Brief Description of Measure:

​CMS147: Preventive Care and Screening: Influenza Immunization:
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

Description of Issue:

We propose to remove the denominator exceptions for medical/patient/system reasons to align with the clinical guidelines and the measure intent. The Advisory Committee on Immunization Practices (ACIP) guidelines for contraindications to the vaccines only include life-threatening allergic reactions (i.e., anaphylactic reactions). The current codes for medical reasons do not include anaphylaxis as there are no codes at this time to indicate anaphylaxis to influenza vaccination. Patients who have not had a severe allergic reaction following a vaccine, but who have a history of possible allergy to a vaccine component can often be vaccinated safely after careful evaluation; people with a history of egg allergy should receive recombinant inactivated influenza or IIV vaccine. 

Proposed Solution:

We propose to remove the denominator exceptions from the measure. The measure header and logic will be updated accordingly:

Current Denominator Exceptions Header:
Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons) .   
Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons).
Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons).
 
Proposed Denominator Exceptions Header:
None

Current Denominator Exceptions Logic:
Denominator Exceptions
exists "Medical Patient or System Reason for Not Performing Influenza Vaccination"
  or exists "Medical Patient or System Reason for Not Administering Influenza Vaccine"
  or exists "Diagnosis of Allergy to Egg"
  or exists "Egg Substance Allergy"
  or exists "Diagnosis of Allergy to Influenza Vaccine"
  or exists "Diagnosis of Intolerance to Influenza Vaccine"
  or exists "Intolerance of Influenza Vaccination Procedure"
  or exists "Allergy or Intolerance to Influenza Vaccine"

Medical Patient or System Reason for Not Administering Influenza Vaccine
["Immunization, Not Administered": "Influenza Vaccine"] NoFluVaccine
  where NoFluVaccine.authorDatetime during "Influenza Season Including August and September of the Prior Year"
    and ( NoFluVaccine.negationRationale in "Medical Reason"
        or NoFluVaccine.negationRationale in "Patient Reason"
        or NoFluVaccine.negationRationale in "System Reason"
        or NoFluVaccine.negationRationale in "Influenza Vaccination Declined"
    )
 
Medical Patient or System Reason for Not Performing Influenza Vaccination
["Procedure, Not Performed": "Influenza Vaccination"] NoFluVaccination
  where NoFluVaccination.authorDatetime during "Influenza Season Including August and September of the Prior Year"
    and ( NoFluVaccination.negationRationale in "Medical Reason"
        or NoFluVaccination.negationRationale in "Patient Reason"
        or NoFluVaccination.negationRationale in "System Reason"
        or NoFluVaccination.negationRationale in "Influenza Vaccination Declined"

Diagnosis of Allergy to Egg
["Diagnosis": "Allergy to Eggs"] EggAllergy
  where EggAllergy.prevalencePeriod overlaps after "Influenza Season"
 

Egg Substance Allergy
["Allergy/Intolerance": "Egg Substance"] AllergyEggSubstance
  where AllergyEggSubstance.prevalencePeriod overlaps after "Influenza Season"
 
Diagnosis of Allergy to Influenza Vaccine
["Diagnosis": "Allergy to Influenza Vaccine"] FluVaccineAllergyDiagnosis
  where FluVaccineAllergyDiagnosis.prevalencePeriod overlaps after "Influenza Season"
 
Diagnosis of Intolerance to Influenza Vaccine
["Diagnosis": "Intolerance to Influenza Vaccine"] FluVaccineIntoleranceDiagnosis
  where FluVaccineIntoleranceDiagnosis.prevalencePeriod overlaps after "Influenza Season"
 
Intolerance of Influenza Vaccination Procedure
["Allergy/Intolerance": "Influenza Vaccination"] FluVaccinationIntolerance
  where FluVaccinationIntolerance.prevalencePeriod overlaps after "Influenza Season"

Allergy or Intolerance to Influenza Vaccine
["Allergy/Intolerance": "Influenza Vaccine"] FluVaccineAllergyIntolerance
  where FluVaccineAllergyIntolerance.prevalencePeriod overlaps after "Influenza Season"

Proposed Logic for Denominator Exceptions:
Remove definition and all associated definitions

Rationale for Change:

We propose to remove the denominator exceptions for medical/patient/system reasons to align with the clinical guidelines and the measure intent. The Advisory Committee on Immunization Practices (ACIP) guidelines for contraindications to the vaccines only include life-threatening allergic reactions (i.e., anaphylactic reactions). The current codes for medical reasons do not include anaphylaxis as there are no codes at this time to indicate anaphylaxis to influenza vaccination. Patients who have not had a severe allergic reaction following a vaccine, but who have a history of possible allergy to a vaccine component can often be vaccinated safely after careful evaluation; people with a history of egg allergy should receive recombinant inactivated influenza or IIV vaccine. 
In addition, the guidelines do not include patient or system reason as a contraindication; therefore, they should not be an exception/exclusion. It is anticipated that the impact of patient and system reason are relatively low and equal across organizations. 

In addition, the guidelines do not include patient or system reason as a contraindication; therefore, they should not be an exception/exclusion. It is anticipated that the impact of patient and system reason are relatively low and equal across organizations. 
 
We propose to remove the patient/medical/system reasons denominator exceptions to align with other immunization measures and clinical guidelines.