eCQM Title | # Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
eCQM Identifier (Measure Authoring Tool) | 161 | eCQM Version Number | 11.0.000
NQF Number | 0104e | GUID | 60176fbf-bfdc-4892-9c9e-604f206553c8
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | Mathematica
Measure Developer | Mathematica
Measure Developer | American Medical Association (AMA)
Measure Developer | PCPI(R) Foundation (PCPI[R])
Endorsed By | National Quality Forum
Description |
    Percentage of all patient visits for those patients that turn 18 or older during the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit
Copyright |
    Copyright 2022 Mathematica Inc. All Rights Reserved.
    The PCPI and AMA's significant past efforts and contributions to the development and updating of the Measure is acknowledged.
Disclaimer |
    The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

    The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, 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.

    Commercial uses of the Measure require a license agreement between the user and Mathematica. Neither Mathematica, the PCPI, nor the American Medical Association (AMA), nor the former AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor their members shall be responsible for any use of the Measure.

    Mathematica encourages use of the Measure by other health care professionals, where appropriate.

    THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Limited proprietary coding may be contained in the Measure specifications for convenience. A license agreement must be entered prior to a third party's use of Current Procedural Terminology (CPT[R]) or other proprietary code set contained in the Measure. Any other use of CPT or other coding by a third party is strictly prohibited. Mathematica, the AMA, and former members of the PCPI disclaim all liability for use or accuracy of any CPT(R) or other coding contained in the specifications.

    CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) is 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 is copyright 2021 World Health Organization. All Rights Reserved.

    Due to technical limitations, registered trademarks are indicated by (R) or [R].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    This measure aims to improve rates of clinician assessment of suicide risk during an encounter where a new or recurrent episode of major depressive disorder (MDD) is identified. In an epidemiologic study of mental illness in the United States with a large, representative sample, 69% of respondents with lifetime suicide attempts had also met diagnostic criteria for MDD. When considering other mood disorders related to depression, such as dysthymia and bipolar disorders, this rate increases to 74% (Bolton & Robinson, 2010). In a study of individuals who had died by suicide and were enrolled in one of eight major health systems in the United States, individuals with a depressive disorder diagnosis had 7.20 increased odds of dying by suicide within one year, after adjusting for age and sociodemographic factors (Yeh et al., 2019). A recent meta-analysis (Moitra et al., 2021) presented similar findings in which depressive disorder conferred a predictive relative risk for suicide of 7.64 after adjusting for relevant factors.

    Suicide is associated with increased use of healthcare services, which provides an opportunity for intervention through assessment and intervention. Individuals who die by suicide are more likely to have any healthcare utilization (Ahmedani et al., 2019) and a higher frequency of healthcare visits than the general population (Chock, Bommersbach, Geske, & Bostwick, 2015). A study of individuals who died by suicide and were enrolled within one of eight health systems in the Mental Health Research Network in the United States found that 50% of these individuals had been seen in a health care setting within four weeks prior to death (Ahmedani et al., 2014). Better assessment and identification of suicide risk in the health care setting should lead to improved connection to treatment and reduction in suicide attempts and deaths by suicide. A recent analysis of depression severity and suicidal ideation symptom trajectories (Witt et al., 2021) found that suicidal ideation among children and young adults (15-25 years) might not improve with depression symptom severity. This evidence suggests the potential utility of continued suicide risk screening after improvements in depression symptoms.
Clinical Recommendation Statement |
    A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder [I] (American Psychiatric Association, 2010a, reaffirmed 2015).

    Such an assessment includes specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety, substance use) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (e.g., positive reasons for living, strong social support); and identification of any family history of suicide or mental illness [I] (American Psychiatric Association, 2010a, reaffirmed 2015).

    As part of the assessment process, impulsivity and potential for risk to others should also be evaluated, including any history of violence or violent or homicidal ideas, plans, or intentions [I] (American Psychiatric Association, 2010a, reaffirmed 2015).

    The patient's risk of harm to him- or herself and to others should also be monitored as treatment proceeds [I] (American Psychiatric Association, 2010a, reaffirmed 2015).

    Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviors (from American Psychiatric Association’s Practice Guideline for Assessment and Treatment of Patients With Suicidal Behaviors, 2010b):

    ADMISSION GENERALLY INDICATED
    After a suicide attempt or aborted suicide attempt if:
    * Patient is psychotic
    * Attempt was violent, near-lethal, or premeditated
    * Precautions were taken to avoid rescue or discovery
    * Persistent plan and/or intent is present
    * Distress is increased or patient regrets surviving
    * Patient is male, older than age 45 years, especially with new onset of psychiatric illness or suicidal thinking
    * Patient has limited family and/or social support, including lack of stable living situation
    * Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident
    * Patient has change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting

    In the presence of suicidal ideation with:
    * Specific plan with high lethality
    * High suicidal intent

    ADMISSION MAY BE NECESSARY
    After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated

    In the presence of suicidal ideation with:
    * Psychosis
    * Major psychiatric disorder
    * Past attempts, particularly if medically serious
    * Possibly contributing medical condition (e.g., acute neurological disorder, cancer, infection)
    * Lack of response to or inability to cooperate with partial hospital or outpatient treatment
    * Need for supervised setting for medication trial or ECT
    * Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting
    * Limited family and/or social support, including lack of stable living situation
    * Lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up
    * Evidence of putting one's affairs in order (e.g., giving away possessions, writing a will)

    In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk

    RELEASE FROM EMERGENCY DEPARTMENT WITH FOLLOW-UP RECOMMENDATIONS MAY BE POSSIBLE
    After a suicide attempt or in the presence of suicidal ideation/plan when:
    * Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient's view of situation has changed since coming to emergency department
    * Plan/method and intent have low lethality
    * Patient has stable and supportive living situation
    * Patient is able to cooperate with recommendations for follow-up, with treater contacted, if possible, if patient is currently in treatment

    Outpatient treatment may be more beneficial than hospitalization

    Patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts, if a safe and supportive living situation is available and outpatient psychiatric care is ongoing
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Psychiatric Association. (2010a). Practice guideline for the treatment of patients with major depressive disorder. 3rd edition. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
    (This guideline was reaffirmed in 2015.)'
Reference |
    Reference Type: CITATION
    Reference Text: 'American Psychiatric Association. (2010b). Guidelines for selecting a treatment setting for patients at risk for suicide or suicidal behaviors. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Ahmedani, B. K., Simon, G. E., Stewart, C., Beck, A., Waitzfelder, B. E., Rossom, R., Solberg, L. I.(2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870-877. doi:10.1007/s11606-014-2767-3'
Reference |
    Reference Type: CITATION
    Reference Text: 'Ahmedani, B. K., Westphal, J., Autio, K., Elsiss, F., Peterson, E. L., Beck, A., Simon, G. E. (2019). Variation in patterns of health care before suicide: A population case-control study. Journal of Preventive Medicine, 127, 105796. doi:10.1016/j.ypmed.2019.105796'
Reference |
    Reference Type: CITATION
    Reference Text: 'Bolton, J. M., & Robinson, J. (2010). Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: Findings from a representative sample of the adult, noninstitutionalized U.S. population. American Journal of Public Health, 100(12), 2473-2480. doi:10.2105/ajph.2010.192252'
Reference |
    Reference Type: CITATION
    Reference Text: 'Chock, M. M., Bommersbach, T. J., Geske, J. L., & Bostwick, J. M. (2015). Patterns of health care usage in the year before suicide: A population-based case-control study. Journal of Mayo Clinic Proceedings, 90(11), 1475-1481. doi:10.1016/j.mayocp.2015.07.023'
Reference |
    Reference Type: CITATION
    Reference Text: 'Moitra, M., Santomauro, D., Degenhardt, L., Collins, P.Y., Whiteford, H., Vos, T., Ferrari, A. (2021). Estimating the risk of suicide associated with mental disorders: A systematic review and meta-regression. Journal of Psychiatric Research, 137, 242-249. doi:10.1016/j.jpsychires.2021.02.053'
Reference |
    Reference Type: CITATION
    Reference Text: 'Witt, K., Madsen, T., Berk, M., Dean, O., Chanen, A., McGorry, P.D., Cotton, S., Davey, C.G., Hetrick, S. (2021). Trajectories of change in depression symptoms and suicidal ideation over the course of evidence-based treatment for depression: Secondary analysis of a randomized controlled trial of cognitive behavioral therapy plus fluoxetine in young people. Australian and New Zealand Journal of Psychiatry, 55(5), 506-516. doi:10.1177/0004867421998763'
Reference |
    Reference Type: CITATION
    Reference Text: 'Yeh, H. H., Westphal, J., Hu, Y., Peterson, E. L., Williams, L. K., Prabhakar, D., Ahmedani, B. K. (2019). Diagnosed mental health conditions and risk of suicide mortality. Psychiatric Services, 70(9), 750-757.  doi:10.1176/appi.ps.201800346'
Definition |
    The specific type and magnitude of the suicide risk assessment is intended to be at the discretion of the individual clinician and should be specific to the needs of the patient. At a minimum, suicide risk assessment should evaluate:
    1) Suicidal ideation
    2) Patient's intent of initiating a suicide attempt
    AND, if either is present,
    3) Patient plans for a suicide attempt
    4) Whether the patient has means for completing suicide

    Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) can also be used. Because no validated assessment tool or instrument fully meets the aforementioned requirements for the suicide risk assessment, individual tools or instruments have not been explicitly included in coding.
Guidance |
    This eCQM is an episode-based measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified in adults that turn 18 or older during the measurement period.

