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  1. eCQM Issue Tracker
  2. CQM-4949

Simplify exclusion criteria and logic and revise applicable risk assessment tools

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

    Description

      Brief Description of Measure:
      ​CMS249: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture:
      Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period

      Description of Issue:
      ​​The combination risk factor logic was originally developed as a proxy for the FRAX algorithm. The measure exclusion logic is complex and difficult for implementers to interpret. The FRAX tool is no longer the only risk assessment tool recommended by USPSTF. There is an opportunity to bring measure in greater alignment with current USPSTF recommendation, simplify the measure logic, and encourage use of clinical risk-assessment tools by replacing the combination exclusion logic with independent risk factors. 
       
      We propose to retain all combination risk factors in the measure as independent risk factors, with the exception of race and smoking status. More research is needed to understand whether race and smoking are appropriate to include as independent risk factors. 
       
      The risk factors are grouped by four buckets relative to when they occur in relation to the measurement period. Please note that FRAX is being moved from Denominator Exclusions into Numerator Exclusion; this is discussed in another issue.
      Remove:
      White race
      Smoker
      Retain:
      Rheumatoid Arthritis
      Malabsorption Syndromes
      Chronic Liver Disease
      Chronic Malnutrition
      Osteoporotic Fracture
      Alcohol assumption
      BMI
      Glucocorticoids (cumulative medication duration >= 90 days)
      Osteopenia
      Hyperthyroidism
      History of hip fracture in parent

      Proposed Solution:
      ​Below are changes to the header.
      //RATIONALE
      //Before
      Clinical information, such as age, body mass index (BMI), parental hip fracture history, and smoking and alcohol use, can be used to determine a woman's fracture risk (U.S. Preventive Services Task Force [USPSTF], 2018).    
      //After
      Clinical information, such as age, body mass index (BMI), parental hip fracture history, and alcohol use,...
      //GUIDANCE
      //Before
      There are two ways that a patient can be excluded from the measure:
      1. The patient has a specific number of "combination" risk factors (the number of risk factors varies by age).
      2. The patient has one or more of the "independent" risk factors, including a 10-year probability of major osteoporotic fracture of 8.4 percent or higher as determined by the FRAX.
      //After
      Patients are excluded from the measure if they have one or more risk factors for osteoporosis, including a result indicating that the patient should be considered for bone density testing on one of the following risk assessment instruments:
      •    10-year probability of major osteoporotic fracture of 8.4 percent or higher as determined by the FRAX.
      ...
      //DENOMINATOR EXCLUSIONS
      //Before
      Exclude patients with a combination of risk factors (as determined by age) or one of the independent risk factors
      Ages: 50-54 (>=4 combination risk factors) or 1 independent risk factor
      Ages: 55-59 (>=3 combination risk factors) or 1 independent risk factor
      Ages: 60-64 (>=2 combination risk factors) or 1 independent risk factor
      COMBINATION RISK FACTORS [The following risk factors are all combination risk factors; they are grouped by when they occur in relation to the measurement period]:
      The following risk factors may occur any time in the patient's history but must be active during the measurement period:
      White (race)
      BMI <= 20 kg/m2 (must be the first BMI of the measurement period)
      Smoker (current during the measurement period)
      Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor))
      The following risk factor may occur any time in the patient's history and must not start during the measurement period:
      Osteopenia
      The following risk factors may occur at any time in the patient's history or during the measurement period:
      Rheumatoid arthritis
      Hyperthyroidism
      Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption
      Chronic liver disease
      Chronic malnutrition
      Osteoporotic fracture
      The following risk factors may occur any time in the patient's history prior to the start of the measurement period but do not need to be active at the start of the measurement period:
      Documentation of history of hip fracture in parent
      Glucocorticoids [cumulative medication duration >= 90 days]
      INDEPENDENT RISK FACTORS (The following risk factors are all independent risk factors; they are grouped by when they occur in relation to the measurement period):
      The following risk factors may occur at any time in the patient's history and must not start during the measurement period:
      Osteoporosis  
      The following risk factors may occur at any time in the patient's history prior to the start of the measurement period, but do not need to be active during the measurement period:
      Gastric bypass
      FRAX[R] ten-year probability of all major osteoporosis related fracture >= 8.4 percent
      Aromatase inhibitors
      The following risk factors may occur at any time in the patient's history or during the measurement period:
      Type I Diabetes
      End stage renal disease
      Osteogenesis imperfecta
      Ankylosing spondylitis
      Psoriatic arthritis
      Ehlers-Danlos syndrome
      Cushing's syndrome
      Hyperparathyroidism
      Marfan syndrome
      Lupus
      //After (Please note that FRAX is being moved from Denominator Exclusions into Numerator Exclusion; this is documented in another issue.)
      Exclude patients with one of the independent following risk factors.
      Risk factors are grouped by when they occur in relation to the measurement period.
      The following risk factors must be active during the measurement period:
      BMI <= 20 kg/m2 (must be the first BMI of the measurement period)
      Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1 oz. of liquor))
      The following risk factors may occur at any time in the patient's history and must notprior to the start during of the measurement period:
      Osteoporosis  
      Osteopenia  
      The following risk factors may occur at any time in the patient's history prior to the start of the measurement period, but do not need to be active during the measurement period:
      Gastric bypass
      Aromatase inhibitors
      Glucocorticoids [cumulative medication duration >= 90 days]
      Documentation of history of hip fracture in parent
      The following risk factors may occur at any time in the patient's history or during the measurement period:
      ...
      Osteoporotic fracture
      Malabsorption Syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis, Crohn's disease, cystic fibrosis, malabsorption
      Chronic malnutrition
      Chronic liver disease
      Rheumatoid arthritis
      Hyperthyroidism
      Type I Diabetes
      End stage renal disease
      Osteogenesis imperfecta
      Ankylosing spondylitis
      Psoriatic arthritis
      Ehlers-Danlos syndrome
      Cushing's syndrome
      Hyperparathyroidism
      Marfan syndrome
      Lupus
      ...
      Below are changes to the value set.
      //Before
      valueset "White": 'urn:oid:2.16.840.1.113883.3.464.1003.123.12.1007'
      valueset "Tobacco Use Screening": 'urn:oid:2.16.840.1.113883.3.526.3.1278'
      valueset "Current Tobacco Smoker": 'urn:oid:2.16.840.1.113883.3.600.2390'
      //After
      (removed)

