eCQM Title | # Appropriate Treatment for Upper Respiratory Infection (URI)
eCQM Identifier (Measure Authoring Tool) | 154 | eCQM Version Number | 11.0.000
NQF Number | Not Applicable | GUID | e455fac0-f2cb-4074-a351-1e68a90fb7cf
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | National Committee for Quality Assurance
Measure Developer | National Committee for Quality Assurance
Endorsed By | None
Description |
    Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order
Copyright |
    This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2021 National Committee for Quality Assurance. All Rights Reserved.

    Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.

    CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved.
Disclaimer |
    The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    • 3 months-17 years
    • 18-64 years
    • 65 years and older
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    Most URI, also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year.
Clinical Recommendation Statement |
    American Family Physician (Fashner, Ericson, and Werner, Khilberg 2012)

    - Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A)

    - Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A)

    - Decongestants, antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B)

    Institute for Clinical Systems Improvement (Short, et al, 2017)
    The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults.
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Centers for Disease Control and Prevention. (2020). Be Antibiotics Aware: Smart Use, Best Care. Retrieved from https://www.cdc.gov/patientsafety/features/be-antibiotics-aware.html'
Reference |
    Reference Type: CITATION
    Reference Text: 'Fashner, J., Ericson, K., & Werner, S. (2012). Treatment of the Common Cold in Children and Adults. American Family Physician, 86(2), 153-159.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Harris, A.M., Hicks, L.A., Qaseem, A. (2016.) "Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care from the American College of Physicians and the Centers for Disease Control and Prevention." Ann Intern Med. 164(6),425-434.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Short S, Bashir H, Marshall P, Miller N, Olmschenk D, Prigge K, Solyntjes L. Institute for Clinical Systems Improvement. Diagnosis and Treatment of Respiratory Illness in Children and Adults. Updated September 2017. Retrieved from https://www.icsi.org/wp-content/uploads/2019/01/RespIllness.pdf.'
Definition |
    None
Guidance |
    This is an episode of care measure that examines all eligible episodes for the patient during the measurement period.

    This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection during the measurement period.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    Outpatient visits, telephone visits, online assessments (i.e. e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of URI during the measurement period among patients 3 months of age and older
Denominator |
    Equals Initial Population
Denominator Exclusions |
    Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date.

    Exclude URI episodes when the patient had an active prescription of antibiotics in the 30 days prior to the episode date but is still active the same day of the encounter.

    Exclude URI episodes when the patient had competing diagnosis on or three days after the episode date.

    Exclude URI episodes when the patient had hospice care for any part of the measurement period.
Numerator |
    URI episodes without a prescription for antibiotic medication on or 3 days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    None
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInMonthsAt(date from start of "Measurement Period")>= 3
              return EncounterWithURI

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     "In Hospice"
              union "Encounter with Upper Respiratory Infection and Antibiotics Active 30 Days Prior Or The First Day of the Encounter"
              union "Encounter with Competing Diagnosis for Upper Respiratory Infection"
              union "Encounter with Comorbid Condition for Upper Respiratory Infection Prior"

- - Numerator

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              without ["Medication, Order": "Antibiotic Medications for Pharyngitis"] OrderedAntibiotic
                such that OrderedAntibiotic.authorDatetime 3 days or less on or after start of EncounterWithURI.relevantPeriod
              return EncounterWithURI

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     None

- - Stratification 1

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInMonthsAt(date from start of "Measurement Period")>= 3
                and AgeInYearsAt(date from start of "Measurement Period")<= 17
              return EncounterWithURI

- - Stratification 2

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInYearsAt(date from start of "Measurement Period")in Interval[18, 64]
              return EncounterWithURI

- - Stratification 3

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInYearsAt(date from start of "Measurement Period")>= 65
              return EncounterWithURI

### Definitions

- - Denominator

    - -     "Initial Population"

  - Denominator Exclusions

    - -     "In Hospice"
              union "Encounter with Upper Respiratory Infection and Antibiotics Active 30 Days Prior Or The First Day of the Encounter"
              union "Encounter with Competing Diagnosis for Upper Respiratory Infection"
              union "Encounter with Comorbid Condition for Upper Respiratory Infection Prior"

