General eCQM Information
| CMS Measure ID | CMS771v2 |
|---|---|
| NQF Number | Not Applicable |
| Measure Description |
Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points |
| Initial Population | Male patients with an initial diagnosis of benign prostatic hyperplasia 6 months prior to, or during the measurement period, and a urinary symptom score assessment within 1 month of initial diagnosis and a follow-up urinary symptom score assessment within 6-12 months, who had a qualifying visit during the measurement period |
| Denominator Statement |
Equals Initial Population |
| Denominator Exclusions |
Patients with urinary retention that starts within 1 year of initial BPH diagnosis. Patients with an initial BPH diagnosis that starts during, or within 30 days of hospitalization. Patients with a diagnosis of morbid obesity, or with a BMI Exam >40 before the follow up urinary symptom score. |
| Numerator Statement |
Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period |
| Numerator Exclusions |
Not Applicable |
| Denominator Exceptions |
None |
| Measure Steward | Large Urology Group Practice Association (LUGPA) |
| Domain | Person and Caregiver-Centered Experience and Outcomes |
| Measure Scoring | Proportion measure |
| Measure Type | Patient Reported Outcome Performance measure |
| Improvement Notation |
A meaningful improvement is a negative 3-point change in the urinary symptom score. The quality improves when a higher proportion of people meet the meaningful improvement definition. |
| Guidance |
The IPSS is inclusive of the symptom index score and the quality of life score. The AUA-SI is the symptom index score alone and must be added to the QOL score. The AUA-SI with the QOL equals the IPSS. Both of these are the urinary symptom score. The patient must have a urinary symptom score (USS) within 1 month after initial diagnosis. If more than one USS in the initial one month, then the first USS counts. The patient must have a USS again at 6-12 months after the initial diagnosis and if more than one USS in this time frame, then the last USS counts. Hospitalization within 30 days of Initial BPH Diagnosis refers to a 30-day period between the end of the hospitalization and the clinical office setting BPH diagnosis. This is due to aggravating factors from hospitalization, such as bed rest, medications, surgery, and altered body functions. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
| Quality ID | 476 |
| Meaningful Measure | Functional Outcomes |
| Telehealth Eligible | No |
| Previous Version |
Data Element Repository
Header
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Changed measure title to shorten.
Measure Section: eCQM Title
Source of Change: Measure Lead
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Updated eCQM Version Number.
Measure Section: eCQM Version Number
Source of Change: Standards Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Standards Update
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Updated measure type.
Measure Section: Measure Type
Source of Change: Measure Lead
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Added text to identify the Quality Data Model (QDM) version used in the measure specification.
Measure Section: Guidance
Source of Change: Standards Update
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Added text to indicate whether the measure is patient-based or episode-based.
Measure Section: Guidance
Source of Change: Standards Update
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Added hyphen to 30-day phrase in Guidance to standardize language.
Measure Section: Guidance
Source of Change: Measure Lead
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Changed numerator exclusions from 'None' to 'Not Applicable' to harmonize with other measures.
Measure Section: Numerator Exclusions
Source of Change: Expert Work Group Review
Logic
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Updated the denominator exclusion logic to require proper information return (is not null) in the definition.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Changed name of definition used in the denominator exclusions from 'Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to 'Has Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to indicate return of a Boolean response.
Measure Section: Definitions
Source of Change: Measure Lead
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Changed alias to 'AUASIAssessment' and 'LastAUASI'. The alias for the primary retrieve (first line of expression) is different than the alias used within the 'LastAUASIOnDate' variable to allow the last AUASI to return for each day that there was an AUASI performed. The 'LastAUASIOnDate' will always be the last AUASI. This accommodates a situation where there may be more than one Urinary Symptom Score in a day to force the last score to count.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated Documented IPSS Assessment Result definition to make the definition cleaner and to align with Clinical Quality Language (CQL) Style Guide.
Measure Section: Definitions
Source of Change: Measure Lead
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Added new definition 'Has Qualifying BPH diagnosis' to streamline initial population logic.
Measure Section: Definitions
Source of Change: Measure Lead
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Changed definition title from 'Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to 'Has Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to reflect a Boolean return type.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period Prevalence Period definition by adding 'First' to capture a first diagnosis in the event of more than one diagnosis.
Measure Section: Definitions
Source of Change: Measure Lead
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Added starts on or before timing to the Morbid Obesity Diagnosis On or Before Follow Up USS Assessment definition to enable an ongoing diagnosis of morbid obesity.
Measure Section: Definitions
Source of Change: Measure Lead
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Changed definition title from Urinary Symptom Score to Urinary Symptom Score Tuple Return to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Measure Lead
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QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value set Morbid Obesity (2.16.840.1.113762.1.4.1164.67): Added Morbid Obesity grouping value set based on terminology updates and to better align with measure intent. The grouping value set includes the ICD-10-CM value set used in the prior version of the measure, Morbid Obesity (2.16.840.1.113762.1.4.1164.65), plus a SNOMED CT value set, Morbid Obesity (2.16.840.1.113762.1.4.1164.66), containing 2 SNOMED CT codes (238136002, 408512008).
Measure Section: Terminology
Source of Change: Annual Update