    As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse, history and seriousness of previous attempts, particularly, recent suicidal behavior, current stressors and potential protective factors (e.g., positive reasons for living, strong social support), family history of suicide or mental illness or recent exposure to suicide, impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions, and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment.

    It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of major depressive disorder (MDD) would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for major depressive disorder (MDD), that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence.

    In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician.

    Suicide risk assessments completed via telehealth services can also meet numerator performance.

    Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below.

    The logic statement for the age requirement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure, so long as the minimum criteria noted above is evaluated. To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS177- Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment covers children and adolescents aged 6 through 17, and CMS161 covers the adult population aged 18 years and older, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone.

    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 |
    Patient visits for patients that turn 18 or older during the measurement period during which a new diagnosis of MDD, single or recurrent episode, was identified
Denominator |
    Equals Initial Population
Denominator Exclusions |
    None
Numerator |
    Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit
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

    - -     "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
              where "AgeInYearsAt"(date from start of "Measurement Period")>= 17

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     None

- - Numerator

    - -     "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
              with ["Intervention, Performed": "Suicide risk assessment (procedure)"] SuicideRiskAssessment
                such that Global."NormalizeInterval" ( SuicideRiskAssessment.relevantDatetime, SuicideRiskAssessment.relevantPeriod ) during NewOrRecurrentMDDEncounter.relevantPeriod

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     None

- - Stratification

    - -     None

### Definitions

- - Denominator

    - -     "Initial Population"

  - Initial Population

    - -     "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
              where "AgeInYearsAt"(date from start of "Measurement Period")>= 17

  - Major Depressive Disorder Encounter

    - -     ( ["Encounter, Performed": "Psych Visit Diagnostic Evaluation"]
              union ["Encounter, Performed": "Emergency Department Visit"]
              union ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Outpatient Consultation"]
              union ["Encounter, Performed": "Psych Visit Psychotherapy"]
              union ["Encounter, Performed": "Psychoanalysis"]
              union ["Encounter, Performed": "Telehealth Services"] ) ValidEncounter
              where exists ( ValidEncounter.diagnoses EncounterDiagnosis
                  where EncounterDiagnosis.code in "Major Depressive Disorder Active"
              )

  - New or Recurrent Major Depressive Disorder Encounter

    - -     "Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
              without "Major Depressive Disorder Encounter" PriorMDDEpisodeEncounter
                such that PriorMDDEpisodeEncounter !~ NewOrRecurrentMDDEncounter
                  and PriorMDDEpisodeEncounter.relevantPeriod ends 104 days or less before day of start of NewOrRecurrentMDDEncounter.relevantPeriod
              where NewOrRecurrentMDDEncounter.relevantPeriod during "Measurement Period"

  - Numerator

    - -     "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
              with ["Intervention, Performed": "Suicide risk assessment (procedure)"] SuicideRiskAssessment
                such that Global."NormalizeInterval" ( SuicideRiskAssessment.relevantDatetime, SuicideRiskAssessment.relevantPeriod ) during NewOrRecurrentMDDEncounter.relevantPeriod

  - 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"]

### 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 "Suicide risk assessment (procedure)" ("SNOMEDCT Code (225337009)")
- valueset "Emergency Department Visit" (2.16.840.1.113883.3.464.1003.101.12.1010)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Major Depressive Disorder Active" (2.16.840.1.113883.3.526.3.1491)
- 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 "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Psych Visit Diagnostic Evaluation" (2.16.840.1.113883.3.526.3.1492)
- valueset "Psych Visit Psychotherapy" (2.16.840.1.113883.3.526.3.1496)
- valueset "Psychoanalysis" (2.16.840.1.113883.3.526.3.1141)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Telehealth Services" (2.16.840.1.113883.3.464.1003.101.12.1031)

### Data Criteria (QDM Data Elements)

- "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.464.1003.101.12.1010)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
- "Encounter, Performed: Psych Visit Diagnostic Evaluation" using "Psych Visit Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492)"
- "Encounter, Performed: Psych Visit Psychotherapy" using "Psych Visit Psychotherapy (2.16.840.1.113883.3.526.3.1496)"
- "Encounter, Performed: Psychoanalysis" using "Psychoanalysis (2.16.840.1.113883.3.526.3.1141)"
- "Encounter, Performed: Telehealth Services" using "Telehealth Services (2.16.840.1.113883.3.464.1003.101.12.1031)"
- "Intervention, Performed: Suicide risk assessment (procedure)" using "Suicide risk assessment (procedure) (SNOMEDCT Code 225337009)"
- "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