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  1. eCQM Issue Tracker
  2. CQM-4824

Revise numerator measure language and logic to remove ambiguity

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

    Description

      Brief Description of Measure:

      ​CMS125: Breast Cancer Screening

      Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period

      Description of Issue:
      ​The HEDIS Breast Cancer Screening (BCS) MY2022 measure uses this language for Numerator requirement: "One or more mammograms any time on or between October 1 two years prior to the measurement period and December 31 of the measurement period". The current CMS125v10 description uses this language "... one or more mammograms during the 27 months prior to the end of the measurement period".

      Proposed Solution:

      ​Specifying 27 months prior to the end of the measurement period could leave room for ambiguity. Since the intent is precisely the period starting October 1 two years prior to the measurement period through end of measurement period, we would like to update the header description and logic. This change should not impact measure performance.

      CURRENT:

      //Header: Initial Population
      Women with one or more mammograms during the 27 months prior to the end of the measurement period

      //Logic
      define "Numerator":
      exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
      where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends 27 months or less on or before day of
      end of "Measurement Period" ) )

      PROPOSED:

      //Header: Initial Population
      Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period

      //Logic
      define "October 1 Two Years Prior to the Measurement Period":
      DateTime((year from start of "Measurement Period" - 2), 10, 1, 0, 0, 0, 0, 0)

      define "Numerator":
      exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
      where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during Interval["October 1 Two Years Prior to the Measurement Period", end of "Measurement Period"] ) )

      Rationale for Change:
      ​The goal of this change is to specify the Numerator requirement in a way that avoids leaving room for ambiguity or misinterpretation.

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