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  2. CQM-7171

CMS871v4 - numerator exclusion not clear in code

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • Stacy Saltzberg
    • 7817745034
    • MEDITECH
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      Thank you for your inquiry on CMS871v4 Hospital Harm - Severe Hyperglycemia. The Guidance and Measure Observation sections of the specification are correct and should be followed. Please refer to the “Measure Calculations (PDF)” document found on the CMS Measures Management System webpage (https://mmshub.cms.gov/tools-and-resources/mms-supplemental-materials). The “Measure Calculations” document states that for ratio measures that include a Measure Observation, the eCQM CQL logic should not explicitly remove the exclusion cases because the execution environment for the eCQM is responsible for removing the exclusion cases and calling the Measure Observation function for each of the remaining cases. Additional detailed information can be found in Requirement 12 and Requirement 13 of HL7® Version 3 Implementation Guide: CQL-based Health Quality Measure Format (HQMF) Release 1, Standard for Trial Use (STU) 3 – US Realm.
      Show
      Thank you for your inquiry on CMS871v4 Hospital Harm - Severe Hyperglycemia. The Guidance and Measure Observation sections of the specification are correct and should be followed. Please refer to the “Measure Calculations (PDF)” document found on the CMS Measures Management System webpage ( https://mmshub.cms.gov/tools-and-resources/mms-supplemental-materials ). The “Measure Calculations” document states that for ratio measures that include a Measure Observation, the eCQM CQL logic should not explicitly remove the exclusion cases because the execution environment for the eCQM is responsible for removing the exclusion cases and calling the Measure Observation function for each of the remaining cases. Additional detailed information can be found in Requirement 12 and Requirement 13 of HL7® Version 3 Implementation Guide: CQL-based Health Quality Measure Format (HQMF) Release 1, Standard for Trial Use (STU) 3 – US Realm.
    • CMS0871v4
    • From eCQM Issue TrackerCQM-7096 MS871v4- Numerator exclusion query, it appears we are to take the Guidance and Measure Observation text in the spec as correct. However, the code does not appear to support the new language in these areas.

      The Guidance in the spec note: 

      In ratio measures, both the Denominator and Numerator populations flow separately from the same Initial Population. Therefore, the same exclusion criteria must be applied to both the Denominator and Numerator to prevent excluded cases from being considered. The Programmer here notes that the code section of the spec is no different from last year and indicates that the numerator is taken from the denominator.

      The Measure Observation notes: 

      There are two Measure Observations: Encounter Observation 2, associated with the numerator of the ratio: The total number of hyperglycemic days during the inpatient hospitalization that meet the numerator criteria and did not meet the numerator exclusion criteria. Days with a hyperglycemic event are defined as: - All days with a glucose level >300 mg/dL (except those occurring in the first 24-hour period after admission to the hospital (including the emergency department and observation)) OR - All days where a glucose was not measured, and it was immediately preceded by two contiguous, consecutive days where at least one glucose value during each of the two days was >=200 mg/dL. Encounter Observation 1, associated with the denominator of the ratio: The total number of eligible days of the inpatient hospitalization which match the initial population/denominator criteria and did not meet the denominator exclusion criteria. The length of stay for all eligible inpatient hospitalizations is truncated to <=10 days when the length exceeds 10 days. Do not count the last day if it was less than a 24-hour period as this is not considered a full day.

       

      This indicates that numerator and denominator exclusions should be taken from each observation. The code does not show this:

      Measure Observation 1 (Association: Denominator)
      Sum (
        singleton from ( "Days with Hyperglycemic Events" EncounterWithEventDays
          where EncounterWithEventDays.encounter = QualifyingEncounter
          return Count(EncounterWithEventDays.eligibleEventDays)
      )
      )
       
      Measure Observation 2 (Association: Numerator)
      Sum (
        singleton from ( "Days with Hyperglycemic Events" EncounterWithEventDays
          where EncounterWithEventDays.encounter = QualifyingEncounter
          return Count(EncounterWithEventDays.eligibleEventDays EligibleEventDay
              where EligibleEventDay.hasHyperglycemicEvent

            JLeflore Joelencia Leflore
            ssaltzberg@meditech.com Stacy Saltzberg (Inactive)
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