eCQM Title | # Controlling High Blood Pressure
eCQM Identifier (Measure Authoring Tool) | 165 | eCQM Version Number | 12.0.000
NQF Number | Not Applicable | GUID | abdc37cc-bac6-4156-9b91-d1be2c8b7268
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 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90 mmHg) during 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 | Intermediate Clinical Outcome
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    High blood pressure (HBP), also known as hypertension, is when the pressure in blood vessels is higher than normal (Centers for Disease Control and Prevention [CDC], 2021). The causes of hypertension are multiple and multifaceted and can be based on genetic predisposition, environmental risk factors, being overweight and obese, sodium intake, potassium intake, physical activity, and alcohol use. High blood pressure is common; according to the American Heart Association, between 2013-2016, approximately 121.5 million US adults >= 20 years of age had HBP and the prevalence of hypertension among US adults 65 and older was 77.0 percent (Virani et al., 2021). In an analysis of adults with hypertension in NHANES, the estimated age-adjusted proportion with controlled BP increased from 31.8 percent in 1999 to 53.8 percent in 2014. However, that proportion declined to 43.7 percent in 2017 to 2018 (Tsao et al., 2022).

    HBP, known as the “silent killer,” increases risks of heart disease and stroke which are two of the leading causes of death in the US; a person who has HBP is four times more likely to die from a stroke and three times more likely to die from heart disease (CDC, 2012). The National Center for Health Statistics reported that in 2020 there were over 670,000 deaths with HBP as a primary or contributing cause (CDC, 2022). Between 2009 and 2019 the number of deaths due to HBP rose by 65.3 percent (Tsao et al., 2022). Managing and treating HBP would reduce cardiovascular disease mortality for males and females by 30.4 percent and 38.0 percent, respectively (Patel et al., 2015). Age-adjusted death rates attributable to HBP in 2019 were more than twice as high in non-Hispanic Black males (56.7 percent) when compared to rates for non-Hispanic White males (25.7 percent) (Tsao et al., 2022).

    HBP costs the U.S. approximately 131 billion dollars each year, averaged over 12 years from 2003 to 2014 (Kirkland et al., 2018). A study on cost-effectiveness on treating hypertension found that controlling HBP in patients with cardiovascular disease and systolic blood pressures (SBP) of >= 160 mmHg could be effective and cost-saving (Moran, 2015).

    Many studies have shown that controlling high blood pressure reduces cardiovascular events and mortality. The Systolic Blood Pressure Intervention Trial (SPRINT) investigated the impact of obtaining a SBP goal of <120 mmHg compared to a SBP goal of <140 mmHg among patients 50 and older with established cardiovascular disease and found that the patients with the former goal had reduced cardiovascular events and mortality (SPRINT Research Group et al., 2015).

    Controlling HBP will significantly reduce the risks of cardiovascular disease mortality and lead to better health outcomes like reduction of heart attacks, stroke, and kidney disease (James et al., 2014). Thus, the relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established.
Clinical Recommendation Statement |
    U.S. Preventive Services Task Force (USPSTF) (2021):

    - The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM). The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. This is a grade A recommendation.

    American College of Cardiology/American Heart Association (2017):

    - For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10 percent or higher, a blood pressure target of less than 130/80 mmHg is recommended (Level of evidence: B-R (for systolic blood pressures), Level of evidence: C-EO (for diastolic blood pressure))

    - For adults with confirmed hypertension, without additional markers of increased CVD risk, a blood pressure target of less than 130/80 mmHg may be reasonable (Note: clinical trial evidence is strongest for a target blood pressure of 140/90 mmHg in this population. However, observational studies suggest that these individuals often have a high lifetime risk and would benefit from blood pressure control earlier in life) (Level of evidence: B-NR (for systolic blood pressure), Level of evidence: C-EO (for diastolic blood pressure)).

    American College of Physicians and the American Academy of Family Physicians (2017):

    - Initiate or intensify pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mmHg (Grade: weak recommendation, Quality of evidence: low)

    - Initiate or intensify pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mmHg to reduce the risk of recurrent stroke (Grade: weak recommendation, Quality of evidence: moderate)

    American Diabetes Association (2021):

    - For individuals with diabetes and hypertension at higher cardiovascular risk (existing atherosclerotic cardiovascular disease or 10-year atherosclerotic cardiovascular disease risk >=15 percent), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained (Level of evidence: C)

