eCQM Title | # Anti-depressant Medication Management
eCQM Identifier (Measure Authoring Tool) | 128 | eCQM Version Number | 12.0.000
NQF Number | Not Applicable | GUID | 8924f2b3-ec06-4650-b634-d70a53dee577
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 patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported.
    a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).
    b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
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 |
    Depression affects over 17 million adults in the U.S. (NIMH, 2021) and is estimated to affect nearly a quarter of adults in their lifetime (Burcusa & Iacono, 2007). Symptoms of depression include disturbances in appetite and sleep, anxiety, decreased concentration, and suicidal ideation (NAMI, 2017; Charbonneau et al., 2005). When left untreated, depression can have a dramatic effect on one’s quality of life, causing constant feelings of hopelessness, loss of interest in daily activities and in some cases suicidal ideation (SAMHSA, 2014).

    The American Psychiatric Association (APA) recommends use of antidepressant medication and behavioral therapies, such as psychotherapy, for the treatment and management of depression (APA, 2010). For the past 60 years, antidepressant medication has proven to be effective, especially for patients with more severe symptoms (Fournier, 2010). However, studies analyzing adherence to antidepressant medications found that prevalence of nonadherence was high, ranging from 13 percent to 55.7 percent (Sansone, 2012).

    Clinical guidelines for depression emphasize the importance of effective clinical management in increasing patients’ medication compliance, monitoring treatment effectiveness, and identifying and managing side effects. If pharmacological treatment is initiated, appropriate dosing and continuation of therapy through the acute and continuation phases decrease recurrence of symptoms. Thus, the evaluation of the duration of pharmacological treatment serves as an important indicator in understanding patient compliance with establishing and maintaining an effective medication regimen.
Clinical Recommendation Statement |
    American Psychological Association (2019):
    - "For initial treatment of adult patients with depression, the panel recommends the following in the context of sharing decision-making with the patient when considering options:
    1. That clinicians offer either psychotherapy or second-generation antidepressant.
    2. If considering combined treatment, the panel recommends cognitive-behavioral therapy or interpersonal psychotherapy plus a second-generation antidepressant.”

    - “For initial treatment of older adult patients with depression, the panel recommends the following in the context of shared decision-making with the patient:
    1. Either group life review treatment or Group Cognitive Behavioral Therapy (either alone or added to usual care) over no treatment
    2. Combined pharmacotherapy and interpersonal psychotherapy (IPT) over IPT alone. Of note, while the study upon which this is based used nortriptyline, the panel recommends a second-generation antidepressant due to the reduced risk of side effects.”

    American Psychiatric Association (2010):
    - “An antidepressant medication is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder [I: Recommended with substantial clinical confidence] and definitely should be provided for those with severe major depressive disorder unless electroconvulsive therapy (ECT) is planned [I: Recommended with substantial clinical confidence].”

    - Patients should be given a realistic notion of what can be expected during the different phases of treatment, including the likely time course of symptom response and the importance of adherence for successful treatment and prophylaxis [I].

    - During the acute phase of treatment, patients should be carefully and systematically monitored on a regular basis to assess their response to pharmacotherapy, identify the emergence of side effects (e.g., gastrointestinal symptoms, sedation, insomnia, activation, changes in weight, and cardiovascular, neurological, anticholinergic, or sexual side effects), and assess patient safety [I].

    - “During the continuation phase of treatment, the patient should be carefully monitored for signs of possible relapse [I: Recommended with substantial clinical confidence]. Systematic assessment of symptoms, side effects, adherence, and functional status is essential [I: Recommended with substantial clinical confidence], and may be facilitated through the use of clinician- and/or patient-administered rating scales [II: Recommended with moderate clinical confidence]. To reduce the risk of relapse, patients who have been treated successfully with antidepressant medications in the acute phase should continue treatment with these agents for 4–9 months [I: Recommended with substantial clinical confidence].”

    Department of Veterans Affairs, and Health Affairs, Department of Defense (2022):
    - “For patients with major depressive disorder (MDD), we suggest using a quantitative measure of depression severity in the initial treatment planning and to monitor treatment progress at regular intervals to guide shared treatment decision making.” [Weak for]

    - “In patients with MDD who achieve remission with antidepressant medication, we recommend continuation of antidepressants at the therapeutic dose for at least six months to decrease risk of relapse.”

