Brief description of measure: CMS117: Childhood Immunization Status Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (Hib); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday ​CMS127: Pneumococcal Vaccination Status for Older Adults Percentage of patients 66 years of age and older who have received a pneumococcal vaccine CMS147: Preventive Care and Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization Description of issue: The Measure Developer had previously removed adverse reaction to vaccines as numerator criteria in CMS117 and CMS127, because the codes/modeling were not sufficient to reach the measure intent. The measure intent is to include severe allergic reaction or anaphylaxis to vaccines as numerator criteria. The Measure Developer had since requested new SNOMED codes that represent anaphylaxis due to specific vaccines, which can now be included in these measures (i.e., CMS117, CMS127, CMS147) to align with the ACIP recommendation that vaccines are only for persons who do not have contraindications. For AU2023, Measure Developer had also concurrently explored other modeling approaches using QDM datatypes Allergy/Intolerance and Adverse Event but would like to defer any additions to future publications in order to allow for more time to conduct research and HEDIS expert review. The Measure Developer does not anticipate substantive impact to reporting due to the following: - Per CDC, “although allergic reactions are a common concern for vaccine providers, these reactions are uncommon and anaphylaxis following vaccines is rare, occurring at a rate of approximately one per million doses for many vaccines.” Reference: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/adverse-reactions.html . - (CMS117) Data from HEDIS also demonstrate that this change should not have a large impact on performance. Per HEDIS MY2018 data on the Childhood Immunization Status measure, commercial health plans reported <0.1% of members met any exclusion criteria, which could include any of the following: anaphylactic reaction to a vaccine or its components; encephalopathy following DTaP; immunodeficiency, HIV, history of intussusception, lymphoreticular cancer, multiple myeloma or leukemia. The following criteria will be added to the respective measures: CMS117: Childhood Immunization Status Anaphylaxis due to IPV (poliovirus) vaccine Anaphylaxis due to MMR vaccine Anaphylaxis due to VZV (varicella) vaccine Anaphylaxis due to pneumococcal vaccine Anaphylaxis due to Hep A vaccine Anaphylaxis due to influenza vaccine Note: Anaphylaxis due to DTap, Hib B, Hep B and Rotavirus vaccines are already included in the current measure requirements. CMS127: Pneumococcal Vaccination Status for Older Adults Anaphylaxis due to pneumococcal vaccine CMS147: Preventive Care and Screening: Influenza Immunization Anaphylaxis due to influenza vaccine Goal of review: Obtain clinical and technical feedback

Proposed solution: /*CMS147*/ //Header - before Numerator: Patients who […] Clinical Recommendation Statement: During the 2021–22 influenza season, the following types of vaccines are expected to be available: inactivated influenza vaccines (IIV4s), recombinant influenza vaccine (RIV4), and live attenuated influenza vaccine (LAIV4) (CDC/Advisory Committee on Immunization Practices [ACIP], 2021). //Header - after Numerator: Patients who […]; or ever had an anaphylaxis due to the vaccine on or before the end of the measurement period Clinical Recommendation Statement: During the 2022–23 influenza season, the following types of vaccines are expected to be available: quadrivalent, containing hemagglutinin (HA) derived from one influenza A(H1N1)pdm09 virus, one influenza A(H3N2) virus, one influenza B/Victoria lineage virus, and one influenza B/Yamagata lineage virus. Inactivated influenza vaccines (IIV4s), recombinant influenza vaccine (RIV4), and live attenuated influenza vaccine (LAIV4) are expected to be available. (CDC/Advisory Committee on Immunization Practices [ACIP], 2022). //Logic and Terminology - before define "Numerator":   exists "Influenza Vaccination Procedure"     […]   //Logic and Terminology - after define "Numerator":   exists "Influenza Vaccination Procedure"     […]     or exists "Influenza Vaccine Anaphylaxis"   define "Influenza Vaccine Anaphylaxis":   ["Diagnosis": "Anaphylaxis caused by vaccine product containing Influenza virus antigen (disorder)"] PneumococcalAdverseRXN   where PneumococcalAdverseRXN.prevalencePeriod starts on or before end of "Measurement Period"   code "Anaphylaxis caused by vaccine product containing Influenza virus antigen (disorder)": '471361000124100' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine product containing Influenza virus antigen (disorder)'   /*CMS127*/ //Header: Numerator - before  Patients who […]   //Header: Numerator - after  Patients who […]; or patients with anaphylaxis due to the pneumococcal vaccine any time before the end of the measurement period.   //Logic and Terminology - before define "Numerator":      "Has Adult Pneumococcal Vaccine Administered"    //Logic and Terminology - after define "Numerator":      "Has Adult Pneumococcal Vaccine Administered"                or "Has Pneumococcal Vaccine Anaphylaxis"   define "Has Pneumococcal VaccineAnaphylaxis":                exists ["Diagnosis": " Anaphylaxis caused by vaccine product containing Streptococcus pneumoniae antigen (disorder)"] PneumococcalAnaphylaxis                  wherePneumococcalAnaphylaxis.prevalencePeriod starts on or before end of "Measurement Period"   code "Anaphylaxis caused by vaccine product containing Streptococcus pneumoniae antigen (disorder)": '471141000124102' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine product containing Streptococcus pneumoniae antigen (disorder)'   /*CMS117*/ //Header: Numerator - before   […] Poliovirus vaccination (IPV) At least three IPV vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.   Measles, mumps, and rubella vaccination (MMR) Children with either of the following meet criteria: • At least one MMR vaccination on or between the child’s first and second birthdays. • All of the following anytime on or before the child’s second birthday (on the same or different date of service): o History of measles o History of mumps o History of rubella  […]   Varicella vaccination (VZV) Children with either of the following meet criteria: • At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays. • History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday.   Pneumococcal Conjugate At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.   Hepatitis A Children with either of the following meet criteria: • At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays. • History of hepatitis A illness on or before the child’s second birthday.   […]   Influenza At least two influenza vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 6 months (180 days) after birth. • One of the two vaccinations can be an LAIV vaccination administered on the child’s second birthday. Do not count an LAIV vaccination administered before the child’s second birthday.   //Header: Numerator - after  [...]  Poliovirus vaccination (IPV) Children with either of the following on or before the child’s second birthday meet criteria: At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. Anaphylaxis due to the IPV vaccine.   Measles, mumps, and rubella vaccination (MMR) Children with any of the following meet criteria: - At least one MMR vaccination on or between the child’s first and second birthdays. - Anaphylaxis due to the MMR vaccine on or before the child’s second birthday. [...] Varicella vaccination (VZV) [...] - Anaphylaxis due to the VZV vaccine on or before the child’s second birthday.   Pneumococcal Conjugate Children with either of the following on or before the child’s second birthday meet criteria: At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. Anaphylaxis due to the pneumococcal vaccine.   Hepatitis A Children with any of the following meet criteria: [...] - Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday. [..]   Influenza Children with either of the following on or before their second birthday meet criteria: [...] - Anaphylaxis due to the influenza vaccine.    //Clinical Recommendation Statement - before   This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) recommended child and adolescent immunization schedule (CDC ACIP 2021).   -- For the 2021–22 season, see the 2021–22 ACIP influenza vaccine recommendations.    //Clinical Recommendation Statement, References - after This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) recommended child and adolescent immunization schedule (CDC ACIP 2022). -- For the 2022–23 season, see the 2022–23 ACIP influenza vaccine recommendations.   //Logic: Numerator - before   define “Numerator”: […] and ( exists ( "Three Polio Vaccinations" ) )   and ( exists ( "One MMR Vaccination" )       or ( exists ( "Measles Indicators" )           and exists ( "Mumps Indicators" )           and exists ( "Rubella Indicators" ) ) )  […]   and ( exists ( "One Chicken Pox Vaccination" )       or exists ( "Varicella Zoster Numerator Inclusion Conditions" ) )   and ( exists ( "Four Pneumococcal Conjugate Vaccinations" ) )   and ( exists ( "One Hepatitis A Vaccinations" )       or exists ( "Hepatitis A Numerator Inclusion Conditions" ) ) […] and ( exists ( "Two Influenza Vaccinations" )       or ( "Two Influenza Vaccinations Including One LAIV Vaccination" ) )   define “Varicella Zoster Numerator Inclusion Conditions”:            ["Diagnosis": "Varicella Zoster"] VaricellaZoster                   where date from start of VaricellaZoster.prevalencePeriod during day of "First Two Years"   define “Hepatitis A Numerator Inclusion Conditions”:                 ["Diagnosis": "Hepatitis A"] HepatitisADiagnosis                   where date from start of HepatitisADiagnosis.prevalencePeriod during day of "First Two Years"     //Logic: Numerator, Definitions, and terminology – after Please note that anaphylaxis due to IPV (poliovirus), MMR, pneumococcal, and Influenza are added as new CQL definitions, whereas anaphylaxis due to Hep A and VZV (varicella) vaccines are added to existing CQL definitions.   