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Global Malnutrition eCQM v2 Measure Observation 6 calculation

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    • Shravanthi S
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      Thank you for your inquiry specific to CMS986v2 [Global Malnutrition Composite Score (GMCS)]. The measure population for this continuous variable measure is acute care hospitalizations for patients aged 65 years or older with a length of stay of 24 hours or greater. The four components for GMCS include:

      Component 1 – Performing a Malnutrition Screening for the Measure Population. Screening is defined as performing the screening and having an identified result (i.e., ‘at risk’ or ‘not at risk’).

      Component 2 – Perform a Nutrition Assessment for the patients identified with an ‘at risk of malnutrition’ result from Component 1 or for patients with a ‘hospital dietitian referral’ order. Assessment is defined as performing the assessment and having an identified status (i.e., ‘not or mildly malnourished’, ‘moderately malnourished’, or ‘severely malnourished’).

      Component 3 – Malnutrition Diagnosis documented for a ‘moderately malnourished’ or ‘severely malnourished’ status identified in Component 2.

      Component 4 – Nutrition Care Plan performed for a ‘moderately malnourished’ or ‘severely malnourished’ malnutrition status identified in Component 2.

       

      In the presented scenario, Component 1 was performed as a Malnutrition Screening was completed and a ‘not at risk’ result was identified. The calculation you present is as follows:

       

      MO1 = 1, MO2 = 1, MO3 = 0, MO4 = 0, MO5 = 2 (1+1), MO6 = 200% (2/1)

       

      You are correct in stating that the “TotalMalnutritionCompositeScore Eligible Denominators will be 1.” Yet performance for “Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage” must be between 0% and 100%. When a ‘not at risk’ result from Component 1 is identified and a ‘hospital dietitian referral’ is not ordered, the calculation should be revised to the following:

       

      (MO1 = 1) + (MO2 = 0) + (MO3 = 0) + (MO4 = 0), MO5 = (1 + 0 + 0 + 0), MO6 = MO5 (1) / Eligible Denominators (1) = (1/1) = 100%

       

      In the scenario, the patient is not eligible for the measure observation 2 denominator as an ‘at risk of malnutrition’ result from Component 1 was not present and a ‘hospital dietitian referral’ was not ordered. Similarly, the patient was not eligible for the measure observations 3 and 4 denominator as a ‘moderately malnourished’ or ‘severely malnourished’ status identified was not present.
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      Thank you for your inquiry specific to CMS986v2 [Global Malnutrition Composite Score (GMCS)]. The measure population for this continuous variable measure is acute care hospitalizations for patients aged 65 years or older with a length of stay of 24 hours or greater. The four components for GMCS include: Component 1 – Performing a Malnutrition Screening for the Measure Population. Screening is defined as performing the screening and having an identified result (i.e., ‘at risk’ or ‘not at risk’). Component 2 – Perform a Nutrition Assessment for the patients identified with an ‘at risk of malnutrition’ result from Component 1 or for patients with a ‘hospital dietitian referral’ order. Assessment is defined as performing the assessment and having an identified status (i.e., ‘not or mildly malnourished’, ‘moderately malnourished’, or ‘severely malnourished’). Component 3 – Malnutrition Diagnosis documented for a ‘moderately malnourished’ or ‘severely malnourished’ status identified in Component 2. Component 4 – Nutrition Care Plan performed for a ‘moderately malnourished’ or ‘severely malnourished’ malnutrition status identified in Component 2.   In the presented scenario, Component 1 was performed as a Malnutrition Screening was completed and a ‘not at risk’ result was identified. The calculation you present is as follows:   MO1 = 1, MO2 = 1, MO3 = 0, MO4 = 0, MO5 = 2 (1+1), MO6 = 200% (2/1)   You are correct in stating that the “TotalMalnutritionCompositeScore Eligible Denominators will be 1.” Yet performance for “Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage” must be between 0% and 100%. When a ‘not at risk’ result from Component 1 is identified and a ‘hospital dietitian referral’ is not ordered, the calculation should be revised to the following:   (MO1 = 1) + (MO2 = 0) + (MO3 = 0) + (MO4 = 0), MO5 = (1 + 0 + 0 + 0), MO6 = MO5 (1) / Eligible Denominators (1) = (1/1) = 100%   In the scenario, the patient is not eligible for the measure observation 2 denominator as an ‘at risk of malnutrition’ result from Component 1 was not present and a ‘hospital dietitian referral’ was not ordered. Similarly, the patient was not eligible for the measure observations 3 and 4 denominator as a ‘moderately malnourished’ or ‘severely malnourished’ status identified was not present.
    • CMS0986v2

      Hi team,

      As part of 2024 Reporting Period Eligible Hospital / Critical Access Hospital eCQMs specification released on May 4th, we had a couple of questions on Global Malnutrition Composite Score eCQM Measure Observation 6 calculation.

      1. Is 200% a valid value for Measure Observation 6?
      2. If not, we observed a scenario where the measure evaluator would give a value of 200%.

      Scenario:

      Patient is Screened for Malnutrition, and the Identified Result is – Not At Risk Result.

      Assessment is performed on the same patient and the Identified Status is – Not or Mildly Malnourished. (This scenario might not be a possible clinical workflow as Assessment need not be performed if the patient is not at-risk during screening., but as per the measure logic we wanted to understand the behavior, so we tried the scenario in Bonnie)

      As per the given scenario., the evaluator will give the following results:

      MO1 = 1, MO2 = 1, MO3 = 0, MO4 = 0, MO5 = 2 (1+1), MO6 = 200% (2/1)

      TotalMalnutritionCompositeScore Eligible Denominators will be 1 as per the below logic:

      if ( ( "Encounter with Malnutrition Risk Screening and Identified Result" contains Encounter      and "Encounter with Malnutrition Screening Not At Risk Result" contains Encounter  )    and not ( "Encounter with Hospital Dietitian Referral" contains Encounter )) then 1

       

      Could you please help us understand how MO6 will be calculated in this scenario?

            JLeflore Mathematica EH eCQM Team
            SS056651 Shravanthi S
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