    Department of Veterans Affairs, and Health Affairs, Department of Defense (2016):
    - ”In patients at high risk for recurrent depressive episodes and who are treated with pharmacotherapy, we recommend offering maintenance pharmacotherapy for at least 12 months and possibly indefinitely.” [Strong For]

    - “After initiation of therapy or a change in treatment, we recommend monitoring patients at least monthly until the patient achieves remission. At minimum, assessments should include a measure of symptoms, adherence to medication and psychotherapy, and emergence of adverse effects.” [Strong For]

    - “In patients with MDD who achieve remission with antidepressant medication, we recommend continuation of antidepressants at the therapeutic dose for at least six months to decrease risk of relapse.” [Strong For]
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder, 3rd edition. Arlington: Author.'
Reference |
    Reference Type: CITATION
    Reference Text: 'American Psychological Association. (2019). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved from https://www.apa.org/depression-guideline'
Reference |
    Reference Type: CITATION
    Reference Text: 'Burcusa, S. L., & Iacono, W. G. (2007). Risk for recurrence in depression. Clinical Psychology Review, 27(8), 959-985.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Charbonneau, A., Bruning, W., Titus-Howard, T., et al. (2005). The community initiative on depression: report from a multiphase work site depression intervention. Journal of Occupational and Environmental Medicine, 47(1), 60-67.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Department of Veterans Affairs and the Department of Defense (VA/DoD). (2022). VA/DoD Clinical Practice Guidelines for the Management of Major Depressive Disorder. Version 4.0 . Retrieved from: https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Department of Veterans Affairs and the Department of Defense (VA/DoD). (2016). VA/DoD Clinical Practice Guidelines for the Management of Major Depressive Disorder. The Management of Major Depressive Disorder Working Group. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Fournier, J. C., DeRubeis, R. J., Hollon, S. D., et al. (2010). Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA, 303(1), 47-53.'
Reference |
    Reference Type: CITATION
    Reference Text: 'National Alliance on Mental Illness (NAMI). (2017). Depression. Retrieved from: https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Depression'
Reference |
    Reference Type: CITATION
    Reference Text: 'NIMH. (2021). Major Depression. Retrieved from: https://www.nimh.nih.gov/health/statistics/major-depression.shtml'
Reference |
    Reference Type: CITATION
    Reference Text: 'Sansone, R. A., & Sansone, L. A. (2012). Antidepressant adherence: are patients taking their medications? Innovations in Clinical Neuroscience, 9(5–6), 41–46.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration.'
Definition |
    Intake Period: The 12-month window starting on May 1 of the year prior to the measurement period and ending on April 30 of the measurement period.

    Index Prescription Start Date (IPSD): The date of the earliest prescription dispensing event for an antidepressant medication during the Intake Period.

    The "continuous treatment" described in this measure allows for gaps in medication treatment up to a total 31 days during the 115-day period (numerator 1) or 52 days during the 232-day period (numerator 2). Gaps can include either gaps used to change medication, or treatment gaps to refill the same medication.
Guidance |
    To identify new treatment episodes for major depression, there must be a 105-day negative medication history (a period during which the patient was not taking antidepressant medication) prior to the dispensing event associated with the IPSD.

    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 |
    Patients 18 years of age and older as of April 30 of the measurement period who were dispensed antidepressant medications during the Intake Period, and were diagnosed with major depression 60 days prior to, or 60 days after the dispensing event and had a visit 60 days prior to, or 60 days after the dispensing event
Denominator |
    Equals Initial Population
Denominator Exclusions |
    Patients who were actively on an antidepressant medication in the 105 days prior to the IPSD.

    Exclude patients who are in hospice care for any part of the measurement period.
Numerator |
    Numerator 1: Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment beginning on the IPSD through 114 days after the IPSD (115 total days).

