eCQM Title | # Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
eCQM Identifier (Measure Authoring Tool) | 143 | eCQM Version Number | 12.0.000
NQF Number | 0086e | GUID | db9d9f09-6b6a-4749-a8b2-8c1fdb018823
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | American Academy of Ophthalmology
Measure Developer | American Academy of Ophthalmology
Measure Developer | American Medical Association (AMA)
Measure Developer | PCPI(R) Foundation (PCPI[R])
Endorsed By | National Quality Forum
Description |
    Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months
Copyright |
    Copyright 2023 American Academy of Ophthalmology. All Rights Reserved.
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 the American Academy of Ophthalmology (Academy). Neither the Academy, its members, the American Medical Association (AMA), nor the former AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor PCPI, nor their members shall be responsible for any use of the Measure.

    The PCPI’s and AMA’s significant past efforts and contributions to the development and updating of the Measures are acknowledged. The National Committee for Quality Assurance's significant past efforts and contributions to the development and updating of the Measure is acknowledged.

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

    Limited proprietary coding is 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 Measures. Any other use of CPT or other coding by the third party is strictly prohibited. The Academy, its members, the AMA, and former members of the PCPI disclaim all liability for use or accuracy of any CPT or other coding contained in the specifications.

    CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is 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 is copyright 2022 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 |
    Glaucoma is a group of diseases that damage the eye’s optic nerve and can result in vision loss and blindness. In 2011, 2.71 million persons in the U.S. had primary open-angle glaucoma (POAG) and in 2050, an estimated 7.32 million persons will have POAG (Vajaranant, Wu, Torres, & Varma, 2012). Furthermore, a study by Rein, Zhang, & Wirth (2006) estimated that the total financial burden of major visual disorders among U.S. residents aged 40 years or older was $35.4 billion in 2004: $16.2 billion in direct medical costs, $11.1 billion in other direct costs, and $8 billion in productivity losses. Of the direct medical costs, approximately $2.9 billion was attributable to glaucoma (Rein, Zhang, & Wirth, 2006). It is imperative that evidence-based care be delivered to all glaucoma patients.

    According to recent guidelines, optic nerve changes are one of the characteristics which reflect progression of glaucoma (the other characteristic is visual field). Examination of the optic nerve head (ONH) and retinal nerve fiber layer (RNFL) provides valuable structural information about optic nerve damage from glaucoma. Visible structural alterations of the ONH or RNFL may precede the onset of visual field defects. Careful study of the optic disc neural rim for small hemorrhages is important because these hemorrhages sometimes signal focal disc damage and visual field loss, and they may signify ongoing optic nerve damage in patients with glaucoma (Gedde et al., 2021). Despite evidence emphasizing the value of an optic nerve evaluation, there is a gap in documentation patterns of the optic nerve for both initial and follow-up care.

    This measure is intended to promote examination and documentation of the structure and function of the optic nerve, and to monitor and detect disease progression among patients diagnosed with POAG.
Clinical Recommendation Statement |
    Ophthalmic Evaluation
    The ophthalmic evaluation specifically focuses on the following elements in the comprehensive adult medical eye evaluation:

    Visual acuity measurement
    Pupil examination
    Anterior segment examination
    IOP measurement
    Gonioscopy
    Optic nerve head (ONH) and retinal nerve fiber layer (RNFL) examination
    Fundus examination
    (Gedde et al., 2021)

    The optic nerve should be carefully examined for the signs of glaucoma damage, and its appearance should be serially documented (I+, moderate quality, strong recommendation) (Gedde et al., 2021).
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Rein, D. B., Zhang, P., & Wirth, K. (2006). The economic burden of major adult visual disorders in the United States. Archives of Ophthalmology, 124(12), 1754-1760. doi:10.1001/archopht.124.12.1754'
Reference |
    Reference Type: CITATION
    Reference Text: 'Vajaranant, T. S., Wu, S., Torres, M., & Varma, R. (2012). The changing face of primary open-angle glaucoma in the United States: Demographic and geographic changes from 2011 to 2050. American Journal of Ophthalmology, 154(2). doi:10.1016/j.ajo.2012.02.024'
Reference |
    Reference Type: CITATION
    Reference Text: 'Gedde, S. J., Vinod, K., Wright, M. M., Muir, K. W., Lind, J. T., Chen, P. P., Li, T., Mansberger, S. L., & American Academy of Ophthalmology Preferred Practice Pattern Glaucoma Panel (2021). Primary Open-Angle Glaucoma Preferred Practice Pattern(R). Ophthalmology, 128(1), P71–P150. https://doi.org/10.1016/j.ophtha.2020.10.022'
Definition |
    None
Guidance |
    Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities. Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy.

    The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but SNOMED-CT does not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible professional or eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality.

    This eCQM is a patient-based measure.

    Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth.

