Brief Description of Measure:

​CMS117: Childhood Immunization Status:
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (Hib); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

Description of Issue:

Currently, the measure contains numerator inclusion​ criteria for immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma or leukemia, and intussusception before their second birthday. After reviewing our HEDIS MY22 measure, we decided this approach does not support the actual intent of the measure and the desired measure calculation. 

Therefore, NCQA is proposing moving the numerator inclusion criteira to the denominator exclusions for  children that have severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma or leukemia, and intussusception before their second birthday.​

Proposed Solution:

Current Denominator Exclusions header language:
Exclude patients who are in hospice care for any part of the measurement period.

Proposed Denominator Exclusions header langauge:
Exclude children with any of the following on or before the child’s second birthday:
•Severe combined immunodeficiency.
•Immunodeficiency.
•HIV.
•Lymphoreticular cancer, multiple myeloma or leukemia.
•Intussusception.  
Exclude children who are in hospice care for any part of the measurement period.

Current Denominator Exclusions logic and affected defintions: 
Denominator Exclusions
Hospice."Has Hospice" 

Numerator
( exists ( "Four DTaP Vaccinations" )
    or exists ( "DTaP Numerator Inclusion Conditions" ))
  and ( exists ( "Three Polio Vaccinations" )
      or exists ( "Polio Numerator Inclusion Conditions" )  )
  and ( exists ( "One MMR Vaccination" )
      or exists ( "MMR Numerator Inclusion Conditions" )
      or ( exists ( "Measles Indicators" )
          and exists ( "Mumps Indicators" )
          and exists ( "Rubella Indicators" ) ) )
  and ( "Has Appropriate Number of Hib Immunizations"
      or exists ( "Hib Numerator Inclusion Conditions" )  )
  and ( exists ( "Three Hepatitis B Vaccinations" )
      or exists ( "Hepatitis B Numerator Inclusion Conditions" )  )
  and ( exists ( "One Chicken Pox Vaccination" )
      or exists ( "Varicella Zoster Numerator Inclusion Conditions" )  )
  and ( exists ( "Four Pneumococcal Conjugate Vaccinations" )
      or exists ( "Pneumococcal Conjugate Numerator Inclusion Conditions" )  )
  and ( exists ( "One Hepatitis A Vaccinations" )
      or exists ( "Hepatitis A Numerator Inclusion Conditions" )  )
  and ( "Has Appropriate Number of Rotavirus Immunizations"
      or exists ( "Rotavirus Numerator Inclusion Conditions" )  )
  and ( exists ( "Two Influenza Vaccinations" )
      or ( "Two Influenza Vaccinations Including One LAIV Vaccination" )
      or exists ( "Influenza Numerator Inclusion Conditions" ))

Influenza Numerator Inclusion Conditions
( ["Diagnosis": "Adverse reaction to vaccine product containing Influenza virus antigen (disorder)"]
  union ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"]
  union ["Diagnosis": "Neomycin adverse reaction (disorder)"]
  union ["Diagnosis": "HIV"]
  union ["Diagnosis": "Disorders of the Immune System"] ) InfluenzaConditions
  where start of InfluenzaConditions.prevalencePeriod during "First Two Years"

MMR Numerator Inclusion Conditions
( ["Diagnosis": "Disorders of the Immune System"]
  union ["Diagnosis": "HIV"]
  union ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"]
  union ["Diagnosis": "Neomycin adverse reaction (disorder)"] ) MMRConditions
  where ( start of MMRConditions.prevalencePeriod during Interval[Patient.birthDatetime, "Date of Second Birthday"])

Rotavirus Numerator Inclusion Conditions
( ( ["Diagnosis": "Anaphylaxis due to rotavirus vaccine (disorder)"]
    union ["Diagnosis": "Severe Combined Immunodeficiency"]
    union ["Diagnosis": "Intussusception"] ) RotavirusConditions
    where start of RotavirusConditions.prevalencePeriod during "First Two Years")
Varicella Zoster Numerator Inclusion Conditions
( ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Titer)"] ChickenPoxTiter
    where ChickenPoxTiter.result >= 1.10)
  union ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Presence)"] ChickenPoxIgGPresence
      where ChickenPoxIgGPresence.result as Code in "Positive Finding"  )
  union ( ["Diagnosis": "Disorders of the Immune System"] ImmuneDisorder
      return "Laboratory Test, Performed" { relevantDatetime: start of ImmuneDisorder.prevalencePeriod }  )
  union ( ["Diagnosis": "HIV"] HIV
      return "Laboratory Test, Performed" { relevantDatetime: start of HIV.prevalencePeriod }  )
  union ( ["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"] LymphaticMalignantNeoplasm
      return "Laboratory Test, Performed" { relevantDatetime: start of LymphaticMalignantNeoplasm.prevalencePeriod }  )
  union ( ["Diagnosis": "Neomycin adverse reaction (disorder)"] NeomycinReaction
      return "Laboratory Test, Performed" { relevantDatetime: start of NeomycinReaction.prevalencePeriod }  )
  union ( ["Diagnosis": "Varicella Zoster"] VaricellaZoster
      return "Laboratory Test, Performed" { relevantDatetime: start of VaricellaZoster.prevalencePeriod }  ) ) VaricellaZosterConditions
  where Global."NormalizeInterval" ( VaricellaZosterConditions.relevantDatetime, VaricellaZosterConditions.relevantPeriod ) ends during "First Two Years"