    Numerator 2: Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment beginning on the IPSD through 231 days after the IPSD (232 total days).
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

- Population Criteria 1
  - - Initial Population

      - -     AgeInYearsAt(date from "April 30 of the Measurement Period")>= 18
                and "Has IPSD and Major Depression Diagnosis"
                and exists "Qualifying Encounters"

  - - Denominator

      - -     "Initial Population"

  - - Denominator Exclusions

      - -     Hospice."Has Hospice Services"
                or exists ( ["Medication, Active": "Antidepressant Medication"] ActiveAntidepressant
                    let ActiveMedPeriod: ActiveAntidepressant Meds
                      return Meds.relevantPeriod
                        intersect Interval[start of "Intake Period",
                        end of "Measurement Period"]
                    where "IPSD" is not null
                      and Global."ToDateInterval" ( ActiveMedPeriod ) overlaps Interval["IPSD" - 105 days, "IPSD" )
                )

  - - Numerator

      - -     "Cumulative Medication Duration Greater Than or Equal to 84 Days"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     None

  - - Stratification

      - -     None

- Population Criteria 2
  - - Initial Population

      - -     AgeInYearsAt(date from "April 30 of the Measurement Period")>= 18
                and "Has IPSD and Major Depression Diagnosis"
                and exists "Qualifying Encounters"

  - - Denominator

      - -     "Initial Population"

  - - Denominator Exclusions

      - -     Hospice."Has Hospice Services"
                or exists ( ["Medication, Active": "Antidepressant Medication"] ActiveAntidepressant
                    let ActiveMedPeriod: ActiveAntidepressant Meds
                      return Meds.relevantPeriod
                        intersect Interval[start of "Intake Period",
                        end of "Measurement Period"]
                    where "IPSD" is not null
                      and Global."ToDateInterval" ( ActiveMedPeriod ) overlaps Interval["IPSD" - 105 days, "IPSD" )
                )

  - - Numerator

      - -     "Cumulative Medication Duration Greater Than or Equal to 180 Days"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     None

  - - Stratification

      - -     None

### Definitions

- - Antidepressant Medication Period Between IPSD and 114 Days After IPSD

    - -     ["Medication, Dispensed": "Antidepressant Medication"] Antidepressant
              let MedicationPeriod: CMD."MedicationDispensedPeriod" ( Antidepressant )
              return MedicationPeriod
                intersect Interval["IPSD", "IPSD" + 114 days]

  - Antidepressant Medication Period Between IPSD and 231 Days After IPSD

    - -     ["Medication, Dispensed": "Antidepressant Medication"] Antidepressant
              let MedicationPeriod: CMD."MedicationDispensedPeriod" ( Antidepressant )
              return MedicationPeriod
                intersect Interval["IPSD", "IPSD" + 231 days]

  - April 30 of the Measurement Period

    - -     DateTime((year from start of "Measurement Period"), 4, 30, 23, 59, 59, 0, 0)

  - Cumulative Medication Duration Greater Than or Equal to 180 Days

    - -     CMD."CumulativeDuration" ( "Antidepressant Medication Period Between IPSD and 231 Days After IPSD" ) >= 180

  - Cumulative Medication Duration Greater Than or Equal to 84 Days

    - -     CMD."CumulativeDuration" ( "Antidepressant Medication Period Between IPSD and 114 Days After IPSD" ) >= 84

  - Denominator

    - -     "Initial Population"

  - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or exists ( ["Medication, Active": "Antidepressant Medication"] ActiveAntidepressant
                  let ActiveMedPeriod: ActiveAntidepressant Meds
                    return Meds.relevantPeriod
                      intersect Interval[start of "Intake Period",
                      end of "Measurement Period"]
                  where "IPSD" is not null
                    and Global."ToDateInterval" ( ActiveMedPeriod ) overlaps Interval["IPSD" - 105 days, "IPSD" )
              )

  - Earliest Antidepressant Dispensed During Intake Period

    - -     First(["Medication, Dispensed": "Antidepressant Medication"] Antidepressant
                where start of Global."NormalizeInterval"(Antidepressant.relevantDatetime, Antidepressant.relevantPeriod)in day of "Intake Period"
                sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
            )

  - Has IPSD and Major Depression Diagnosis

    - -     exists ( ["Diagnosis": "Major Depression"] MajorDepression
                where "IPSD" is not null
                  and date from start of MajorDepression.prevalencePeriod within 60 days of "IPSD"
            )

  - 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

    - -     AgeInYearsAt(date from "April 30 of the Measurement Period")>= 18
              and "Has IPSD and Major Depression Diagnosis"
              and exists "Qualifying Encounters"

  - Intake Period

    - -     Interval["May 1 of the Year Prior to the Measurement Period", "April 30 of the Measurement Period"]

  - IPSD

    - -     date from start of Global."NormalizeInterval" ( "Earliest Antidepressant Dispensed During Intake Period".relevantDatetime, "Earliest Antidepressant Dispensed During Intake Period".relevantPeriod )