    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 |
    All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
Denominator |
    Equals Initial Population
Denominator Exclusions |
    None
Numerator |
    Patients who have an optic nerve head evaluation during one or more visits within 12 months
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Documentation of medical reason(s) for not performing an optic nerve head evaluation
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

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 18
              and exists "Primary Open Angle Glaucoma Encounter"

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     None

- - Numerator

    - -     exists "Cup to Disc Ratio Performed with Result"
              and exists "Optic Disc Exam Performed with Result"

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     exists "Medical Reason for Not Performing Cup to Disc Ratio"
              or exists "Medical Reason for Not Performing Optic Disc Exam"

- - Stratification

    - -     None

### Definitions

- - Cup to Disc Ratio Performed with Result

    - -     ["Diagnostic Study, Performed": "Cup to Disc Ratio"] CupToDiscExamPerformed
              with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
                such that Global."NormalizeInterval" ( CupToDiscExamPerformed.relevantDatetime, CupToDiscExamPerformed.relevantPeriod ) during EncounterWithPOAG.relevantPeriod
              where CupToDiscExamPerformed.result is not null

  - Denominator

    - -     "Initial Population"

  - Denominator Exceptions

    - -     exists "Medical Reason for Not Performing Cup to Disc Ratio"
              or exists "Medical Reason for Not Performing Optic Disc Exam"

  - Initial Population

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 18
              and exists "Primary Open Angle Glaucoma Encounter"

  - Medical Reason for Not Performing Cup to Disc Ratio

    - -     ["Diagnostic Study, Not Performed": "Cup to Disc Ratio"] CupToDiscExamNotPerformed
              with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
                such that CupToDiscExamNotPerformed.authorDatetime during EncounterWithPOAG.relevantPeriod
              where CupToDiscExamNotPerformed.negationRationale in "Medical Reason"

  - Medical Reason for Not Performing Optic Disc Exam

    - -     ["Diagnostic Study, Not Performed": "Optic Disc Exam for Structural Abnormalities"] OpticDiscExamNotPerformed
              with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
                such that OpticDiscExamNotPerformed.authorDatetime during EncounterWithPOAG.relevantPeriod
              where OpticDiscExamNotPerformed.negationRationale in "Medical Reason"

  - Numerator

    - -     exists "Cup to Disc Ratio Performed with Result"
              and exists "Optic Disc Exam Performed with Result"

  - Optic Disc Exam Performed with Result

    - -     ["Diagnostic Study, Performed": "Optic Disc Exam for Structural Abnormalities"] OpticDiscExamPerformed
              with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
                such that Global."NormalizeInterval" ( OpticDiscExamPerformed.relevantDatetime, OpticDiscExamPerformed.relevantPeriod ) during EncounterWithPOAG.relevantPeriod
              where OpticDiscExamPerformed.result is not null

  - Primary Open Angle Glaucoma Encounter

    - -     "Qualifying Encounter During Measurement Period" ValidQualifyingEncounter
              with ["Diagnosis": "Primary Open Angle Glaucoma"] PrimaryOpenAngleGlaucoma
                such that PrimaryOpenAngleGlaucoma.prevalencePeriod overlaps ValidQualifyingEncounter.relevantPeriod

  - Qualifying Encounter During Measurement Period

    - -     ( ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Ophthalmological Services"]
              union ["Encounter, Performed": "Outpatient Consultation"]
              union ["Encounter, Performed": "Nursing Facility Visit"]
              union ["Encounter, Performed": "Care Services in Long Term Residential Facility"] ) QualifyingEncounter
              where QualifyingEncounter.relevantPeriod during "Measurement Period"
                and QualifyingEncounter.class !~ "virtual"

  - 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 "virtual" ("ActCode Code (VR)")
- valueset "Care Services in Long Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014)
- valueset "Cup to Disc Ratio" (2.16.840.1.113883.3.526.3.1333)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Medical Reason" (2.16.840.1.113883.3.526.3.1007)
- 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 "Ophthalmological Services" (2.16.840.1.113883.3.526.3.1285)
- valueset "Optic Disc Exam for Structural Abnormalities" (2.16.840.1.113883.3.526.3.1334)
- 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 "Primary Open Angle Glaucoma" (2.16.840.1.113883.3.526.3.326)
- valueset "Race" (2.16.840.1.114222.4.11.836)

### Data Criteria (QDM Data Elements)

- "Diagnosis: Primary Open Angle Glaucoma" using "Primary Open Angle Glaucoma (2.16.840.1.113883.3.526.3.326)"
- "Diagnostic Study, Not Performed: Cup to Disc Ratio" using "Cup to Disc Ratio (2.16.840.1.113883.3.526.3.1333)"
- "Diagnostic Study, Not Performed: Optic Disc Exam for Structural Abnormalities" using "Optic Disc Exam for Structural Abnormalities (2.16.840.1.113883.3.526.3.1334)"
- "Diagnostic Study, Performed: Cup to Disc Ratio" using "Cup to Disc Ratio (2.16.840.1.113883.3.526.3.1333)"
- "Diagnostic Study, Performed: Optic Disc Exam for Structural Abnormalities" using "Optic Disc Exam for Structural Abnormalities (2.16.840.1.113883.3.526.3.1334)"
- "Encounter, Performed: Care Services in Long Term Residential Facility" using "Care Services in Long Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)"
- "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: Ophthalmological Services" using "Ophthalmological Services (2.16.840.1.113883.3.526.3.1285)"
- "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
- "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