  - Encounter with Comorbid Condition for Upper Respiratory Infection Prior

    - -     ( "Encounter with Upper Respiratory Infection" EncounterWithURI
                with ["Diagnosis": "Comorbid Conditions for Respiratory Conditions"] ComorbidCondition
                  such that start of ComorbidCondition.prevalencePeriod in day of Interval[start of EncounterWithURI.relevantPeriod - 1 year, start of EncounterWithURI.relevantPeriod]
                return EncounterWithURI
            )

  - Encounter with Competing Diagnosis for Upper Respiratory Infection

    - -     ( "Encounter with Upper Respiratory Infection" EncounterWithURI
                with ["Diagnosis": "Competing Conditions for Respiratory Conditions"] CompetingCondition
                  such that CompetingCondition.prevalencePeriod starts 3 days or less on or after day of start of EncounterWithURI.relevantPeriod
                return EncounterWithURI
            )

  - Encounter with Upper Respiratory Infection

    - -     from
              "Qualifying Encounters" QualifyingEncounters,
              ["Diagnosis": "Upper Respiratory Infection"] URI
              where URI.prevalencePeriod starts during day of QualifyingEncounters.relevantPeriod
                or URI.prevalencePeriod overlaps before QualifyingEncounters.relevantPeriod
              return QualifyingEncounters

  - Encounter with Upper Respiratory Infection and Antibiotics Active 30 Days Prior Or The First Day of the Encounter

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              with ["Medication, Active": "Antibiotic Medications for Pharyngitis"] ActiveAntibiotic
                such that ( Global."NormalizeInterval" ( ActiveAntibiotic.relevantDatetime, ActiveAntibiotic.relevantPeriod ) overlaps day of Interval[start of EncounterWithURI.relevantPeriod - 30 days, start of EncounterWithURI.relevantPeriod - 1 day])
              return EncounterWithURI

  - Hospice.Has Hospice Services

    - -     exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
                where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
                    or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
                )
                  and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
            )
              or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
                  where HospiceEncounter.relevantPeriod overlaps "Measurement Period"
              )
              or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
                  where HospiceAssessment.result ~ "Yes (qualifier value)"
                    and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps "Measurement Period"
              )
              or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
                  where HospiceOrder.authorDatetime during day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
                  where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period"
              )

  - In Hospice

    - -     "Initial Population" InitialPopulation
              where Hospice."Has Hospice Services"

  - Initial Population

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInMonthsAt(date from start of "Measurement Period")>= 3
              return EncounterWithURI

  - Numerator

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              without ["Medication, Order": "Antibiotic Medications for Pharyngitis"] OrderedAntibiotic
                such that OrderedAntibiotic.authorDatetime 3 days or less on or after start of EncounterWithURI.relevantPeriod
              return EncounterWithURI

  - Qualifying Encounters

    - -     ( ["Encounter, Performed": "Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital observation status if the discharge is on other than the initial date of observation status. To report services to a patient designated as observation status or inpatient status and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])"]
              union ["Encounter, Performed": "Emergency Department Visit"]
              union ["Encounter, Performed": "Home Healthcare Services"]
              union ["Encounter, Performed": "Initial Hospital Observation Care"]
              union ["Encounter, Performed": "Medical Disability Exam"]
              union ["Encounter, Performed": "Observation"]
              union ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Outpatient Consultation"]
              union ["Encounter, Performed": "Preventive Care Services Group Counseling"]
              union ["Encounter, Performed": "Preventive Care Services Individual Counseling"]
              union ["Encounter, Performed": "Preventive Care Services, Initial Office Visit, 0 to 17"]
              union ["Encounter, Performed": "Preventive Care, Established Office Visit, 0 to 17"]
              union ["Encounter, Performed": "Preventive Care Services Established Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Preventive Care Services Initial Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Telephone Visits"]
              union ["Encounter, Performed": "Online Assessments"]
              union ["Encounter, Performed": "Unlisted preventive medicine service"] ) ValidEncounters
              where ValidEncounters.relevantPeriod during day of "Measurement Period"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

  - Stratification 1

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInMonthsAt(date from start of "Measurement Period")>= 3
                and AgeInYearsAt(date from start of "Measurement Period")<= 17
              return EncounterWithURI

  - Stratification 2

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInYearsAt(date from start of "Measurement Period")in Interval[18, 64]
              return EncounterWithURI

  - Stratification 3

    - -     "Encounter with Upper Respiratory Infection" EncounterWithURI
              where AgeInYearsAt(date from start of "Measurement Period")>= 65
              return EncounterWithURI