      Below are changes to the logic.
      //Before
      define "Denominator Exclusions":
        "Has Age Dependent Combination Risk Factors"
          or "Has Osteoporosis Before Measurement Period"
          or "Has Independent Risk Factors Applicable Any Time"
          or "Has Independent Risk Factors Before Measurement Period"
      define "Has Age Dependent Combination Risk Factors":
        singleton from ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
            let Age: Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ),
            NumberOfRiskFactors: "Count of Distinct Age Dependent Combination Risk Factors" + ( if "Has 90 or More Active Glucocorticoid Medication Days" then 1
                else 0
            )
            return ( ( Age between 50 and 54
                  and NumberOfRiskFactors >= 4
              )
                or ( Age between 55 and 59
                    and NumberOfRiskFactors >= 3
                )
                or ( Age between 60 and 63
                    and NumberOfRiskFactors >= 2
                )
            )
        )
      define "Count of Distinct Age Dependent Combination Risk Factors":
        Count("Age Dependent Combination Risk Factors")
      define "Age Dependent Combination Risk Factors":
        "Combination Risk Factors Applicable Any Time"
          union "Osteoporotic Fracture from Patient History"
          union "Parent History of Hip Fracture Assessment"
          union "Osteopenia Before Measurement Period"
          union "First Tobacco Use Screening Indicating Current Smoker"
          union "First Average Number of Drinks Assessments Indicating More Than Two Per Day"
          union "First BMI in Measurement Period Less Than or Equal to 20 kg m2"
          union ["Patient Characteristic Race": "White"]
      define "Combination Risk Factors Applicable Any Time":
        (

      { "RiskFactorInPatientHistory"(["Diagnosis": "Rheumatoid Arthritis"]), "RiskFactorInPatientHistory"(["Diagnosis": "Hyperthyroidism"]), "RiskFactorInPatientHistory"(["Diagnosis": "Malabsorption Syndromes"]), "RiskFactorInPatientHistory"(["Diagnosis": "Chronic Liver Disease"]), "RiskFactorInPatientHistory"(["Diagnosis": "Chronic Malnutrition"])}

      )
      define "Osteoporotic Fracture from Patient History":
      ["Diagnosis": "Osteoporotic Fractures"] PathologicalFracture
        where PathologicalFracture.prevalencePeriod starts on or before day of
        end of "Measurement Period"
      define "Parent History of Hip Fracture Assessment":
      ...
      define "Osteopenia Before Measurement Period":
      ...
      define "First Tobacco Use Screening Indicating Current Smoker":