    - For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year atherosclerotic cardiovascular disease risk <15 percent), treat to a blood pressure target of <140/90 mmHg (Level of evidence: A)
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Diabetes Association. (2021). 10. Cardiovascular disease and risk management: Standards of medical care in diabetes—2021. Diabetes Care 2021, 44(Suppl. 1), S125-S150. https://doi.org/10.2337/dc21-S010'
Reference |
    Reference Type: CITATION
    Reference Text: 'Centers for Disease Control and Prevention. (2012). Vital signs: Getting blood pressure under control. Retrieved from https://www.cdc.gov/vitalsigns/hypertension/index.html'
Reference |
    Reference Type: CITATION
    Reference Text: 'Centers for Disease Control and Prevention. (2021). Facts About Hypertension. Retrieved from https://www.cdc.gov/bloodpressure/facts.htm'
Reference |
    Reference Type: CITATION
    Reference Text: 'Centers for Disease Control and Prevention, National Center for Health Statistics. About Multiple Cause of Death, 1999–2020. CDC WONDER Online Database website. Atlanta, GA: Centers for Disease Control and Prevention; 2022. Available from http://www.cdc.gov/nchs/data_access/Vitalstatsonline.htm#Mortality_Multiple'
Reference |
    Reference Type: CITATION
    Reference Text: 'James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. doi: 10.1001/jama.2013.284427. Erratum in: JAMA. 2014 May 7;311(17):1809. PMID: 24352797.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Kirkland, E. B., Heincelman, M., Bishu, K. G., Schumann, S. O., Schreiner, A., Axon, R. N., Mauldin, P. D., & Moran, W. P. (2018). Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003–2014. Journal of the American Heart Association, 7(11), e008731. https://doi.org/10.1161/JAHA.118.008731'
Reference |
    Reference Type: CITATION
    Reference Text: 'Moran, A. E., Odden, M. C., Thanataveerat, A., et al. (2015). Cost-effectiveness of hypertension therapy according to 2014 guidelines. [published correction appears in N Engl J. Med. 2015;372:1677]. New England Journal of Medicine. 2015 ;372, 447-455. doi: 10.1056/NEJMsa1406751. [published correction appears on page 1677]'
Reference |
    Reference Type: CITATION
    Reference Text: 'Patel, S. A., Winkel, M., Ali, M. K., et al. (2015). Cardiovascular mortality associated with 5 leading risk factors: National and state preventable fractions estimated from survey data. Annals of Internal Medicine, 163(4), 245-253. doi: 10.7326/M14-1753'
Reference |
    Reference Type: CITATION
    Reference Text: 'Qaseem, A., Wilt, T. J., Rich, R., et al. (2017). Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Annals of Internal Medicine, 166(6), 430-437. Retrieved from https://annals.org/aim/fullarticle/2598413/pharmacologic-treatment-hypertension-adults-aged-60-years-older-higher-versus'
Reference |
    Reference Type: CITATION
    Reference Text: 'SPRINT Research Group, Wright, J. T., Jr., Williamson, J. D., et al. (2015). A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine, 373(22), 2103–2116.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Alonso, A., Beaton, A. Z., Bittencourt, M. S., Boehme, A. K., Buxton, A. E., Carson, A. P., Commodore-Mensah, Y., Elkind, M. S. V., Evenson, K. R., Eze-Nliam, C., Ferguson, J. F., Generoso, G., Ho, J. E., Kalani, R., Khan, S. S., Kissela, B. M., et al. (2022). Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation, 145(8), e153–e639. https://doi.org/10.1161/CIR.0000000000001052'
Reference |
    Reference Type: CITATION
    Reference Text: 'U.S. Preventive Services Task Force. (2015). Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 163(10), 778-787. Retrieved from https://annals.org/aim/fullarticle/2456129/screening-high-blood-pressure-adults-u-s-preventive-services-task'
Reference |
    Reference Type: CITATION
    Reference Text: 'Virani, S.S., Alonso, A., Aparicio, H.J., et al.; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2021). Heart disease and stroke statistics—2021 update: a report from the American Heart Association. Circulation. 2021;143:e254–e743. doi: 10.1161/CIR.0000000000000950'
Reference |
    Reference Type: CITATION
    Reference Text: 'Whelton, P. K., Carey, R. M., Aronow, W. S., et al. (2017). Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. https://doi.org/10.1161/HYP.0000000000000065'
Definition |
    None
Guidance |
    In reference to the numerator element, only blood pressure readings performed by a clinician or an automated blood pressure monitor or device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by an automated blood pressure monitor or device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the automated blood pressure monitor or device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record.

    Do not include BP readings taken during an acute inpatient stay or an ED visit.

    If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled".

    If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. Ranges and thresholds do not meet criteria for this measure. A distinct numeric result for both the systolic and diastolic BP reading is required for numerator compliance.