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
- code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital observation status if the discharge is on other than the initial date of observation status. To report services to a patient designated as observation status or inpatient status and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])" ("CPT Code (99217)")
- code "Unlisted preventive medicine service" ("CPT Code (99429)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Antibiotic Medications for Pharyngitis" (2.16.840.1.113883.3.464.1003.196.12.1001)
- valueset "Comorbid Conditions for Respiratory Conditions" (2.16.840.1.113883.3.464.1003.102.12.1025)
- valueset "Competing Conditions for Respiratory Conditions" (2.16.840.1.113883.3.464.1003.102.12.1017)
- valueset "Emergency Department Visit" (2.16.840.1.113883.3.464.1003.101.12.1010)
- valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
- valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "Initial Hospital Observation Care" (2.16.840.1.113883.3.464.1003.101.12.1002)
- valueset "Medical Disability Exam" (2.16.840.1.113883.3.464.1003.101.12.1073)
- valueset "Observation" (2.16.840.1.113883.3.464.1003.101.12.1086)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Online Assessments" (2.16.840.1.113883.3.464.1003.101.12.1089)
- valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
- valueset "Preventive Care Services Group Counseling" (2.16.840.1.113883.3.464.1003.101.12.1027)
- valueset "Preventive Care Services Individual Counseling" (2.16.840.1.113883.3.464.1003.101.12.1026)
- valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
- valueset "Preventive Care Services, Initial Office Visit, 0 to 17" (2.16.840.1.113883.3.464.1003.101.12.1022)
- valueset "Preventive Care, Established Office Visit, 0 to 17" (2.16.840.1.113883.3.464.1003.101.12.1024)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
- valueset "Upper Respiratory Infection" (2.16.840.1.113883.3.464.1003.102.12.1022)

### Data Criteria (QDM Data Elements)

- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Diagnosis: Comorbid Conditions for Respiratory Conditions" using "Comorbid Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1025)"
- "Diagnosis: Competing Conditions for Respiratory Conditions" using "Competing Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1017)"
- "Diagnosis: Upper Respiratory Infection" using "Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.102.12.1022)"
- "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.464.1003.101.12.1010)"
- "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
- "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
- "Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
- "Encounter, Performed: Initial Hospital Observation Care" using "Initial Hospital Observation Care (2.16.840.1.113883.3.464.1003.101.12.1002)"
- "Encounter, Performed: Medical Disability Exam" using "Medical Disability Exam (2.16.840.1.113883.3.464.1003.101.12.1073)"
- "Encounter, Performed: Observation" using "Observation (2.16.840.1.113883.3.464.1003.101.12.1086)"
- "Encounter, Performed: Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital observation status if the discharge is on other than the initial date of observation status. To report services to a patient designated as observation status or inpatient status and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])" using "Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital observation status if the discharge is on other than the initial date of observation status. To report services to a patient designated as observation status or inpatient status and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) (CPT Code 99217)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Online Assessments" using "Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089)"
- "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
- "Encounter, Performed: Preventive Care Services Established Office Visit, 18 and Up" using "Preventive Care Services Established Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1025)"
- "Encounter, Performed: Preventive Care Services Group Counseling" using "Preventive Care Services Group Counseling (2.16.840.1.113883.3.464.1003.101.12.1027)"
- "Encounter, Performed: Preventive Care Services Individual Counseling" using "Preventive Care Services Individual Counseling (2.16.840.1.113883.3.464.1003.101.12.1026)"
- "Encounter, Performed: Preventive Care Services Initial Office Visit, 18 and Up" using "Preventive Care Services Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
- "Encounter, Performed: Preventive Care Services, Initial Office Visit, 0 to 17" using "Preventive Care Services, Initial Office Visit, 0 to 17 (2.16.840.1.113883.3.464.1003.101.12.1022)"
- "Encounter, Performed: Preventive Care, Established Office Visit, 0 to 17" using "Preventive Care, Established Office Visit, 0 to 17 (2.16.840.1.113883.3.464.1003.101.12.1024)"
- "Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
- "Encounter, Performed: Unlisted preventive medicine service" using "Unlisted preventive medicine service (CPT Code 99429)"
- "Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Medication, Active: Antibiotic Medications for Pharyngitis" using "Antibiotic Medications for Pharyngitis (2.16.840.1.113883.3.464.1003.196.12.1001)"
- "Medication, Order: Antibiotic Medications for Pharyngitis" using "Antibiotic Medications for Pharyngitis (2.16.840.1.113883.3.464.1003.196.12.1001)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None