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 measure developer reviewed the measure specification and determined that timing precision revisions are needed for four criteria:
   - follow up visit in 30 days after Index Prescription Start Date (IPSD),
   - acute inpatient stay 30 days after IPSD,
   - acute inpatient stay 300 days after IPSD, and
   - narcolepsy exclusion.
 
When "...on or…" is used for timing comparison, it assesses whether Event A and Event B occur at the same time. In the case of "Follow up visit in 30 days after IPSD", the measure developer is interested in assessing whether a follow up visit occurs in the 30-day period after the day of IPSD, not including on the day of IPSD; therefore, "...on or..." should be removed from the logic. In order to improve timing precision and measure intent expression, the measure developer proposes to revise the use of "...on or..." accordingly. 
 
The following example illustrates this precision issue.
//Follow up visit in 30 days after IPSD
The measure intent for Numerator 1 is to look for follow up visits occurring during the Intake Period (30-day period after the IPSD). For example, for an index prescription on 1/1/2012 12:00AM, a follow up visit during the timeframe of 1/2/2012 12:00AM – 1/31/2012 11:59PM should meet Numerator 1  requirement; the current logic assesses a period of 1/1/2012 12:00AM –  1/31/2012 12:00AM, which does not meet intent.

Proposed Solution:
//Please note that this issue focuses on the removal of "...on or..."; the addition of "day of" within the proposed logic below is discussed in another issue.
 
//Before
define "Encounter 30 Days after Initial Phase ADHD Medication":
( "Qualifying Numerator Encounter" ValidNumeratorEncounter
    with "First ADHD Medication Dispensed during Intake Period" InitialADHDMedication
      such that ValidNumeratorEncounter.relevantPeriod starts 30 days or less on or after InitialADHDMedication.relevantDatetime)
 
//After
... such that ValidNumeratorEncounter.relevantPeriod starts 30 days or less after day of InitialADHDMedication.relevantDatetime
 
 

//Before
define "Inpatient Stay with Qualifying Diagnosis within 30 Days of Initial ADHD Dispense":
"Inpatient Stay with Qualifying Diagnosis" InpatientStay
  with "First ADHD Medication Dispensed during Intake Period" InitialADHDMedication
    such that InpatientStay.relevantPeriod starts 30 days or less on or after InitialADHDMedication.relevantDatetime
 
//After
... such that InpatientStay.relevantPeriod starts 30 days or less after day of InitialADHDMedication.relevantDatetime
 

//Before
define "Inpatient Stay with Qualifying Diagnosis within 300 Days of Initial ADHD Dispense":
    "Inpatient Stay with Qualifying Diagnosis" InpatientStay
      with "First ADHD Medication Dispensed during Intake Period" InitialADHDMedication
        such that InpatientStay.relevantPeriod starts 300 days or less on or after day of InitialADHDMedication.relevantDatetime
 

//After
... such that InpatientStay.relevantPeriod starts 300 days or less after day of InitialADHDMedication.relevantDatetime
 
 
//Please note that "...on or..." is added.
//Before
define "Narcolepsy Exclusion":
["Diagnosis": "Narcolepsy"] Narcolepsy
  where Narcolepsy.prevalencePeriod starts before
  end "Measurement Period"
 
//After
…
  where Narcolepsy.prevalencePeriod starts on or before
  end "Measurement Period"

Rationale for Change:
The goal of this change is to improve timing precision and align the CQL expression with the measure intent.