eCQM Title | # Breast Cancer Screening
eCQM Identifier (Measure Authoring Tool) | 125 | eCQM Version Number | 12.0.000
NQF Number | Not Applicable | GUID | 19783c1b-4fd1-46c1-8a96-a2f192b97ee0
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 women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period
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) 2012-2022 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) codes, descriptions and other data are copyright 2022. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

    LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc.

    This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation.

    ICD-10 copyright 2022 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 |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Noone et al., 2018). In 2015, over 3 million women were estimated to be living with breast cancer in the U.S. and it is estimated that 12 percent of women will be diagnosed with breast cancer at some point during their lifetime (Noone et al., 2018).

    While there are other factors that affect a woman's risk of developing breast cancer, advancing age is a primary risk factor. Breast cancer is most frequently diagnosed among women ages 55-64; the median age at diagnosis is 62 years (Noone et al., 2018).

    The chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 68; by age 50 it becomes 1 in 43; by age 60, it is 1 in 29 (American Cancer Society, 2017).
Clinical Recommendation Statement |
    The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation) (USPSTF, 2016).

    The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years (C recommendation) (USPSTF, 2016).

    The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older (I statement) (USPSTF, 2016).

    The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer (I statement) (USPSTF, 2016).

    The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (I statement) (USPSTF, 2016).

    The National Comprehensive Cancer Network (NCCN) and the American College of Radiology (ACR) recommend using conventional mammography or DBT for screening women at low, intermediate or high risk for breast cancer (NCCN, 2021) (ACR, 2017).
Improvement Notation |
    Higher score equals better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Cancer Society. (2017). Breast Cancer Facts & Figures 2017-2018. Retrieved February 8, 2019, from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'American College of Radiology (ACR). (2017). ACR Appropriateness Criteria: Breast Cancer Screening. Retrieved from https://acsearch.acr.org/docs/70910/Narrative/'
Reference |
    Reference Type: CITATION
    Reference Text: 'National Comprehensive Cancer Network (NCCN). (2021). Breast Cancer Screening and Diagnosis. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Noone, A.M., Howlader, N., Krapcho, M., Miller, D., Brest, A., Yu, M., Ruhl, J., Tatalovich, Z., Mariotto, A., Lewis, D.R., Chen, H.S., Feuer, E.J., Cronin, K.A. (eds). (2018). SEER Cancer Statistics Review, 1975-2015. National Cancer Institute. Bethesda, MD. Retrieved February 8, 2019, from https://seer.cancer.gov/csr/1975_2015/'
Reference |
    Reference Type: CITATION
    Reference Text: 'U.S. Preventive Services Task Force. (2016). Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 164(4), 279-296.'
Definition |
    None
Guidance |
    This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.

    Please note the measure may include screenings performed outside the age range of patients referenced in the initial population. Screenings that occur prior to the measurement period are valid to meet measure criteria.

    This eCQM is a patient-based measure.

    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 |
    Women 52-74 years of age by the end of the measurement period with a visit during the measurement period
Denominator |
    Equals Initial Population
Denominator Exclusions |
    Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy on or before the end of the measurement period.

    Exclude patients who are in hospice care for any part of the measurement period.

    Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period.

    Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria:
    - Advanced illness with two outpatient encounters during the measurement period or the year prior
    - OR advanced illness with one inpatient encounter during the measurement period or the year prior
    - OR taking dementia medications during the measurement period or the year prior

    Exclude patients receiving palliative care for any part of the measurement period.
Numerator |
    Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period
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

    - -     exists ( ["Patient Characteristic Sex": "Female"] )
              and AgeInYearsAt(date from
                end of "Measurement Period"
              )in Interval[52, 74]
              and exists AdultOutpatientEncounters."Qualifying Encounters"

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or ( ( exists ( "Right Mastectomy Diagnosis" )
                    or exists ( "Right Mastectomy Procedure" )
                )
                  and ( exists ( "Left Mastectomy Diagnosis" )
                      or exists ( "Left Mastectomy Procedure" )
                  )
              )
              or exists "Bilateral Mastectomy Diagnosis"
              or exists "Bilateral Mastectomy Procedure"
              or AIFrailLTCF."Is Age 66 or Older with Advanced Illness and Frailty"
              or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"
              or PalliativeCare."Has Palliative Care in the Measurement Period"

- - Numerator

    - -     exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
                where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period",
                  end of "Measurement Period"]
                )
            )

