposed Solution:
      The measure developer plans to remove header language and logic for the medical reasons for not providing tobacco cessation (e.g. limited life expectancy, other medical reasons) as denominator exceptions and add denominator exclusions.

      CURRENT STATE:

      Current Denominator Exclusions (header language and logic for all 3 populations):
      None. 

      Current denominator exceptions language:
      Population 1:
      Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason)
      Population 2:
      Documentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason)
      Population 3:
      Documentation of medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (e.g., limited life expectancy, other medical reason)
      Current Denominator Exception Logic Population 1:
      exists "Medical Reason for Not Screening for Tobacco Use"
      or "Has Limited Life Expectancy"
       
      Current Denominator Exception Logic Population 2:
      exists "Medical Reason for Not Counseling Tobacco User"
      or exists "Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy"
      or "Has Limited Life Expectancy"
       

      Current Denominator Exception Logic Population 3:
      exists "Medical Reason for Not Screening for Tobacco Use"
      or exists "Medical Reason for Not Counseling Tobacco User"
      or exists "Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy"
      or "Has Limited Life Expectancy"

      Medical Reason for Not Screening for Tobacco Use
      ["Assessment, Not Performed": "Tobacco Use Screening"] NoTobaccoUseScreening
      where NoTobaccoUseScreening.authorDatetime during "Measurement Period"
      and NoTobaccoUseScreening.negationRationale in "Medical Reason"

      Has Limited Life Expectancy
      exists ( ["Diagnosis": "Limited Life Expectancy"] LimitedLifeExpectancy
      where LimitedLifeExpectancy.prevalencePeriod overlaps after "Measurement Period")

      Medical Reason for Not Counseling Tobacco User
      ["Intervention, Not Performed": "Tobacco Use Cessation Counseling"] NoTobaccoCessationCounseling
      where NoTobaccoCessationCounseling.authorDatetime during "Measurement Period"
      and NoTobaccoCessationCounseling.negationRationale in "Medical Reason"

      Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy
      ["Medication, Not Ordered": "Tobacco Use Cessation Pharmacotherapy"] NoCessationPharmacotherapyOrdered
      where NoCessationPharmacotherapyOrdered.authorDatetime during "Measurement Period"
      and NoCessationPharmacotherapyOrdered.negationRationale in "Medical Reason"

       
      PROPOSED REVISIONS:
      Updated Denominator Exceptions language (for all 3 populations):
      None.
      Remove the following value sets:
      "Limited Life Expectancy" (2.16.840.1.113883.3.526.3.1259)
      "Medical Reason" (2.16.840.1.113883.3.526.3.1007)
      We are adding denominator exclusions for hospice and advanced illness and frailty using libraries used across several NCQA-stewarded measures. 

      Proposed Denominator Exclusion header language for all 3 populations:
      Exclude patients who are in hospice care for any part of the measurement period.

      Exclude patients 66-80 by the end of the measurement period with an indication of frailty for any part of the measurement period who meet any of the following criteria:

      -Advanced illness with two outpatient encounters during the measurement period or the year prior

      -OR advanced illness with one inpatient encounter during the measurement period or the year prior

      -OR taking dementia medications during the measurement period or the year prior

      Exclude patients 81 and older by end of the measurement period with an indication of frailty for any part of the measurement period.

      Proposed Denominator Exclusion logic for all 3 populations:

      Hospice.Has Hospice Services
        or AIFrailLTCF."Advanced Illness and Frailty Exclusion for Age 66 to 80 or Frailty Exclusion for Age 81 and Older"
        or ( exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
            where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime,
              end of "Measurement Period" ) >= 66
            )
              and AIFrailLTCF."Living Long Term in a Nursing Home" is not null

       
      define "Has Hospice Services":

        exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter

            where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"

                or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" )

              and InpatientEncounter.relevantPeriod ends during day of "Measurement Period" )

          or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter

              where HospiceEncounter.relevantPeriod overlaps "Measurement Period" )

          or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment

              where HospiceAssessment.result ~ "Yes (qualifier value)"

                and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod )overlaps "Measurement Period"  )

          or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder

              where HospiceOrder.authorDatetime during day of "Measurement Period"  )

          or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed

              where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period" )

      define "Advanced Illness and Frailty Exclusion for Age 66 and Older":
        exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate

            where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime,

            end of "Measurement Period" ) >= 66

              and "Has Criteria Indicating Frailty"

              and ( exists "Two Outpatient Encounters with Advanced Illness on Different Dates of Service"

                  or exists "Inpatient Encounter with Advanced Illness"

                  or exists "Dementia Medications in Year Before or During Measurement Period"    ) )

