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  2. CQM-4939

Move current denominator exclusions that are not clinical conditions into initial population criteria

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Details

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

    Description

      Brief Description of Measure:
      ​CMS136: Follow-Up Care for Children Prescribed ADHD Medication (ADD):
      Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.
      a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.
      b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

      Description of Issue:
      The current specification excludes patients who meet the following criteria:

      • Denominator Exclusion 1: Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 30 days after the IPSD
      • Denominator Exclusion 2: Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 300 days after the IPSD
      • Denominator Exclusion 1 and 2: Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date
         
        The measure intent is to remove patients meeting criteria from the initial population, instead of through the Denominator Exclusions.
         
        This change in the measure intent is related to internal NCQA efforts to distinguish between "denominator exclusions" and “removals in the initial population" to improve consistency across HEDIS measures. This change is implemented in the HEDIS MY2022 Follow-Up Care for Children Prescribed ADHD Medication (ADD) measure, which is the measure the eCQM ADD measure is derived from. NCQA would like to implement the same change made in the HEDIS MY2022 ADD measure in the eCQM ADD measure to ensure the measure intents are aligned, and to reduce burden on implementers who report on both measures.
         
        For additional context, NCQA is implementing the following guiding principle: the "Denominator Exclusions" for the measure should be clinical exclusions, which are clinical conditions that would warrant exclusion from the measure (i.e., a diagnosis of narcolepsy, or receipt of hospice care); "removals within the initial population" are methodological removals, and are generally defined as cases where the member would not have equal opportunity to satisfy numerator requirements (i.e., no clean negative medication lookback period, or an inpatient stay within the follow-up timeframe).
         
        The header and the logic will be updated to reflect the change of moving these exclusions criteria into the Initial Population. Please note that the term "exclude/exclusion" is replaced with the word "remove".

      Proposed Solution:
      Before

      //Header- Initial Population
      Initial Population 1:
      Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who had a visit during the measurement period.

      Initial Population 2:
      Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who remained on the medication for at least 210 days out of the 300 days following the IPSD, and who had a visit during the measurement period.

      //Header- Denominator Exclusions
      Denominator Exclusion 1:
      Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.
      Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 30 days after the IPSD.
      Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.
      Exclude patients who are in hospice care for any part of the measurement period.

      Denominator Exclusion 2:
      Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.
      Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 300 days after the IPSD.
      Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.
      Exclude patients who are in hospice care for any part of the measurement period.

      //Logic
      define "Initial Population 1":
      exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
        where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[6, 12 )
          and exists ( "Qualifying Encounter" )
          and "First ADHD Medication Dispensed during Intake Period" is not null

      define "Initial Population 2":
      exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
        where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[6, 12 )
          and exists ( "Qualifying Encounter" )
          and "First ADHD Medication Dispensed during Intake Period" is not null
          and "Has ADHD Cumulative Medication Duration Greater Than or Equal to 210 Days"

      define "Denominator Exclusions 1":
      Hospice."Has Hospice"
        or exists ( "Narcolepsy Exclusion" )
        or exists ( "Inpatient Stay with Qualifying Diagnosis within 30 Days of Initial ADHD Dispense" )
        or exists ( "Previously on ADHD Medication Exclusion" )

      define "Denominator Exclusions 2":
      Hospice."Has Hospice"
        or exists ( "Narcolepsy Exclusion" )
        or exists ( "Inpatient Stay with Qualifying Diagnosis within 300 Days of Initial ADHD Dispense" )
        or exists ( "Previously on ADHD Medication Exclusion" )

      define "Previously on ADHD Medication Exclusion":
      ...

      After

      //Header- Initial Population
      Initial Population 1: Children 6-12 years of age ... who were prescribed an ADHD medication during the Intake Period and who had a visit during the measurement period. Children are removed if they were actively on ADHD medication in the 120 days prior to the IPSD, or had an acute inpatient stay with a principal diagnosis of mental, behavioral or neurodevelopmental disorder during the Initiation Phase.  

      Initial Population 2: Children 6-12 years of age ... who were prescribed an ADHD medication during the Intake Period and remained on the medication for at least 210 days during the 301-day period, beginning on the IPSD through 300 days after the IPSD, and who had a visit during the measurement period. Children are removed if they were actively on ADHD medication in the 120 days prior to the IPSD, or had an acute inpatient stay with a principal diagnosis of mental, behavioral or neurodevelopmental disorder during the Continuation and Maintenance Phase.

      //Header- Denominator Exclusions
      Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.
      Exclude patients who are in hospice care for any part of the measurement period.

      //Logic
      define "Initial Population 1":
      exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
        where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[6, 12 )
          and exists ( "Qualifying Encounter" )
          and "First ADHD Medication Dispensed during Intake Period" is not null
          and not exists "Previously on ADHD Medication"    
          and not exists "Inpatient Stay with Qualifying Diagnosis within 30 Days of Initial ADHD Dispense"

      define "Initial Population 2":
      exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
        where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[6, 12 )
          and exists ( "Qualifying Encounter" )
          and "First ADHD Medication Dispensed during Intake Period" is not null
          and "Has ADHD Cumulative Medication Duration Greater Than or Equal to 210 Days"
          and not exists "Previously on ADHD Medication"    
          and not exists "Inpatient Stay with Qualifying Diagnosis within 300 Days of Initial ADHD Dispense"

      define "Previously on ADHD Medication":
      ...

      define "Denominator Exclusions 1":
      Hospice."Has Hospice"
        or exists ( "Narcolepsy Exclusion" )

      define "Denominator Exclusions 2":
      "Denominator Exclusions 1"

      Rationale for Change:
      ​The goal of this change is to ensure the measure intents are aligned between the HEDIS and eCQM versions of this measure, and to reduce burden on implementers who report on both measures.

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