  - May 1 of the Year Prior to the Measurement Period

    - -     DateTime((year from start of "Measurement Period" - 1), 5, 1, 0, 0, 0, 0, 0)

  - Numerator 1

    - -     "Cumulative Medication Duration Greater Than or Equal to 84 Days"

  - Numerator 2

    - -     "Cumulative Medication Duration Greater Than or Equal to 180 Days"

  - Qualifying Encounters

    - -     ( ["Encounter, Performed": "Office 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": "Annual Wellness Visit"]
              union ["Encounter, Performed": "Nursing Facility Visit"]
              union ["Encounter, Performed": "Psych Visit Diagnostic Evaluation"]
              union ["Encounter, Performed": "Psych Visit Psychotherapy"]
              union ["Encounter, Performed": "Telephone Visits"]
              union ["Encounter, Performed": "Online Assessments"] ) ValidEncounter
              where date from start of ValidEncounter.relevantPeriod within 60 days of "IPSD"

  - 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

- - CMD.CodeToDaily(Frequency Code)

    - -     case
              when Frequency ~ "Once daily (qualifier value)" then 1.0
              when Frequency ~ "Twice a day (qualifier value)" then 2.0
              when Frequency ~ "Three times daily (qualifier value)" then 3.0
              when Frequency ~ "Four times daily (qualifier value)" then 4.0
              when Frequency ~ "Every twenty four hours (qualifier value)" then 1.0
              when Frequency ~ "Every twelve hours (qualifier value)" then 2.0
              when Frequency ~ "Every thirty six hours (qualifier value)" then 0.67
              when Frequency ~ "Every eight hours (qualifier value)" then 3.0
              when Frequency ~ "Every four hours (qualifier value)" then 6.0
              when Frequency ~ "Every six hours (qualifier value)" then 4.0
              when Frequency ~ "Every seventy two hours (qualifier value)" then 0.33
              when Frequency ~ "Every forty eight hours (qualifier value)" then 0.5
              when Frequency ~ "Every eight to twelve hours (qualifier value)" then 3.0
              when Frequency ~ "Every six to eight hours (qualifier value)" then 4.0
              when Frequency ~ "Every three to four hours (qualifier value)" then 8.0
              when Frequency ~ "Every three to six hours (qualifier value)" then 8.0
              when Frequency ~ "Every two to four hours (qualifier value)" then 12.0
              when Frequency ~ "One to four times a day (qualifier value)" then 4.0
              when Frequency ~ "One to three times a day (qualifier value)" then 3.0
              when Frequency ~ "One to two times a day (qualifier value)" then 2.0
              when Frequency ~ "Two to four times a day (qualifier value)" then 4.0
              else null
            end

  - CMD.CumulativeDuration(Intervals List<Interval<Date>>)

    - -     if Intervals is not null then ( Sum((collapse Intervals per day)X
                  return all(difference in days between start of X and
                    end of X
                  )+ 1
              )
            )
              else null

  - CMD.MedicationDispensedPeriod(MedDispense "Medication, Dispensed")

    - -     MedDispense Dispense
              let startDate: date from Coalesce(Dispense.relevantPeriod.low, Dispense.relevantDatetime, Dispense.authorDatetime),
              totalDaysSupplied: Coalesce(Dispense.supply.value /(Dispense.dosage.value * ToDaily(Dispense.frequency)), Dispense.daysSupplied)
              return if startDate is null then null
                else if totalDaysSupplied is not null then Interval[startDate, startDate + Quantity { value: totalDaysSupplied - 1, unit: 'day' }]
                else if Dispense.relevantPeriod.high is not null then Interval[startDate, date from end of Dispense.relevantPeriod]
                else null

  - CMD.QuantityToDaily(Frequency Quantity)