    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 18-85 years of age by the end of the measurement period who had a visit during the measurement period and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period
Denominator |
    Equals Initial Population
Denominator Exclusions |
    Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during 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 66-80 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 81 and older by the end of the measurement period with an indication of frailty for any part of the measurement period.

    Exclude patients receiving palliative care for any part of the measurement period.
Numerator |
    Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during 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

    - -     AgeInYearsAt(date from
              end of "Measurement Period"
            )in Interval[18, 85]
              and exists "Essential Hypertension Diagnosis"
              and exists AdultOutpatientEncounters."Qualifying Encounters"

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or exists ( "Pregnancy or Renal Diagnosis" )
              or exists ( "End Stage Renal Disease Procedures" )
              or exists ( "End Stage Renal Disease Encounter" )
              or AIFrailLTCF."Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with 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

    - -     "Has Systolic Blood Pressure Less Than 140"
              and "Has Diastolic Blood Pressure Less Than 90"

- - 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 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty

    - -     ( AgeInYearsAt(date from
                end of "Measurement Period"
              )in Interval[66, 80]
                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"
                )
            )
              or ( AgeInYearsAt(date from
                  end of "Measurement Period"
                )>= 81
                  and "Has Criteria Indicating Frailty"
              )

  - 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"]

  - Blood Pressure Days

    - -     ( "Qualifying Diastolic Blood Pressure Reading" DBPExam
                return date from Global."LatestOf" ( DBPExam.relevantDatetime, DBPExam.relevantPeriod )
            )
              intersect ( "Qualifying Systolic Blood Pressure Reading" SBPExam
                  return date from Global."LatestOf" ( SBPExam.relevantDatetime, SBPExam.relevantPeriod )
              )

  - Denominator

    - -     "Initial Population"

  - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or exists ( "Pregnancy or Renal Diagnosis" )
              or exists ( "End Stage Renal Disease Procedures" )
              or exists ( "End Stage Renal Disease Encounter" )
              or AIFrailLTCF."Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty"
              or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"
              or PalliativeCare."Has Palliative Care in the Measurement Period"

  - End Stage Renal Disease Encounter

    - -     ["Encounter, Performed": "ESRD Monthly Outpatient Services"] ESRDEncounter
              where ESRDEncounter.relevantPeriod starts on or before
              end of "Measurement Period"

  - End Stage Renal Disease Procedures

    - -     ( ["Procedure, Performed": "Kidney Transplant"]
              union ["Procedure, Performed": "Dialysis Services"] ) ESRDProcedure
              where
              end of Global."NormalizeInterval" ( ESRDProcedure.relevantDatetime, ESRDProcedure.relevantPeriod ) on or before
              end of "Measurement Period"

  - Essential Hypertension Diagnosis

    - -     ["Diagnosis": "Essential Hypertension"] Hypertension
              where Hypertension.prevalencePeriod overlaps Interval[start of "Measurement Period", start of "Measurement Period" + 6 months )

  - Has Diastolic Blood Pressure Less Than 90

    - -     "Lowest Diastolic Reading on Most Recent Blood Pressure Day".result < 90 'mm[Hg]'

  - Has Systolic Blood Pressure Less Than 140

    - -     "Lowest Systolic Reading on Most Recent Blood Pressure Day".result < 140 'mm[Hg]'

  - 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
              end of "Measurement Period"
            )in Interval[18, 85]
              and exists "Essential Hypertension Diagnosis"
              and exists AdultOutpatientEncounters."Qualifying Encounters"

  - Lowest Diastolic Reading on Most Recent Blood Pressure Day

    - -     First("Qualifying Diastolic Blood Pressure Reading" DBPReading
                where Global."LatestOf"(DBPReading.relevantDatetime, DBPReading.relevantPeriod)same day as "Most Recent Blood Pressure Day"
                sort by(result as Quantity)
            )

  - Lowest Systolic Reading on Most Recent Blood Pressure Day

    - -     First("Qualifying Systolic Blood Pressure Reading" SBPReading
                where Global."LatestOf"(SBPReading.relevantDatetime, SBPReading.relevantPeriod)same day as "Most Recent Blood Pressure Day"
                sort by(result as Quantity)
            )

  - Most Recent Blood Pressure Day

    - -     Last("Blood Pressure Days" BPDays
                sort asc
            )

  - Numerator

    - -     "Has Systolic Blood Pressure Less Than 140"
              and "Has Diastolic Blood Pressure Less Than 90"

  - 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"
              )

