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  2. CQM-5696

CRP: Add 4th population related to the 10-year ASCVD risk assessment

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    • Other
    • Resolution: Resolved
    • Moderate
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      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 with an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD) or ever had 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
      ​​​To align with the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, the measure developer is adding a 10-year ASCVD risk assessment tool to the measure as a 4th Population criterion, at the direction of the measure steward and expert workgroup.

      This was submitted to CRP during the last annual update cycle, under the ticket CQM-4955

      Goal of review
      Obtain clinical and technical feedback
      Show
      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 with an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD) or ever had 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 ​​​To align with the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, the measure developer is adding a 10-year ASCVD risk assessment tool to the measure as a 4th Population criterion, at the direction of the measure steward and expert workgroup. This was submitted to CRP during the last annual update cycle, under the ticket CQM-4955 .  Goal of review Obtain clinical and technical feedback
    • Hide
      Proposed solution
      ​​The measure developer proposes adding a 4th Population:
       
      PROPOSED HEADER LANGUAGE CHANGES
      ADD THE FOLLOWING STATEMENT TO THE DESCRIPTION:
      Patients aged 40 to 75 with LDL-C >= 70 and < 190 mg/dL, without diabetes mellitus, and with 10-year ASCVD risk of >= 20 percent (high risk)
       
      ADD THE FOLLOWING STATEMENT TO RATE AGGREGATION:
      Population 4: Patients aged 40 to 75 at the beginning of the measurement period with LDL-C >= 70 and < 190 mg/dL, without diabetes mellitus, and with 10-year ASCVD risk of >= 20 percent (high risk) during the measurement period.


      REVISE THE EXISTING CONTENT IN RATE AGGREGATION TO:
      For the purposes of this measure, a single performance rate can be calculated as follows:

      Performance Rate = (Numerator 1 + Numerator 2 + Numerator 3 + Numerator 4)/ [(Denominator 1 - Denominator Exclusions 1- Denominator Exceptions 1) + (Denominator 2 - Denominator Exclusions 2 - Denominator Exceptions 2) + (Denominator 3 - Denominator Exclusions 3 - Denominator Exceptions 3) + (Denominator 4 - Denominator Exclusions 4 - Denominator Exceptions 4)]

      ADD THE FOLLOWING CLINICAL RECOMMENDATION STATEMENT:
      To facilitate decisions about preventive interventions, it is recommended to screen for traditional ASCVD risk factors and apply the race- and sex-specific Pooled Cohort Equations (PCE) to estimate 10-year ASCVD risk for asymptomatic adults 40 to 75 years of age. The higher the estimated risk, the more likely the patient is to benefit from statin treatment (Grundy et al., 2019).

      ADD THE FOLLOWING GUIDANCE:
      To meet Initial Population 4:
      If the patient’s most recent LDL-C is >= 70 <190 mg/dL during the measurement period.


      The 10-year ASCVD risk options:
      The 10-year ASCVD risk is calculated using the Pooled Cohort Equations, either the 2013 ACC/AHA ASCVD Risk Estimator or the ACC Risk Estimator Plus. The 10-year ASCVD risk assessment must be performed during the measurement period.  


      ADD THE FOLLOWING TO THE INITIAL POPULATION STATEMENT:
      Population 4: Patients aged 40 to 75 at the beginning of the measurement period with LDL-C >= 70 and < 190 mg/dL, without diabetes mellitus, and with 10-year ASCVD risk (i.e., 2013 ACC/AHA ASCVD Risk Estimator or the ACC Risk Estimator Plus) of >= 20 percent (high risk) during the measurement period.


      Denominator Exception, Denominator Exclusion and Numerator are the same as the other 3 populations.   