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     None

- - Stratification

    - -     None

### Definitions

- - AdultOutpatientEncounters.Qualifying Encounters

    - -     ( ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Annual Wellness Visit"]
              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": "Home Healthcare Services"]
              union ["Encounter, Performed": "Online Assessments"]
              union ["Encounter, Performed": "Telephone Visits"] ) ValidEncounter
              where ValidEncounter.relevantPeriod during day of "Measurement Period"

  - AIFrailLTCF.Has Criteria Indicating Frailty

    - -     exists ( ["Device, Order": "Frailty Device"] FrailtyDeviceOrder
                where FrailtyDeviceOrder.authorDatetime during day of "Measurement Period"
            )
              or exists ( ["Assessment, Performed": "Medical equipment used"] EquipmentUsed
                  where EquipmentUsed.result in "Frailty Device"
                    and Global."NormalizeInterval" ( EquipmentUsed.relevantDatetime, EquipmentUsed.relevantPeriod ) ends during day of "Measurement Period"
              )
              or exists ( ["Diagnosis": "Frailty Diagnosis"] FrailtyDiagnosis
                  where FrailtyDiagnosis.prevalencePeriod overlaps "Measurement Period"
              )
              or exists ( ["Encounter, Performed": "Frailty Encounter"] FrailtyEncounter
                  where FrailtyEncounter.relevantPeriod overlaps "Measurement Period"
              )
              or exists ( ["Symptom": "Frailty Symptom"] FrailtySymptom
                  where FrailtySymptom.prevalencePeriod overlaps "Measurement Period"
              )

  - AIFrailLTCF.Has Dementia Medications in Year Before or During Measurement Period

    - -     exists (["Medication, Active": "Dementia Medications"] DementiaMedication
              where Global."NormalizeInterval" ( DementiaMedication.relevantDatetime, DementiaMedication.relevantPeriod ) overlaps Interval[start of "Measurement Period" - 1 year,
              end of "Measurement Period"])

  - AIFrailLTCF.Has Inpatient Encounter with Advanced Illness

    - -     exists( ["Encounter, Performed": "Acute Inpatient"] InpatientEncounter
              where exists ( InpatientEncounter.diagnoses Diagnosis
                  where Diagnosis.code in "Advanced Illness"
              )
                and InpatientEncounter.relevantPeriod starts during day of Interval[start of "Measurement Period" - 1 year,
                end of "Measurement Period"])

  - AIFrailLTCF.Has Two Outpatient Encounters with Advanced Illness on Different Dates of Service

    - -     exists (
            from
              "Outpatient Encounters with Advanced Illness" OutpatientEncounter1,
              "Outpatient Encounters with Advanced Illness" OutpatientEncounter2
              where OutpatientEncounter2.relevantPeriod ends 1 day or more after day of
              end of OutpatientEncounter1.relevantPeriod
              return OutpatientEncounter1
              )

  - AIFrailLTCF.Is Age 66 or Older Living Long Term in a Nursing Home

    - -     ( AgeInYearsAt(date from
                end of "Measurement Period"
              )>= 66
            )
              and ( ( Last(["Assessment, Performed": "Housing status"] HousingStatus
                    where Global."NormalizeInterval"(HousingStatus.relevantDatetime, HousingStatus.relevantPeriod)ends on or before
                    end of "Measurement Period"
                    sort by
                    end of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)asc
                )) LastHousingStatus
                  where LastHousingStatus.result ~ "Lives in a nursing home (finding)"
              ) is not null

  - AIFrailLTCF.Is Age 66 or Older with Advanced Illness and Frailty

    - -     ( AgeInYearsAt(date from
                end of "Measurement Period"
              )>= 66
                and "Has Criteria Indicating Frailty"
                and ( "Has Two Outpatient Encounters with Advanced Illness on Different Dates of Service"
                    or "Has Inpatient Encounter with Advanced Illness"
                    or "Has Dementia Medications in Year Before or During Measurement Period"
                )
            )

  - AIFrailLTCF.Outpatient Encounters with Advanced Illness

    - -     ( ["Encounter, Performed": "Outpatient"]
              union ["Encounter, Performed": "Observation"]
              union ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"]
              union ["Encounter, Performed": "Nonacute Inpatient"] ) OutpatientEncounter
              where exists ( OutpatientEncounter.diagnoses Diagnosis
                  where Diagnosis.code in "Advanced Illness"
              )
                and OutpatientEncounter.relevantPeriod starts during day of Interval[start of "Measurement Period" - 1 year,
                end of "Measurement Period"]