  - Pregnancy or Renal Diagnosis

    - -     ( ["Diagnosis": "Pregnancy"]
              union ["Diagnosis": "End Stage Renal Disease"]
              union ["Diagnosis": "Kidney Transplant Recipient"]
              union ["Diagnosis": "Chronic Kidney Disease, Stage 5"] ) PregnancyESRDDiagnosis
              where PregnancyESRDDiagnosis.prevalencePeriod overlaps "Measurement Period"

  - Qualifying Diastolic Blood Pressure Reading

    - -     ["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
              without ( ["Encounter, Performed": "Encounter Inpatient"]
                union ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"] ) DisqualifyingEncounter
                such that Global."LatestOf" ( DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod ) during day of DisqualifyingEncounter.relevantPeriod
              where DiastolicBP.result.unit = 'mm[Hg]'
                and Global."LatestOf" ( DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod ) during day of "Measurement Period"

  - Qualifying Systolic Blood Pressure Reading

    - -     ["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
              without ( ["Encounter, Performed": "Encounter Inpatient"]
                union ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"] ) DisqualifyingEncounter
                such that Global."LatestOf" ( SystolicBP.relevantDatetime, SystolicBP.relevantPeriod ) during day of DisqualifyingEncounter.relevantPeriod
              where SystolicBP.result.unit = 'mm[Hg]'
                and Global."LatestOf" ( SystolicBP.relevantDatetime, SystolicBP.relevantPeriod ) during day of "Measurement Period"

  - SDE Ethnicity

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

  - SDE Payer

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

  - SDE Race

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

  - SDE Sex

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

### Functions

- - Global.HasEnd(period Interval<DateTime>)

    - -     not (
              end of period is null
                or
                end of period = maximum DateTime
            )

  - Global.Latest(period Interval<DateTime>)

    - -     if ( HasEnd(period)) then
            end of period
              else start of period

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

    - -     Latest(NormalizeInterval(pointInTime, period))

  - 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 "Diastolic blood pressure" ("LOINC Code (8462-4)")
- code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
- code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
- 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 "Lives in a nursing home (finding)" ("SNOMEDCT Code (160734000)")
- code "Medical equipment used" ("LOINC Code (98181-1)")
- code "Systolic blood pressure" ("LOINC Code (8480-6)")
- 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 "Chronic Kidney Disease, Stage 5" (2.16.840.1.113883.3.526.3.1002)
- valueset "Dementia Medications" (2.16.840.1.113883.3.464.1003.196.12.1510)
- valueset "Dialysis Services" (2.16.840.1.113883.3.464.1003.109.12.1013)
- 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 "End Stage Renal Disease" (2.16.840.1.113883.3.526.3.353)
- valueset "ESRD Monthly Outpatient Services" (2.16.840.1.113883.3.464.1003.109.12.1014)
- valueset "Essential Hypertension" (2.16.840.1.113883.3.464.1003.104.12.1011)
- 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 "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 "Kidney Transplant" (2.16.840.1.113883.3.464.1003.109.12.1012)
- valueset "Kidney Transplant Recipient" (2.16.840.1.113883.3.464.1003.109.12.1029)
- 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 "Pregnancy" (2.16.840.1.113883.3.526.3.378)
- 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 "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)

### 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: Chronic Kidney Disease, Stage 5" using "Chronic Kidney Disease, Stage 5 (2.16.840.1.113883.3.526.3.1002)"
- "Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease (2.16.840.1.113883.3.526.3.353)"
- "Diagnosis: Essential Hypertension" using "Essential Hypertension (2.16.840.1.113883.3.464.1003.104.12.1011)"
- "Diagnosis: Frailty Diagnosis" using "Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074)"
- "Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
- "Diagnosis: Kidney Transplant Recipient" using "Kidney Transplant Recipient (2.16.840.1.113883.3.464.1003.109.12.1029)"
- "Diagnosis: Palliative Care Diagnosis" using "Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167)"
- "Diagnosis: Pregnancy" using "Pregnancy (2.16.840.1.113883.3.526.3.378)"
- "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: ESRD Monthly Outpatient Services" using "ESRD Monthly Outpatient Services (2.16.840.1.113883.3.464.1003.109.12.1014)"
- "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: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Physical Exam, Performed: Diastolic blood pressure" using "Diastolic blood pressure (LOINC Code 8462-4)"
- "Physical Exam, Performed: Systolic blood pressure" using "Systolic blood pressure (LOINC Code 8480-6)"
- "Procedure, Performed: Dialysis Services" using "Dialysis Services (2.16.840.1.113883.3.464.1003.109.12.1013)"
- "Procedure, Performed: Kidney Transplant" using "Kidney Transplant (2.16.840.1.113883.3.464.1003.109.12.1012)"
- "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