    - -     case Frequency.unit
                when 'h' then (24.0 / Frequency.value)
                when 'min' then (24.0 / Frequency.value) * 60
                when 's' then (24.0 / Frequency.value) * 60 * 60
                when 'd' then (24.0 / Frequency.value) / 24
                when 'wk' then (24.0 / Frequency.value) / (24 * 7)
                when 'mo' then (24.0 / Frequency.value) / (24 * 30) /* assuming 30 days in month */
                when 'a' then (24.0 / Frequency.value) / (24 * 365) /* assuming 365 days in year */
                when 'hour' then (24.0 / Frequency.value)
                when 'minute' then (24.0 / Frequency.value) * 60
                when 'second' then (24.0 / Frequency.value) * 60 * 60
                when 'day' then (24.0 / Frequency.value) / 24
                when 'week' then (24.0 / Frequency.value) / (24 * 7)
                when 'month' then (24.0 / Frequency.value) / (24 * 30) /* assuming 30 days in month */
                when 'year' then (24.0 / Frequency.value) / (24 * 365) /* assuming 365 days in year */
                when 'hours' then (24.0 / Frequency.value)
                when 'minutes' then (24.0 / Frequency.value) * 60
                when 'seconds' then (24.0 / Frequency.value) * 60 * 60
                when 'days' then (24.0 / Frequency.value) / 24
                when 'weeks' then (24.0 / Frequency.value) / (24 * 7)
                when 'months' then (24.0 / Frequency.value) / (24 * 30) /* assuming 30 days in month */
                when 'years' then (24.0 / Frequency.value) / (24 * 365) /* assuming 365 days in year */
                else null
              end

  - CMD.ToDaily(Frequency Choice<Quantity, Code>)

    - -     case
              when Frequency is Quantity then QuantityToDaily(Frequency as Quantity)
              else CodeToDaily(Frequency as Code)
            end

  - 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>

  - Global.ToDateInterval(period Interval<DateTime>)

    - -     Interval[date from start of period, date from end of period]

### 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 "Every eight hours (qualifier value)" ("SNOMEDCT Code (307469008)")
- code "Every eight to twelve hours (qualifier value)" ("SNOMEDCT Code (396140003)")
- code "Every forty eight hours (qualifier value)" ("SNOMEDCT Code (396131002)")
- code "Every four hours (qualifier value)" ("SNOMEDCT Code (225756002)")
- code "Every seventy two hours (qualifier value)" ("SNOMEDCT Code (396143001)")
- code "Every six hours (qualifier value)" ("SNOMEDCT Code (307468000)")
- code "Every six to eight hours (qualifier value)" ("SNOMEDCT Code (396139000)")
- code "Every thirty six hours (qualifier value)" ("SNOMEDCT Code (396126004)")
- code "Every three to four hours (qualifier value)" ("SNOMEDCT Code (225754004)")
- code "Every three to six hours (qualifier value)" ("SNOMEDCT Code (396127008)")
- code "Every twelve hours (qualifier value)" ("SNOMEDCT Code (307470009)")
- code "Every twenty four hours (qualifier value)" ("SNOMEDCT Code (396125000)")
- code "Every two to four hours (qualifier value)" ("SNOMEDCT Code (225752000)")
- code "Four times daily (qualifier value)" ("SNOMEDCT Code (307439001)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Once daily (qualifier value)" ("SNOMEDCT Code (229797004)")
- code "One to four times a day (qualifier value)" ("SNOMEDCT Code (396109005)")
- code "One to three times a day (qualifier value)" ("SNOMEDCT Code (396108002)")
- code "One to two times a day (qualifier value)" ("SNOMEDCT Code (396107007)")
- code "Three times daily (qualifier value)" ("SNOMEDCT Code (229798009)")
- code "Twice a day (qualifier value)" ("SNOMEDCT Code (229799001)")
- code "Two to four times a day (qualifier value)" ("SNOMEDCT Code (396111001)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
- valueset "Antidepressant Medication" (2.16.840.1.113883.3.464.1003.196.12.1213)
- 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 Diagnosis" (2.16.840.1.113883.3.464.1003.1165)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "Major Depression" (2.16.840.1.113883.3.464.1003.105.12.1007)
- valueset "Nursing Facility Visit" (2.16.840.1.113883.3.464.1003.101.12.1012)
- 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 "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 "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 "Race" (2.16.840.1.114222.4.11.836)
- valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)

### Data Criteria (QDM Data Elements)

- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
- "Diagnosis: Major Depression" using "Major Depression (2.16.840.1.113883.3.464.1003.105.12.1007)"
- "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
- "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: Nursing Facility Visit" using "Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012)"
- "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: 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: 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: 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)"
- "Medication, Active: Antidepressant Medication" using "Antidepressant Medication (2.16.840.1.113883.3.464.1003.196.12.1213)"
- "Medication, Dispensed: Antidepressant Medication" using "Antidepressant Medication (2.16.840.1.113883.3.464.1003.196.12.1213)"
- "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