Breast Cancer: Hormonal Therapy for Stage I (T1b)-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer

Last updated: February 1, 2017

CMS Measure ID: CMS140v5
Version: 5
NQF Number: 0387
Measure Description:

Percentage of female patients aged 18 years and older with Stage I (T1b) through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period

Initial Patient Population:

All female patients aged 18 years and older with a diagnosis of breast cancer

Denominator Statement:

Equals Initial Population with Stage I (T1b) through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer

Denominator Exclusions:

None

Numerator Statement:

Patients who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period

Numerator Exclusions:

Not Applicable

Denominator Exceptions:
  • Documentation of medical reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient's disease has progressed to metastatic, patient is receiving a gonadotropin-releasing hormone analogue, patient has received oophorectomy, patient is receiving radiation or chemotherapy, patient's diagnosis date is within 120 days of the end of the 12 month reporting period, other medical reasons)
  • Documentation of patient reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient refusal, other patient reasons)
  • Documentation of system reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient is currently enrolled in a clinical trial, other system reasons)
Measure Steward: PCPI(R) Foundation (PCPI[R])
Domain: Effective Clinical Care
Previous Version: Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
Improvement Notation:

Higher score indicates better quality

Guidance:

For the eCQM version of this measure, the initial population for this measure has been limited to patients with a first recorded breast cancer diagnosis within the past 5 years, as opposed to accounting for that patient population through the use of an exception (as is the case for claims implementation). The numerator captures patients who are ordered adjuvant tamoxifen or AI, or are already taking adjuvant tamoxifen or AI during the 12 month period. Date of breast cancer diagnosis is defined as date of pathologic diagnosis.

The requirement of Count >=2 of Encounter, Performed is to establish that the eligible professional has an existing relationship with the patient.

The denominator exception Clinical Trial Participant data element should be specific to breast cancer. For instance, the patient should be participating in a clinical trial related to breast cancer treatment in order to meet the Clinical Trial Participant data element in the denominator exceptions. In the given example, the reason the patient did not receive an order for or is not taking tamoxifen or aromatase inhibitor is because she is in a clinical trial and may be receiving different treatments.

Specifications

Release Notes

Header

  • Updated Clinical Recommendation Statements.

    Section: Clinical Recommendation Statement

    Source: Measure Lead

  • ​Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: Definition

    Source: Measure Lead

  • Updated Denominator to align with current guidelines. Reference to Stage IC has been replaced with Stage I (T1b).

    Section: Denominator

    Source: Measure Lead

  • Updated Denominator Exceptions to pluralize medical reason.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Updated Description to align with current guidelines. Reference to Stage IC has been replaced with Stage I (T1b).

    Section: Description

    Source: Measure Lead

  • Updated Disclaimer.

    Section: Disclaimer

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Annual Update

  • Added Guidance in reference to the 'Clinical Trial Participant' data element to clarify that the patient should be participating in a clinical trial related to breast cancer treatment in order to qualify as a denominator exception.

    Section: Guidance

    Source: JIRA (CQM-1809)

  • Updated Guidance to clarify that the numerator captures patients who are ordered adjuvant tamoxifen or AI, or are already taking adjuvant tamoxifen or AI during the 12 month reporting period.

    Section: Guidance

    Source: Measure Lead

  • Updated Measure Developer.

    Section: Measure Developer

    Source: Measure Lead

  • Updated Measure Steward.

    Section: Measure Steward

    Source: Measure Lead

  • Updated Rationale to align with current guidelines. References to Stage IC have been replaced with Stage I (T1b).

    Section: Rationale

    Source: Measure Lead

  • Updated Reference.

    Section: Reference

    Source: Measure Lead

  • Updated eMeasure Title to align with current guidelines. Reference to Stage IC has been replaced with Stage I (T1b).

    Section: Title

    Source: Measure Lead

Logic

  • Renamed 'Clinical Staging Procedure' value set to 'Pathology Evaluation' to align with value set content.

    Section: Denominator

    Source: JIRA (CQM-1500)

  • Renamed 'Clinical Staging Procedure' value set to 'Pathology Evaluation' to align with value set content.

    Section: Denominator

    Source: JIRA (CQM-1497)

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Denominator

    Source: QDM Standards

  • Revised to include primary tumor size T1b in appropriate stage combination section to allow for capture of Stage I (T1b).

    Section: Denominator

    Source: Measure Lead

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Denominator Exceptions

    Source: QDM Standards

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Initial Population

    Source: QDM Standards

  • Revised logic to capture first ever diagnosis of breast cancer. This diagnosis is then constrained to occur within five years of the encounter.

    Section: Initial Population

    Source: Measure Lead

  • Renamed 'Clinical Staging Procedure' value set to 'Pathology Evaluation' (2.16.840.1.113883.3.526.3.1098) to align with value set content.

    Section: QDM Data Elements

    Source: JIRA (CQM-1500)

  • Renamed 'Clinical Staging Procedure' value set to 'Pathology Evaluation' (2.16.840.1.113883.3.526.3.1098) to align with value set content.

    Section: QDM Data Elements

    Source: JIRA (CQM-1497)

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

  • Value set Female (2.16.840.1.113883.3.560.100.2): Changed code system from 'AdministrativeSex' to 'AdministrativeGender'.

    Section: QDM Data Elements

    Source: Code System Update

Value Set

  • Renamed 'Clinical Staging Procedure' value set to 'Pathology Evaluation' (2.16.840.1.113883.3.526.3.1098) to align with value set content.

    Section: None

    Source: JIRA (CQM-1500)

  • Renamed 'Clinical Staging Procedure' value set to 'Pathology Evaluation' (2.16.840.1.113883.3.526.3.1098) to align with value set content.

    Section: None

    Source: JIRA (CQM-1497)

  • Value set Breast Cancer (2.16.840.1.113883.3.526.3.389): Added 1 SNOMEDCT code (708921005) and deleted 1 SNOMEDCT code (286892007).

    Section: None

    Source: None

  • Value set Clinical Trial Participant (2.16.840.1.113883.3.526.3.1125): Deleted 2 SNOMEDCT codes (399223003, 444734003).

    Section: None

    Source: None

  • Value set Female (2.16.840.1.113883.3.560.100.2): Changed code system from 'AdministrativeSex' to 'AdministrativeGender'.

    Section: None

    Source: Code System Update

  • Value set Gonadotropin-Releasing Hormone Analogue Medication (2.16.840.1.113883.3.526.3.1316): Added 2 RXNORM codes (1488616, 1488618) and deleted 6 RXNORM codes (1116124, 348161, 348163, 545844, 545848, 583425).

    Section: None

    Source: None

  • Value set Medical Reason (2.16.840.1.113883.3.526.3.1007): Deleted 1 SNOMEDCT code (161590003).

    Section: None

    Source: None

  • Value set Patient Reason (2.16.840.1.113883.3.526.3.1008): Deleted 1 SNOMEDCT code (5015009).

    Section: None

    Source: None

External Resources