      { First(["Assessment, Performed": "Tobacco Use Screening"] TobaccoScreen     where TobaccoScreen.result in "Current Tobacco Smoker"       and start of Global."NormalizeInterval"(TobaccoScreen.relevantDatetime, TobaccoScreen.relevantPeriod)during "Measurement Period"     sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod) )}

      define "First Average Number of Drinks Assessments Indicating More Than Two Per Day":
      { First(["Assessment, Performed": "Average Number of Drinks per Drinking Day"] AverageDrinks
          where start of Global."NormalizeInterval"(AverageDrinks.relevantDatetime, AverageDrinks.relevantPeriod)during "Measurement Period"
            and AverageDrinks.result > 2 '

      {drinks}/d'
          sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
      )}
      define "First BMI in Measurement Period Less Than or Equal to 20 kg m2":
      ...
      define "First BMI in Measurement Period": { First(["Physical Exam, Performed": "BMI Ratio"] BMI     where start of Global."NormalizeInterval"(BMI.relevantDatetime, BMI.relevantPeriod)during "Measurement Period"       and BMI.result is not null     sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod) )}
      define "Has Osteoporosis Before Measurement Period":
      ...
      define "Has Independent Risk Factors Before Measurement Period":
      ...
      define "Has Independent Risk Factors Applicable Any Time":
      ...
      //After (Please note that FRAX is being moved from Denominator Exclusions into Numerator Exclusion; this is documented in another issue.)
      define "Denominator Exclusions":
        "Has Risk Factor Active During the Measurement Period"
          or "Has Risk Factor Any Time in History or During Measurement Period"
          or "Has Risk Factor Any Time in History Prior to Start of Measurement Period"
          or "Has Risk Factor Any Time in History Prior to Start of Measurement Period and Do Not Need to be Active During Measurement Period"
      define "Has Risk Factor Active During the Measurement Period":
        "First BMI in Measurement Period Less Than or Equal to 20 kg m2" is not null
          or "First Average Number of Drinks Assessment Indicating More Than Two Per Day" is not null
      define "First BMI in Measurement Period Less Than or Equal to 20 kg m2":
      ...
      define "First BMI in Measurement Period":
        First(["Physical Exam, Performed": "Body mass index (BMI) [Ratio]"] BMI
            where start of Global."NormalizeInterval"(BMI.relevantDatetime, BMI.relevantPeriod)during "Measurement Period"
              and BMI.result is not null
            sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
        )
      define "First Average Number of Drinks Assessments Indicating More Than Two Per Day":
       First(["Assessment, Performed": "Average Number of Drinks per Drinking Day"] AverageDrinks
          where start of Global."NormalizeInterval"(AverageDrinks.relevantDatetime, AverageDrinks.relevantPeriod)during "Measurement Period"
            and AverageDrinks.result > 2 '{drinks}

      /d'
          sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
      )
      define "Has Independent Risk Factors Applicable Any Time"  :
        "Has Osteoporosis Before Measurement Period"
          or exists "Osteopenia Before Measurement Period"
      define "Has Osteoporosis Before Measurement Period":
      ...
      define "Osteopenia Before Measurement Period":
      ...
      define "Has Independent Risk Factors Before Measurement Period":
        exists ( ...
            union "Parent History of Hip Fracture Assessment"
        )
      define "Has Risk Factor Any Time in History or During Measurement Period":
        "Has 90 or More Active Glucocorticoid Medication Days"
          or exists ( "DiagnosisInPatientHistory"(["Diagnosis": "Osteoporotic Fractures"]
                union ["Diagnosis": "Malabsorption Syndromes"]
                union ["Diagnosis": "Chronic Malnutrition"]
                union ["Diagnosis": "Chronic Liver Disease"]
                union ["Diagnosis": "Rheumatoid Arthritis"]
                union ["Diagnosis": "Hyperthyroidism"]
                ....
            )
          )
      define function "DiagnosisInPatientHistory"(Diagnosis List<"Diagnosis"> ):
        Diagnosis Dx
          where Dx.prevalencePeriod starts on or before day of
          end of "Measurement Period"

      Rationale for Change:
      We propose to replace the combination exclusion logic with independent risk factors in order to simplify the measure exclusion logic and further align the measure with the current USPSTF recommendation. With the addition of other risk assessment tools to the measure, the measure no longer relies exclusively on the FRAX to determine osteoporosis and osteoporotic fracture risk. Stakeholders agreed that this approach will help simplify the logic and further align with the current USPSTF recommendation. 

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