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  1. eCQM Issue Tracker
  2. CQM-4887

Add denominator exclusion for patients in hospice



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


      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:

      The current measure includes Denominator Exceptions for a "Medical Reason for Not Performing Influenza Vaccine", and was previously stewarded by another measure developer. NCQA now stewards the measure and is proposing to remove the Denominator Exceptions (information on this proposed change is available in a separate CRP issue). ** 

      This measure currently does not have an exclusion for patients in hospice. NCQA proposes adding an exclusion for patients in hospice to align with other immunization measures that exclude patients in hospice because this population has a limited life expectancy and shared decision making on receiving services, such as immunizations, should occur. However, it is important to exclude patients from the measure when the vaccine is not clinically appropriate. Therefore, we propose adding a Denominator Exclusion for "Has Hospice Services".{}

      Proposed Solution:

      NCQA proposes adding a denominator exclusion to this measure to remove patients in hospice.​
      Proposed denominator exclusions header language: 
      Exclude patients who are in hospice care for any part of the measurement period.
      Proposed additional logic:
      Denominator Exclusions =
         Hospice."Has Hospice Services" 
      Hospice.Has Hospice =
         exists ( ["Encounter, Performed": "Encounter Inpatient"] DischargeHospice 
          where ( DischargeHospice.dischargeDisposition ~ "Discharge to home for hospice care (procedure)" 
          or DischargeHospice.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"   ) 
            and DischargeHospice.relevantPeriod ends during "Measurement Period" ) 
        or exists ( ["Intervention, Order": "Hospice care ambulatory"] HospiceOrder 
             where HospiceOrder.authorDatetime during "Measurement Period" ) 
         or exists ( ["Intervention, Performed": "Hospice care ambulatory"] HospicePerformed 
             where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period"  ) 

      Rationale for Change:

      This change will align this measure with other immunization measures (CMS117, CMS127) in which patients in hospice are excluded because this population has a limited life expectancy and shared decision making on receiving services should occur.




            khancock Mathematica EC eCQM Team
            sgearhart Mathematica EH eCQM Team
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