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  2. CQM-7270

Requesting acknowledgment of distinct average BP as acceptable for CMS-165 (MIPS Quality 236)

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Ben Chappell
    • University of Colorado Medicine (CIN member) on behalf of Trinsic (CIN)
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      Thank you for your inquiry regarding CMS165v13 (Controlling High Blood Pressure). A reading from an Automated Office Blood Pressure (AOBP) setup is acceptable if it is the latest documented reading. As long as systolic and diastolic readings are recorded in EHRs as distinct numeric values (not ranges and thresholds), they can be used for measure calculations. General guidance on which methods are acceptable can be found in the measure narrative at https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS165v13.html.
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      Thank you for your inquiry regarding CMS165v13 (Controlling High Blood Pressure). A reading from an Automated Office Blood Pressure (AOBP) setup is acceptable if it is the latest documented reading. As long as systolic and diastolic readings are recorded in EHRs as distinct numeric values (not ranges and thresholds), they can be used for measure calculations. General guidance on which methods are acceptable can be found in the measure narrative at https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS165v13.html .
    • CMS0165v13
    • CMS0165v12
    • Reporting team for our entire clinically integrated network (~200,000 Medicare lives) requires this acknowledgment to map the use of AOBP machines to our reports for MIPS, PCF, and other value-based and regulatory programs

      We are writing to seek confirmation that use of blood pressure values obtained via Automated Office Blood Pressure (AOBP) measurement, which produces an average of readings (usually 3) obtained in the office, measured 1 minute apart, are acceptable for MIPS metrics. 

      This measurement technique is already explicitly acknowledged in the 2024 version of the Controlling High Blood Pressure Measure steward, NCQA, which is also the steward for CMS's HEDIS measures, and for QRS measures.

      https://www.cms.gov/files/document/2024-qrs-measure-technical-specifications.pdf

      The text reads: "A BP noted as an "average BP" (e.g., "average BP: 139/70") is eligible for use. Must be documented as a distinct value"

      This language does not appear to have been explicitly added to MIPS Measure #236, though it is also not specifically excluded.

      According to the American Heart Association's 2019 Scientific Statement published in Hypertension: "The use of a validated AOBP device that can be programmed to take and average at least 3 BP readings should be considered the preferred approach for evaluating office BP."

      https://www.ahajournals.org/doi/10.1161/CIR.0000000000000678

      • The rationale provided in this document, is as follows:
      • "Several studies have reported that BP measured with AOBP versus the auscultatory (single manual) method is closer to awake out-of-office BP levels measured with [24 hour] ambulatory BP monitoring."
      • "AOBP has demonstrated a stronger association with subclinical CVD, ... compared with BP measured with the auscultatory technique."
      • "AOBP has demonstrated high short-term reproducibility" (compared to routine office BP measurement) [Myers MG. Blood Press Monit. 2009. doi:10.1097/MBP.0b013e32832c5167]

      A recent meta-analysis Roereke M. JAMA Intern Med 2022 doi: [10.1001/jamainternmed.2018.6551 concludes "Based on the evidence, AOBP should be the preferred method for recording BP in routine clinical practice."

      The American Heart Association sponsors a hypertension quality recognition program (Target BP), which is based upon MIPS Measure #236, and has explicitly approved use of AOBP values for quality reporting for this program.

            AIR EC eCQM Team AIR EC eCQM Team
            Ben Chappell Benjamin Chappell
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