define "Numerator":                 [...]                   and ( exists ( "Three Polio Vaccinations" )                 or exists ( "Polio Numerator Inclusion Conditions" ) )                   and ( exists ( "One MMR Vaccination" )                 or exists ( "MMR Numerator Inclusion Conditions" )                       or ( exists ( "Measles Indicators" )                           and exists ( "Mumps Indicators" )                           and exists ( "Rubella Indicators" ) ) )                   [...]                   and ( exists ( "Four Pneumococcal Conjugate Vaccinations" )                  or exists ( "Pneumococcal Conjugate Numerator Inclusion Conditions" ) )                   [...]                   and ( exists ( "Two Influenza Vaccinations" )                       or ( "Two Influenza Vaccinations Including One LAIV Vaccination" )                 or exists ( "Influenza Numerator Inclusion Conditions" ) )   define “Hepatitis A Numerator Inclusion Conditions”:                 (["Diagnosis": "Hepatitis A"]                 union ["Diagnosis": "Anaphylaxis caused by vaccine product containing Hepatitis A virus antigen (disorder)”] ) HepatitisADiagnosis                   where date from start of HepatitisADiagnosis.prevalencePeriod during day of "First Two Years"   define “Influenza Numerator Inclusion Conditions”:                 ["Diagnosis": "Anaphylaxis caused by vaccine product containing Influenza virus antigen (disorder) "] InfluenzaConditions                   where date from start of InfluenzaConditions.prevalencePeriod during day of "First Two Years"   define “MMR Numerator Inclusion Conditions”:                 ["Diagnosis": " Anaphylaxis caused by vaccine product containing Measles morbillivirus and Mumps orthobulavirus and Rubella virus antigens (disorder) "] MMRConditions                   where date from start of MMRConditions.prevalencePeriod during day of “First Two Years”   define “Pneumococcal Conjugate Numerator Inclusion Conditions”:                 ["Diagnosis": "Anaphylaxis caused by vaccine product containing Streptococcus pneumoniae antigen (disorder)"] PneumococcalReaction                   where date from start of PneumococcalReaction.prevalencePeriod during day of "First Two Years"   define “Polio Numerator Inclusion Conditions”:                 ["Diagnosis": " Anaphylaxis caused by vaccine product containing human poliovirus antigen (disorder)"] PolioConditions                   where date from start of PolioConditions.prevalencePeriod during day of "First Two Years   define “Varicella Zoster Numerator Inclusion Conditions”:                 (["Diagnosis": "Varicella Zoster"]                 union ["Diagnosis": Anaphylaxis caused by vaccine containing Human alphaherpesvirus 3 antigen (disorder)"] ) VaricellaZoster                   where date from start of VaricellaZoster.prevalencePeriod during day of "First Two Years"   code "Anaphylaxis caused by vaccine containing Human alphaherpesvirus 3 antigen (disorder)": '471341000124104' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine containing Human alphaherpesvirus 3 antigen (disorder)'   code "Anaphylaxis caused by vaccine product containing Hepatitis A virus antigen (disorder)": '471311000124103' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine product containing Hepatitis A virus antigen (disorder)'   code "Anaphylaxis caused by vaccine product containing Influenza virus antigen (disorder)": '471361000124100' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine product containing Influenza virus antigen (disorder)'   code "Anaphylaxis caused by vaccine product containing Measles morbillivirus and Mumps orthorubulavirus and Rubella virus antigens (disorder)": '471331000124109' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine product containing Measles morbillivirus and Mumps orthorubulavirus and Rubella virus antigens (disorder)'   code "Anaphylaxis caused by vaccine product containing Streptococcus pneumoniae antigen (disorder)": '471141000124102' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine product containing Streptococcus pneumoniae antigen (disorder)'   code "Anaphylaxis caused by vaccine product containing human poliovirus antigen (disorder)": '471321000124106' from "SNOMEDCT" display 'Anaphylaxis caused by vaccine product containing human poliovirus antigen (disorder)' Rationale for change: ​The Measure Developer recommends adding anaphylaxis as an option for meeting the numerator requirement for CMS117, CMS127, and CMS147. This aligns with the ACIP (Centers for Disease Control and Prevention Advisory Committee on Immunization Practices) recommendation for immunizations.