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  2. CQM-6674

CMS117v12 Childhood Immunization Status: Hib logic discrepancy

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Heather Clodfelter
    • Johns Hopkins Medicine
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      Thank you for your inquiry about CMS117v12, Childhood Immunization Status. The intent of the measure is to include patients who have had either the HiB 3 dose regimens or Hib 4 dose regimens. The logic for the "Has Appropriate Number of Hib Immunizations" will first check to see if a patient has at least 4 doses of either the 4-dose or 3-dose HiB vaccine. If a patient does not have at least 4 doses of the HiB vaccine, the logic will then evaluate to see if the patient has at least 3 doses of the 3-dose HiB vaccine. We will consider updates to the measure logic in a future annual update cycle.
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      Thank you for your inquiry about CMS117v12, Childhood Immunization Status. The intent of the measure is to include patients who have had either the HiB 3 dose regimens or Hib 4 dose regimens. The logic for the "Has Appropriate Number of Hib Immunizations" will first check to see if a patient has at least 4 doses of either the 4-dose or 3-dose HiB vaccine. If a patient does not have at least 4 doses of the HiB vaccine, the logic will then evaluate to see if the patient has at least 3 doses of the 3-dose HiB vaccine. We will consider updates to the measure logic in a future annual update cycle.
    • CMS0117v12
    • Disconnect between measure definition and logic provided to Epic resulting in patients not meeting the metric for Hib non-compliance when patients did complete the appropriate # of Hib vaccines. Resulting in overall decreased (and inaccurate) performance

      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
       
      Pt DOB 3/13/2022.
      HiB (Pedvax Hib LIM 86)- administered 5/20/2022
      Hib (Pedvax Hib LIM 86)- administered 7/22/2022.
      Dtap/IPV/Hepb/Vaxelis (LIM 43)- administered 8/4/2023
      The 8/4/2023 dose is the booster dose, Vaxelis. As per CDC guidelines, a booster dose can be any licensed conjugate HIB vaccination adminstered at age 12-15 months. The booster dose will be dose 3 or 4 depending on vaccine type used in primary series. THis patient's primary series was the 2-dose series of PedvaxHIB. Therefore the 3rd Vaxelis HIB dose should complete their HIB series (3-doses).
       
      However, the CMS CQL logic is written in a way that it would not consider the previous two dose series of PedvaxHIB because they have received a vaccination that is a part of a 4 dose series (under the CVX code associated with the LIM record).
       
      The CMS CQL logic first checks all the unique Hib administrations a patient has received. If any of those administrations is linked to a CVX code defined as a 4 dose series , then there must be 4 unique administrations. Otherwise, 3 will be passing criteria.
      It seems to be the logic should look at the CVX code of the first chronological dose (of the primary series). Not ANY of the doses. 

            edave Mathematica EC eCQM Team
            hclodfe1 Heather Clodfeler
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