  - Bilateral Mastectomy Diagnosis

    - -     ["Diagnosis": "History of bilateral mastectomy"] BilateralMastectomyHistory
              where BilateralMastectomyHistory.prevalencePeriod starts on or before
              end of "Measurement Period"

  - Bilateral Mastectomy Procedure

    - -     ["Procedure, Performed": "Bilateral Mastectomy"] BilateralMastectomyPerformed
              where Global."NormalizeInterval" ( BilateralMastectomyPerformed.relevantDatetime, BilateralMastectomyPerformed.relevantPeriod ) ends on or before
              end of "Measurement Period"

  - Denominator

    - -     "Initial Population"

  - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or ( ( exists ( "Right Mastectomy Diagnosis" )
                    or exists ( "Right Mastectomy Procedure" )
                )
                  and ( exists ( "Left Mastectomy Diagnosis" )
                      or exists ( "Left Mastectomy Procedure" )
                  )
              )
              or exists "Bilateral Mastectomy Diagnosis"
              or exists "Bilateral Mastectomy Procedure"
              or AIFrailLTCF."Is Age 66 or Older with Advanced Illness and Frailty"
              or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"
              or PalliativeCare."Has Palliative Care in the Measurement Period"

  - 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 day of "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 day of "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 day of "Measurement Period"
              )
            or exists ( ["Diagnosis": "Hospice Diagnosis"] HospiceCareDiagnosis
                  where HospiceCareDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
              )

  - Initial Population

    - -     exists ( ["Patient Characteristic Sex": "Female"] )
              and AgeInYearsAt(date from
                end of "Measurement Period"
              )in Interval[52, 74]
              and exists AdultOutpatientEncounters."Qualifying Encounters"

  - Left Mastectomy Diagnosis

    - -     ( ["Diagnosis": "Status Post Left Mastectomy"]
              union ( ["Diagnosis": "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
                  where UnilateralMastectomyDiagnosis.anatomicalLocationSite ~ "Left (qualifier value)"
              ) ) LeftMastectomy
              where LeftMastectomy.prevalencePeriod starts on or before
              end of "Measurement Period"

  - Left Mastectomy Procedure

    - -     ["Procedure, Performed": "Unilateral Mastectomy Left"] UnilateralMastectomyLeftPerformed
              where Global."NormalizeInterval" ( UnilateralMastectomyLeftPerformed.relevantDatetime, UnilateralMastectomyLeftPerformed.relevantPeriod ) ends on or before
              end of "Measurement Period"

  - Numerator

    - -     exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
                where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period",
                  end of "Measurement Period"]
                )
            )

  - October 1 Two Years Prior to the Measurement Period

    - -     DateTime((year from start of "Measurement Period" - 2), 10, 1, 0, 0, 0, 0, 0)

  - PalliativeCare.Has Palliative Care in the Measurement Period

    - -     exists ( ["Assessment, Performed": "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment
                where Global."NormalizeInterval" ( PalliativeAssessment.relevantDatetime, PalliativeAssessment.relevantPeriod ) overlaps day of "Measurement Period"
            )
              or exists ( ["Diagnosis": "Palliative Care Diagnosis"] PalliativeDiagnosis
                  where PalliativeDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter
                  where PalliativeEncounter.relevantPeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Palliative Care Intervention"] PalliativeIntervention
                  where Global."NormalizeInterval" ( PalliativeIntervention.relevantDatetime, PalliativeIntervention.relevantPeriod ) overlaps day of "Measurement Period"
              )

  - Right Mastectomy Diagnosis

    - -     ( ["Diagnosis": "Status Post Right Mastectomy"] RightMastectomyProcedure
              union ( ["Diagnosis": "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
                  where UnilateralMastectomyDiagnosis.anatomicalLocationSite ~ "Right (qualifier value)"
              ) ) RightMastectomy
              where RightMastectomy.prevalencePeriod starts on or before
              end of "Measurement Period"

  - Right Mastectomy Procedure

    - -     ["Procedure, Performed": "Unilateral Mastectomy Right"] UnilateralMastectomyRightPerformed
              where Global."NormalizeInterval" ( UnilateralMastectomyRightPerformed.relevantDatetime, UnilateralMastectomyRightPerformed.relevantPeriod ) ends on or before
              end 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"]

