Brief Description of Measure:

​CMS161 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment: All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit

Description of Issue:

​The measure's age requirements have been a point of confusion, as the header indicates patients aged 18 years and older, while the logic references greater than or equal to 17 years of age at the start of the measurement period. The measure developer has identified this as an opportunity to better align the patient age description in the narrative with the CQL logic.
 
The current logic for the Initial Population is as follows:
Initial Population
   "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
     with ["Patient Characteristic Birthdate": "Birth date"] BirthDate        such that Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 17
 
The measure developer proposes updating the header of the measure to align with the measure intent and the aforementioned logic.

Proposed Solution:

​Current Description: 
All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit
 
Proposed Description:
Percentage of all patient visits for those patients that turn 18 or older during the measurement period which a new or recurrent diagnosis of MDD was identified and a suicide risk assessment was completed during the visit.
 
Current Initial Population:
Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified
 
Proposed Initial Population:
Patient visits for those patients that turn 18 or older during the measurement period during which a new diagnosis of MDD or recurrent episode, was identified
 
Current Guidance:
This eCQM is an episode-based measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified in adults 18 years or older.  
 
Proposed Guidance:
This eCQM is an episode-based measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified in adults that turn 18 or older during the measurement period.

Rationale for Change:

 ​The proposed changes to the narrative sections are to align better with patient age description in the CQL logic.