      PROPOSED LOGIC FOR POPULATION CRITERIA 4:
      Note: for Pop​ulation Criteria 4, Denominator Exception, Denominator Exclusion and Numerator are the same as the other 3 populations.   

      define "Initial Population 4":
          "Patients Age 40 to 75 Years and LDL Greater than or Equal to 70 but less than 190 and have a 10 Year CVD Risk of High without ASCVD and High LDL and Diabetes"
            and exists "Qualifying Encounter during Day of Measurement Period"

      define "Patients Age 40 to 75 Years and LDL Greater than or Equal to 70 but less than 190 and have a 10 Year CVD Risk of High without ASCVD and High LDL and Diabetes":
          AgeInYearsAt(date from start of "Measurement Period")in Interval[40, 75]
             and exists ( "Most Recent LDL Result Greater Than or Equal To 70 and Less Than 190" )
              and "Ten Year CVD Risk is High"
            and not ( exists "ASCVD Diagnosis or Procedure before End of Measurement Period"
                or exists "Hypercholesterolemia Diagnosis"
                or exists "LDL Result Greater Than or Equal To 190"
                or "Has Diabetes Diagnosis" )

      define "Most Recent LDL Result Greater Than or Equal To 70 and Less Than 190":
          { Last(["Laboratory Test, Performed": "LDL Cholesterol"] LDL70ToLessThan190
              where(LDL70ToLessThan190.result >= 70 'mg/dL'
                  and LDL70ToLessThan190.result < 190 'mg/dL'    )
                and Global."NormalizeInterval"(LDL70ToLessThan190.relevantDatetime, LDL70ToLessThan190.relevantPeriod)starts before end of "Measurement Period"
              sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod))}

      define "Ten Year CVD Risk is High":
          ( ( exists ["Intervention, Performed": "Assessment for risk of cardiovascular disease (procedure)"] AtRiskCVD
                where AtRiskCVD.result as Quantity >= 20 '%'
                  and Global."NormalizeInterval" ( AtRiskCVD.relevantDatetime, AtRiskCVD.relevantPeriod ) during "Measurement Period"  )
              or exists ( ["Intervention, Performed": "Assessment for risk of cardiovascular disease (procedure)"] CVDRisk
                  where CVDRisk.result = "High (qualifier value)"
                    and Global."NormalizeInterval" ( CVDRisk.relevantDatetime, CVDRisk.relevantPeriod ) during "Measurement Period"    )
              or ( exists "ASCVD 10 Year Risk Estimators" AtRiskCVD
                    where AtRiskCVD.result as Quantity >= 20 '%'
                      and Global."NormalizeInterval" ( AtRiskCVD.relevantDatetime, AtRiskCVD.relevantPeriod ) during "Measurement Period"    )
             or exists ( "ASCVD 10 Year Risk Estimators" CVDRisk
                   where CVDRisk.result = "High (qualifier value)"
                      and Global."NormalizeInterval" ( CVDRisk.relevantDatetime, CVDRisk.relevantPeriod ) during "Measurement Period"    ))

      define "ASCVD 10 Year Risk Estimators"
          ["Assessment, Performed": "Cardiovascular disease 10Y risk"]
            union ["Assessment, Performed": "Cardiovascular disease 10Y risk [Likelihood]"]
            union ["Assessment, Performed": "Cardiovascular disease 10Y risk [Likelihood] ACC-AHA Pooled Cohort by Goff 2013"]

      Note: definitions for "ASCVD Diagnosis or Procedure before End of Measurement Period" ; "Hypercholesterolemia Diagnosis"; "LDL Result Greater Than or Equal To 190" and  "Has Diabetes Diagnosis" are the same as prior years. 


      PROPOSED CODING*
      code "Cardiovascular disease 10Y risk" ("LOINC Code (99056-4)")
      code "Cardiovascular disease 10Y risk [Likelihood]" ("LOINC Code (99055-6)")
      code "Cardiovascular disease 10Y risk [Likelihood] ACC-AHA Pooled Cohort by Goff 2013" ("LOINC Code (79423-0)")
       
      *The measure steward and expert workgroup also agreed that that clinicians should use the Pooled Cohort Equations (PCE) risk assessment tools - ACC/AHA 2013 ASCVD risk calculator and ACC ASCVD Risk Estimator Plus. There were no LOINC codes for the ASCVD Risk Estimator Plus. The measure steward created general LOINC codes (i.e.,99056-4 and 99055-6) which need to be used for ASCVD Risk Estimator Plus. 