       

      define "Dementia Medications in Year Before or During Measurement Period":

        ["Medication, Active": "Dementia Medications"] DementiaMedication

          where Global."NormalizeInterval" ( DementiaMedication.relevantDatetime, DementiaMedication.relevantPeriod ) overlaps Interval[start of "Measurement Period" - 1 year,

          end of "Measurement Period"]

       

      define "Inpatient Encounter with Advanced Illness":

        ["Encounter, Performed": "Acute Inpatient"] InpatientEncounter

          where exists ( InpatientEncounter.diagnoses Diagnosis

              where Diagnosis.code in "Advanced Illness" )

            and InpatientEncounter.relevantPeriod starts during day of Interval[start of "Measurement Period" - 1 year,

            end of "Measurement Period"]

       

      define "Outpatient Encounters with Advanced Illness":

        ( ["Encounter, Performed": "Outpatient"]

          union ["Encounter, Performed": "Observation"]

          union ["Encounter, Performed": "Emergency Department Visit"]

          union ["Encounter, Performed": "Nonacute Inpatient"] ) OutpatientEncounter

          where exists ( OutpatientEncounter.diagnoses Diagnosis

              where Diagnosis.code in "Advanced Illness" )

            and OutpatientEncounter.relevantPeriod starts during day of Interval[start of "Measurement Period" - 1 year,

            end of "Measurement Period"]

       

      define "Two Outpatient Encounters with Advanced Illness on Different Dates of Service":

        from

          "Outpatient Encounters with Advanced Illness" OutpatientEncounter1,

          "Outpatient Encounters with Advanced Illness" OutpatientEncounter2

          where OutpatientEncounter2.relevantPeriod ends 1 day or more after day of

          end of OutpatientEncounter1.relevantPeriod

          return OutpatientEncounter1

       

      define "Advanced Illness and Frailty Exclusion for Age 66 to 80 or Frailty Exclusion for Age 81 and Older":

        exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate

            where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime,

              end of "Measurement Period" ) in Interval[66, 80]      )

              and "Has Criteria Indicating Frailty"

              and ( exists "Two Outpatient Encounters with Advanced Illness on Different Dates of Service"

                  or exists "Inpatient Encounter with Advanced Illness"

                  or exists "Dementia Medications in Year Before or During Measurement Period"       )  )

          or exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate

              where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime,

                end of "Measurement Period" ) >= 81        )

                and "Has Criteria Indicating Frailty"    )

       

      define "Living Long Term in a Nursing Home":

        ( Last(["Assessment, Performed": "Housing status"] HousingStatus

            where Global."NormalizeInterval"(HousingStatus.relevantDatetime, HousingStatus.relevantPeriod)ends on or before

            end of "Measurement Period"

            sort by

            end of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)asc

        )) LastHousingStatus

          where LastHousingStatus.result ~ "Lives in a nursing home (finding)"

       

      define "Has Criteria Indicating Frailty":

        exists ( ["Device, Order": "Frailty Device"] FrailtyDeviceOrder

            where FrailtyDeviceOrder.authorDatetime during day of "Measurement Period"  )

          or exists ( ["Assessment, Performed": "Medical equipment used"] EquipmentUsed

              where EquipmentUsed.components.result in "Frailty Device"

                and Global."NormalizeInterval" ( EquipmentUsed.relevantDatetime, EquipmentUsed.relevantPeriod ) ends during day of "Measurement Period"    )

          or exists ( ["Diagnosis": "Frailty Diagnosis"] FrailtyDiagnosis

              where FrailtyDiagnosis.prevalencePeriod overlaps "Measurement Period"    )

          or exists ( ["Encounter, Performed": "Frailty Encounter"] FrailtyEncounter

              where FrailtyEncounter.relevantPeriod overlaps "Measurement Period"    )

          or exists ( ["Symptom": "Frailty Symptom"] FrailtySymptom

              where FrailtySymptom.prevalencePeriod overlaps "Measurement Period"    )

      Rationale for Change:
      ​The measure developer plans to remove the denominator exceptions for the medical reasons for not completing the screening or interventions since they no longer meet the clinical intent of our measures. We are now adding denominator exclusions for hospice and advanced illness and frailty to align with our HEDIS measures.

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            khancock Mathematica EC eCQM Team
            khancock Mathematica EC eCQM Team
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              Updated: