Brief Description of Measure:

CMS347: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease - percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:

*All patients who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR

*Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR

*Patients aged 40-75 years with a diagnosis of diabetes

Description of Issue:

CMS347 has several Denominator Exceptions for not ordering a statin therapy, including active liver or hepatic disease or insufficiency, end-stage renal disease, palliative or hospice care, statin-associated muscle systems, and allergy to statin medication. However, there is no denominator exception for other, general medical reasons. 
 
The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease states that there should be a risk discussion between the clinician and patient before starting statin therapy to review net clinical benefit, weighing the potential for ASCVD risk reduction against the potential for statin-associated side effects, statin–drug interactions, and safety, while emphasizing that side effects can be addressed successfully. The measure steward and expert work group believe the guidelines support adding a general medical reason denominator exception to the measure. This exception would cover any medical reason that is not listed in the current denominator exception. Additionally, this denominator exception is commonly used in other eCQMs that include medications including CMS135, CMS144 and CMS145. 
 

Proposed Solution:

Header: Denominator Exceptions 
Add "Patients with documentation of a medical reason for not being prescribed statin therapy."
 
Current Logic:
Denominator Exceptions
"Has Allergy to Statin"
  or "Has Order or Receiving Hospice Care or Palliative Care"
  or "Has Hepatitis or Liver Disease Diagnosis"
  or "Has Statin Associated Muscle Symptoms"
  or "Has ESRD Diagnosis"
  or "Has Adverse Reaction to Statin"
 
Proposed Logic:
Denominator Exceptions
  "Has Allergy to Statin"
    or ...
    or "Has Adverse Reaction to Statin"
    or "Has Medical Reason for Not Ordering Statin Therapy"
 
Has Medical Reason for Not Ordering Statin Therapy
  exists ( ["Medication, Not Ordered": "Low Intensity Statin Therapy"]
    union ["Medication, Not Ordered": "Moderate Intensity Statin Therapy"]
    union ["Medication, Not Ordered": "High Intensity Statin Therapy"] ) NoStatinTherapyOrdered
    with "Qualifying Encounter during Measurement Period" QualifyingEncounter
      such that NoStatinTherapyOrdered.authorDatetime during QualifyingEncounter.relevantPeriod
    where NoStatinTherapyOrdered.negationRationale in "Medical Reason"
 
Add the following value set:
valueset "Medical Reason" (2.16.840.1.113883.3.526.3.1007)

Rationale for Change:

Adding a general medical reason exception is supported by the ACC/AHA guidelines, the measure steward and the expert work group. This would also align with common representation of medical reason exceptions in other eCQMs.