      Rationale for change
      The addition of a fourth population criterion related to the 10-year ASCVD risk assessment tool to the measure aligns with the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.
      Show
      Proposed solution ​​The measure developer proposes adding a 4th Population:   PROPOSED HEADER LANGUAGE CHANGES ADD THE FOLLOWING STATEMENT TO THE DESCRIPTION: Patients aged 40 to 75 with LDL-C >= 70 and < 190 mg/dL, without diabetes mellitus, and with 10-year ASCVD risk of >= 20 percent (high risk)   ADD THE FOLLOWING STATEMENT TO RATE AGGREGATION: Population 4: Patients aged 40 to 75 at the beginning of the measurement period with LDL-C >= 70 and < 190 mg/dL, without diabetes mellitus, and with 10-year ASCVD risk of >= 20 percent (high risk) during the measurement period. REVISE THE EXISTING CONTENT IN RATE AGGREGATION TO: For the purposes of this measure, a single performance rate can be calculated as follows: Performance Rate = (Numerator 1 + Numerator 2 + Numerator 3 + Numerator 4)/ [(Denominator 1 - Denominator Exclusions 1- Denominator Exceptions 1) + (Denominator 2 - Denominator Exclusions 2 - Denominator Exceptions 2) + (Denominator 3 - Denominator Exclusions 3 - Denominator Exceptions 3) + (Denominator 4 - Denominator Exclusions 4 - Denominator Exceptions 4)] ADD THE FOLLOWING CLINICAL RECOMMENDATION STATEMENT: To facilitate decisions about preventive interventions, it is recommended to screen for traditional ASCVD risk factors and apply the race- and sex-specific Pooled Cohort Equations (PCE) to estimate 10-year ASCVD risk for asymptomatic adults 40 to 75 years of age. The higher the estimated risk, the more likely the patient is to benefit from statin treatment (Grundy et al., 2019). ADD THE FOLLOWING GUIDANCE: To meet Initial Population 4: If the patient’s most recent LDL-C is >= 70 <190 mg/dL during the measurement period. The 10-year ASCVD risk options: The 10-year ASCVD risk is calculated using the Pooled Cohort Equations, either the 2013 ACC/AHA ASCVD Risk Estimator or the ACC Risk Estimator Plus. The 10-year ASCVD risk assessment must be performed during the measurement period.   ADD THE FOLLOWING TO THE INITIAL POPULATION STATEMENT: Population 4: Patients aged 40 to 75 at the beginning of the measurement period with LDL-C >= 70 and < 190 mg/dL, without diabetes mellitus, and with 10-year ASCVD risk (i.e., 2013 ACC/AHA ASCVD Risk Estimator or the ACC Risk Estimator Plus) of >= 20 percent (high risk) during the measurement period. Denominator Exception, Denominator Exclusion and Numerator are the same as the other 3 populations.    PROPOSED LOGIC FOR POPULATION CRITERIA 4: Note: for Pop​ulation Criteria 4, Denominator Exception, Denominator Exclusion and Numerator are the same as the other 3 populations.    define "Initial Population 4":     "Patients Age 40 to 75 Years and LDL Greater than or Equal to 70 but less than 190 and have a 10 Year CVD Risk of High without ASCVD and High LDL and Diabetes"       and exists "Qualifying Encounter during Day of Measurement Period" define "Patients Age 40 to 75 Years and LDL Greater than or Equal to 70 but less than 190 and have a 10 Year CVD Risk of High without ASCVD and High LDL and Diabetes":     AgeInYearsAt(date from start of "Measurement Period")in Interval[40, 75]        and exists ( "Most Recent LDL Result Greater Than or Equal To 70 and Less Than 190" )         and "Ten Year CVD Risk is High"       and not ( exists "ASCVD Diagnosis or Procedure before End of Measurement Period"           or exists "Hypercholesterolemia Diagnosis"           or exists "LDL Result Greater Than or Equal To 190"           or "Has Diabetes Diagnosis" ) define "Most Recent LDL Result Greater Than or Equal To 70 and Less Than 190":     { Last(["Laboratory Test, Performed": "LDL Cholesterol"] LDL70ToLessThan190         where(LDL70ToLessThan190.result >= 70 'mg/dL'             and LDL70ToLessThan190.result < 190 'mg/dL'    )           and Global."NormalizeInterval"(LDL70ToLessThan190.relevantDatetime, LDL70ToLessThan190.relevantPeriod)starts before end of "Measurement Period"         sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod))} define "Ten Year CVD Risk is High":     ( ( exists ["Intervention, Performed": "Assessment for risk of cardiovascular disease (procedure)"] AtRiskCVD           where AtRiskCVD.result as Quantity >= 20 '%'             and Global."NormalizeInterval" ( AtRiskCVD.relevantDatetime, AtRiskCVD.relevantPeriod ) during "Measurement Period"  )         or exists ( ["Intervention, Performed": "Assessment for risk of cardiovascular disease (procedure)"] CVDRisk             where CVDRisk.result = "High (qualifier value)"               and Global."NormalizeInterval" ( CVDRisk.relevantDatetime, CVDRisk.relevantPeriod ) during "Measurement Period"    )         or ( exists "ASCVD 10 Year Risk Estimators" AtRiskCVD               where AtRiskCVD.result as Quantity >= 20 '%'                 and Global."NormalizeInterval" ( AtRiskCVD.relevantDatetime, AtRiskCVD.relevantPeriod ) during "Measurement Period"    )        or exists ( "ASCVD 10 Year Risk Estimators" CVDRisk              where CVDRisk.result = "High (qualifier value)"                 and Global."NormalizeInterval" ( CVDRisk.relevantDatetime, CVDRisk.relevantPeriod ) during "Measurement Period"    )) define "ASCVD 10 Year Risk Estimators"     ["Assessment, Performed": "Cardiovascular disease 10Y risk"]       union ["Assessment, Performed": "Cardiovascular disease 10Y risk [Likelihood]"]       union ["Assessment, Performed": "Cardiovascular disease 10Y risk [Likelihood] ACC-AHA Pooled Cohort by Goff 2013"] Note: definitions for "ASCVD Diagnosis or Procedure before End of Measurement Period" ; "Hypercholesterolemia Diagnosis"; "LDL Result Greater Than or Equal To 190" and  "Has Diabetes Diagnosis" are the same as prior years.  PROPOSED CODING* code "Cardiovascular disease 10Y risk" ("LOINC Code (99056-4)") code "Cardiovascular disease 10Y risk [Likelihood]" ("LOINC Code (99055-6)") code "Cardiovascular disease 10Y risk [Likelihood] ACC-AHA Pooled Cohort by Goff 2013" ("LOINC Code (79423-0)")   *The measure steward and expert workgroup also agreed that that clinicians should use the Pooled Cohort Equations (PCE) risk assessment tools - ACC/AHA 2013 ASCVD risk calculator and ACC ASCVD Risk Estimator Plus. There were no LOINC codes for the ASCVD Risk Estimator Plus. The measure steward created general LOINC codes (i.e.,99056-4 and 99055-6) which need to be used for ASCVD Risk Estimator Plus.  Rationale for change The addition of a fourth population criterion related to the 10-year ASCVD risk assessment tool to the measure aligns with the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.

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          edave Mathematica EC eCQM Team
          edave Mathematica EC eCQM Team
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