### 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 "Female" ("AdministrativeGender Code (F)")
- code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Housing status" ("LOINC Code (71802-3)")
- code "Left (qualifier value)" ("SNOMEDCT Code (7771000)")
- code "Lives in a nursing home (finding)" ("SNOMEDCT Code (160734000)")
- code "Medical equipment used" ("LOINC Code (98181-1)")
- code "Right (qualifier value)" ("SNOMEDCT Code (24028007)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Acute Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1083)
- valueset "Advanced Illness" (2.16.840.1.113883.3.464.1003.110.12.1082)
- valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
- valueset "Bilateral Mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1005)
- valueset "Dementia Medications" (2.16.840.1.113883.3.464.1003.196.12.1510)
- valueset "Emergency Department Evaluation and Management 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 "Frailty Device" (2.16.840.1.113883.3.464.1003.118.12.1300)
- valueset "Frailty Diagnosis" (2.16.840.1.113883.3.464.1003.113.12.1074)
- valueset "Frailty Encounter" (2.16.840.1.113883.3.464.1003.101.12.1088)
- valueset "Frailty Symptom" (2.16.840.1.113883.3.464.1003.113.12.1075)
- valueset "History of bilateral mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1068)
- 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 Diagnosis" (2.16.840.1.113883.3.464.1003.1165)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "Mammography" (2.16.840.1.113883.3.464.1003.108.12.1018)
- valueset "Nonacute Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1084)
- 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" (2.16.840.1.113883.3.464.1003.101.12.1087)
- valueset "Palliative Care Diagnosis" (2.16.840.1.113883.3.464.1003.1167)
- valueset "Palliative Care Encounter" (2.16.840.1.113883.3.464.1003.101.12.1090)
- valueset "Palliative Care Intervention" (2.16.840.1.113883.3.464.1003.198.12.1135)
- 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 Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Status Post Left Mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1069)
- valueset "Status Post Right Mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1070)
- valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
- valueset "Unilateral Mastectomy Left" (2.16.840.1.113883.3.464.1003.198.12.1133)
- valueset "Unilateral Mastectomy Right" (2.16.840.1.113883.3.464.1003.198.12.1134)
- valueset "Unilateral Mastectomy, Unspecified Laterality" (2.16.840.1.113883.3.464.1003.198.12.1071)

### Data Criteria (QDM Data Elements)

- "Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" using "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) (LOINC Code 71007-9)"
- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Assessment, Performed: Housing status" using "Housing status (LOINC Code 71802-3)"
- "Assessment, Performed: Medical equipment used" using "Medical equipment used (LOINC Code 98181-1)"
- "Device, Order: Frailty Device" using "Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300)"
- "Diagnosis: Frailty Diagnosis" using "Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074)"
- "Diagnosis: History of bilateral mastectomy" using "History of bilateral mastectomy (2.16.840.1.113883.3.464.1003.198.12.1068)"
- "Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
- "Diagnosis: Palliative Care Diagnosis" using "Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167)"
- "Diagnosis: Status Post Left Mastectomy" using "Status Post Left Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1069)"
- "Diagnosis: Status Post Right Mastectomy" using "Status Post Right Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1070)"
- "Diagnosis: Unilateral Mastectomy, Unspecified Laterality" using "Unilateral Mastectomy, Unspecified Laterality (2.16.840.1.113883.3.464.1003.198.12.1071)"
- "Diagnostic Study, Performed: Mammography" using "Mammography (2.16.840.1.113883.3.464.1003.108.12.1018)"
- "Encounter, Performed: Acute Inpatient" using "Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083)"
- "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
- "Encounter, Performed: Emergency Department Evaluation and Management Visit" using "Emergency Department Evaluation and Management 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: Frailty Encounter" using "Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088)"
- "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: Nonacute Inpatient" using "Nonacute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1084)"
- "Encounter, Performed: Observation" using "Observation (2.16.840.1.113883.3.464.1003.101.12.1086)"
- "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" using "Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087)"
- "Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090)"
- "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 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: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
- "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)"
- "Intervention, Performed: Palliative Care Intervention" using "Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135)"
- "Medication, Active: Dementia Medications" using "Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510)"
- "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: Female" using "Female (AdministrativeGender Code F)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Procedure, Performed: Bilateral Mastectomy" using "Bilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1005)"
- "Procedure, Performed: Unilateral Mastectomy Left" using "Unilateral Mastectomy Left (2.16.840.1.113883.3.464.1003.198.12.1133)"
- "Procedure, Performed: Unilateral Mastectomy Right" using "Unilateral Mastectomy Right (2.16.840.1.113883.3.464.1003.198.12.1134)"
- "Symptom: Frailty Symptom" using "Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075)"

### 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