[CQM-6673] CMS 117 - Rotavirus - 2 or 3 dose Narrative vs Logic Created: 01/02/24  Updated: 02/19/24  Resolved: 01/16/24

Status: Closed
Project: eCQM Issue Tracker
Component/s: None

Type: EC eCQMs - Eligible Clinicians Priority: Moderate
Reporter: Crystal Harvey Assignee: Mathematica EC eCQM Team (Inactive)
Resolution: Answered Votes: 0
Labels: Guidance, LOGIC

Attachments: PNG File image-2024-01-02-10-20-30-406.png    
Contact Name: Crystal Harvey
Institution/Name: Medisolv
Solution: Thank you for your inquiry about CMS117v11: Childhood Immunization Status. The logic for the "Has Appropriate Number of Rotavirus Immunizations" definition will identify all rotavirus doses occurring on different days. In the logic, the "HasThreeDose" will be set to true if a patient has a rotavirus 3 dose immunization or procedure. The logic further evaluates if the patient has an appropriate number of doses of either of the combinations mentioned below. If a patient does not have the appropriate number of doses for the three-dose rotavirus, the logic will then evaluate to see if the patient had two doses of the two-dose rotavirus vaccine.

CMS117v11:
• At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
• At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
• At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine, all on different dates of service, on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
Solution Posted On:
2023 Performance Period EC eCQMs:
CMS0117v11
Impact: Rotavirus 2 or 3 dose logic seems to contradict the narrative description. This may negatively impact performance scores.
Last Commented Date:

 Description   

In the measure description, this is the criteria for the Rotavirus:

Rotavirus    
Children with any of the following meet criteria:
•    At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
•    At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
•    At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine, all on different dates of service, on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
•    Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday.

 

For the third option of at least one dose of the two-dose and at least two doses of the three-dose, the narrative appears to contradict the logic. In the logic it appears to check to see if the patient has had ANY rotavirus 3 dose immunization or procedure. If the patient does, this "HasThreeDose" gets set to True. It will not get set to False anywhere further down, so the check for >/= 2 records at the bottom is never evaluated. The presence of the three dose code basically forces the measure to require 3 rotavirus vaccine records. 

 

Is this the correct interpretation? Please advise.

 Comments   
Comment by Mathematica EC eCQM Team (Inactive) [ 02/19/24 ]

Thank you for your follow-up comment about CMS117v11. It is correct that if a patient has at least one or more doses of the 3-dose rotavirus vaccine, HasThreeDose would be true. Although the "HasThreeDose" will be set to true if the patient has at least one or more doses of the 3-dose rotavirus vaccine, the "Count(...)...>=3" in the logic below counts against "All Rotavirus Vaccinations" (2-dose or 3-dose) to look for the appropriate combinations of the rotavirus on different days. A patient must still have the correct number of combinations which is either at least three doses of the 3-dose rotavirus OR at least one dose of the 2-dose and two doses of the 3-dose rotavirus to fully meet criteria.

Has Appropriate Number of Rotavirus Immunizations
exists ( "All Rotavirus Vaccinations" RotavirusImmunization
let HasThreeDose: Count("Rotavirus 3 Dose Immunizations or Procedures")> 0
where ( HasThreeDose
and Count(distinct("All Rotavirus Vaccinations" RotavirusVaccinations
return Global."NormalizeInterval"(RotavirusVaccinations.relevantDatetime, RotavirusVaccinations.relevantPeriod)
)
)>= 3
)...

Comment by Mathematica EC eCQM Team (Inactive) [ 02/16/24 ]

We recognize the importance of a timely resolution and apologize for the inconvenience. The response will be posted as soon as possible.
 

Comment by Taryn Faherty (Inactive) [ 02/15/24 ]

edave Hello, have you had another chance to review? Thank you!

Comment by Crystal Harvey [ 02/07/24 ]

edave Do you happen to have an update on this? Thank you so much!

Comment by Taryn Faherty (Inactive) [ 02/01/24 ]

edave Hello, do you have any updates on this? Thank you!

Comment by Mathematica EC eCQM Team (Inactive) [ 01/23/24 ]

Thank you for the follow-up question. We will review your ticket and provide a response as soon as possible.

Comment by Taryn Faherty (Inactive) [ 01/22/24 ]

edave 

Hello,

I understand what you are saying from a narrative perspective, but I do not understand how this would work in the measure logic. Please review again:

If a patient has > 0 rotavirus 3 dose immunizations or procedures (so at least one or more), HasThreeDose would be true. How would that same patient ever go through the clause that checks for >=2 rotaviurs vaccinations when the clause starts with "HasThreeDose is false"? How would that get set to false if a patient has > 0 rotavirus 3 dose immunizations or procedures? Thank you!

Comment by Mathematica EC eCQM Team (Inactive) [ 01/10/24 ]

We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience.

Comment by Mathematica EC eCQM Team (Inactive) [ 01/03/24 ]

Thank you for submitting your question. We will review your ticket and provide a response as soon as possible.

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