Proposed Denominator Exclusions logic and affected defintions: 
Denominator Exclusions:
Hospice."Has Hospice Services" 
or "Has Severe Combined Immunodeficiency"
    or "Has Immunodeficiency"
    or "Has HIV"
    or "Has Lymphoreticular Cancer, Multiple Myeloma or Leukemia"
    or "Has Intussusception" 

Has Severe Combined Immunodeficiency
(["Diagnosis": "Severe Combined Immunodeficiency"]) SevereImmuneDisorder
  where day of start of SevereImmuneDisorder.prevalencePeriod during "First Two Years"

Has Immunodeficiency
(["Diagnosis": "Disorders of the Immune System"]) ImmuneDisorder
  where day of start of ImmuneDisorder.prevalencePeriod during "First Two Years"

Has HIV
(["Diagnosis": "HIV"]) HIV 
  where day of start of HIV.prevalencePeriod during "First Two Years"

Has Has Lymphoreticular Cancer, Multiple Myeloma or Leukemia
(["Diagnosis": "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"]) LymphaticMalignantNeoplasm
  where day of start of LymphaticMalignantNeoplasm.prevalencePeriod during "First Two Years"

Has Intussusception
(["Diagnosis": "Intussusception"]) IntussusceptionDisorder 
  where day of  start of IntussusceptionDisorder.prevalencePeriod during "First Two Years"

Numerator
( exists ( "Four DTaP Vaccinations" )
    or exists ( "DTaP Numerator Inclusion Conditions" ))
  and ( exists ( "Three Polio Vaccinations" )
      or exists ( "Polio Numerator Inclusion Conditions" )  )
  and ( exists ( "One MMR Vaccination" )
      or ( exists ( "Measles Indicators" )
          and exists ( "Mumps Indicators" )
          and exists ( "Rubella Indicators" )      ) )
  and ( "Has Appropriate Number of Hib Immunizations"
      or exists ( "Hib Numerator Inclusion Conditions" )  )
  and ( exists ( "Three Hepatitis B Vaccinations" )
      or exists ( "Hepatitis B Numerator Inclusion Conditions" )  )
  and ( exists ( "One Chicken Pox Vaccination" )
      or exists ( "Varicella Zoster Numerator Inclusion Conditions" )  )
  and ( exists ( "Four Pneumococcal Conjugate Vaccinations" )
      or exists ( "Pneumococcal Conjugate Numerator Inclusion Conditions" ))
  and ( exists ( "One Hepatitis A Vaccinations" )
      or exists ( "Hepatitis A Numerator Inclusion Conditions" )  )
  and ( "Has Appropriate Number of Rotavirus Immunizations"
      or exists ( "Rotavirus Numerator Inclusion Conditions" )  )
  and ( exists ( "Two Influenza Vaccinations" )
      or ( "Two Influenza Vaccinations Including One LAIV Vaccination" ))

Rotavirus Numerator Inclusion Conditions
( ( ["Diagnosis": "Anaphylaxis due to rotavirus vaccine (disorder)"] ) RotavirusConditions
    where start of RotavirusConditions.prevalencePeriod during "First Two Years")

Varicella Zoster Numerator Inclusion Conditions
( ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Titer)"] ChickenPoxTiter
    where ChickenPoxTiter.result >= 1.10)
  union ( ["Laboratory Test, Performed": "Varicella Zoster Antibody Test (IgG Antibody Presence)"] ChickenPoxIgGPresence
      where ChickenPoxIgGPresence.result as Code in "Positive Finding"  )
  union ( ["Diagnosis": "Neomycin adverse reaction (disorder)"] NeomycinReaction
      return "Laboratory Test, Performed" { relevantDatetime: start of NeomycinReaction.prevalencePeriod }  )
  union ( ["Diagnosis": "Varicella Zoster"] VaricellaZoster
      return "Laboratory Test, Performed" { relevantDatetime: start of VaricellaZoster.prevalencePeriod }  ) ) VaricellaZosterConditions
  where Global."NormalizeInterval" ( VaricellaZosterConditions.relevantDatetime, VaricellaZosterConditions.relevantPeriod ) ends during "First Two Years"

Rationale for Change:

​We plan to move the numerator inclusion criteria to denominator exclusions. We are moving this criteria to exclude children that have severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma or leukemia, and intussusception before their second birthday. We believe it is more appropriate to specify immunocompromising conditions as denominator exclusions, rather than as numerator inclusion statements, as this measure is intended to focus on routine vaccination for children. This change also aligns with NCQA's HEDIS equivalent measure.