Appropriate Treatment for Upper Respiratory Infection (URI)

Compare Versions of: "Appropriate Treatment for Upper Respiratory Infection (URI)"

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Measure Information	2023 Performance Period	2024 Performance Period	2025 Performance Period
Title	Appropriate Treatment for Upper Respiratory Infection (URI)	Appropriate Treatment for Upper Respiratory Infection (URI)	Appropriate Treatment for Upper Respiratory Infection (URI)
CMS eCQM ID	CMS154v11	CMS154v12	CMS154v13
CBE ID*	Not Applicable	Not Applicable	Not Applicable
MIPS Quality ID	065	065	065
Measure Steward	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance
Description	Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order	Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order	Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process	Process	Process
Stratification	*See CMS154v11.html	- 3 months-17 years - 18-64 years - 65 years and older	- 3 months-17 years - 18-64 years - 65 years and older
Risk Adjustment	*See CMS154v11.html	None	None
Rationale	*See CMS154v11.html	Most URI, also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least... 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year (Centers for Disease Control and Prevention [CDC], 2020). Show more > Most URI, also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year (Centers for Disease Control and Prevention [CDC], 2020). Show less	Most URI, also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least... 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year (Centers for Disease Control and Prevention [CDC], 2020). Show more > Most URI, also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year (Centers for Disease Control and Prevention [CDC], 2020). Show less
Clinical Recommendation Statement	*See CMS154v11.html	American Family Physician (Fashner, Ericson, and Werner, 2012) - Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A) - Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A) - Decongestants,... antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B) Institute for Clinical Systems Improvement (Short, et al., 2017) The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults. Show more > American Family Physician (Fashner, Ericson, and Werner, 2012) - Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A) - Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A) - Decongestants, antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B) Institute for Clinical Systems Improvement (Short, et al., 2017) The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults. Show less	American Family Physician (Fashner, Ericson, & Werner, 2012) - Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A) - Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A) - Decongestants,... antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B) Institute for Clinical Systems Improvement (ICSI) (Short et al., 2017) The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults. Show more > American Family Physician (Fashner, Ericson, & Werner, 2012) - Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A) - Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A) - Decongestants, antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B) Institute for Clinical Systems Improvement (ICSI) (Short et al., 2017) The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults. Show less
Improvement Notation	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality
Definition	*See CMS154v11.html	None	None
Guidance	This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory... infection during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more > This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less	This is an episode of care measure that examines all eligible episodes for the patient. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection from January 1 to... December 28 of the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more > This is an episode of care measure that examines all eligible episodes for the patient. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection from January 1 to December 28 of the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less	This is an episode of care measure that examines all eligible episodes for the patient. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection from January 1 to... December 28 of the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more > This is an episode of care measure that examines all eligible episodes for the patient. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection from January 1 to December 28 of the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less
Initial Population	Outpatient visits, telephone visits, online assessments (i.e. e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of URI during the measurement period among patients 3 months of age and older	Outpatient visits, telephone visits, online assessments (i.e., e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of URI from January 1 to December 28 of the measurement period for patients 3 months of age and older	Outpatient visits, telephone visits, virtual encounter (i.e., e-visit or virtual check-in), or emergency department visits with a diagnosis of URI from January 1 to December 28 of the measurement period for patients 3 months of age and older
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes when the patient had an active prescription of antibiotics in the 30 days prior to the episode date but is still active the same day of the encounter. E... xclude URI episodes when the patient had competing diagnosis on or three days after the episode date. Exclude URI episodes when the patient had hospice care for any part of the measurement period. Show more > Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes when the patient had an active prescription of antibiotics in the 30 days prior to the episode date but is still active the same day of the encounter. Exclude URI episodes when the patient had competing diagnosis on or three days after the episode date. Exclude URI episodes when the patient had hospice care for any part of the measurement period. Show less	Exclude URI episodes when the patient had hospice care for any part of the measurement period. Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes where the patient is taking antibiotics in the 30 days... prior to the episode date. Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date. Show more > Exclude URI episodes when the patient had hospice care for any part of the measurement period. Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes where the patient is taking antibiotics in the 30 days prior to the episode date. Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date. Show less	Exclude URI episodes when the patient had hospice care for any part of the measurement period. Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes where the patient is taking antibiotics in the 30 days... prior to the episode date. Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date. Show more > Exclude URI episodes when the patient had hospice care for any part of the measurement period. Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes where the patient is taking antibiotics in the 30 days prior to the episode date. Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date. Show less
Numerator	URI episodes without a prescription for antibiotic medication on or 3 days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection	URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection	URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, virtual encounter, or emergency department visit for an upper respiratory infection
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS154v12	CMS154v13	No Version Available
Previous Version	No Version Available	CMS154v11	CMS154v12

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Specifications

Additional Resources for CMS154v11

CMS154v11-TRN.xlsx

Header

Revised the description to use 'order' instead of 'dispense' to align with the measure logic.
Measure Section: Description
Source of Change: Measure Lead
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated the clinical recommendation statement based on literature review.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
Updated the denominator exclusion language to align with the measure logic.
Measure Section: Denominator Exclusions
Source of Change: ONC Project Tracking System (JIRA): CQM-4749
Updated grammar and punctuation to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead

Logic

Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
Revised the logic to exclude patients with an antibiotic that is active before the encounter but is still active the same day of the encounter date.
Measure Section: Definitions
Source of Change: ONC Project Tracking System (JIRA): CQM-4749
Added QDM datatypes Encounter, Performed and Assessment, Performed and associated logic to the Hospice.'Has Hospice Services' definition to provide additional approaches for identifying patients receiving hospice services.
Measure Section: Definitions
Source of Change: Measure Lead
Replaced value set Preventive Care Services Other (2.16.840.1.113883.3.464.1003.101.12.1030) with direct reference code CPT code (99429).
Measure Section: Definitions
Source of Change: Measure Lead
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the version number of the Hospice Library to v4.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead

Value set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Competing Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1017): Added 136 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 55 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-10-CM code (A04.7) based on validity of code during timing of look back period.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Comorbid Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1025): Added 8 SNOMED CT codes (1092771000119104, 1144499001, 1149259003, 1153413001, 1153415008, 15984271000119108, 16016231000119109, 16016311000119107) based on review by technical experts, SMEs, and/or public feedback. Deleted 9 SNOMED CT codes (266355005, 77690003, 34320001, 186231006, 203271005, 25042006, 418750009, 59190009, 724502006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Antibiotic Medications for Pharyngitis (2.16.840.1.113883.3.464.1003.196.12.1001): Added 11 RxNorm codes (1291986, 1650198, 1809083, 2099768, 2122343, 309042, 351121, 757968, 758019, 853019, 861416) based on review by technical experts, SMEs, and/or public feedback. Deleted 94 RxNorm codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set (2.16.840.1.113883.3.464.1003.101.12.1026): Renamed to Preventive Care Services Individual Counseling based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1002): Renamed to Initial Hospital Observation Care based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1023): Renamed to Preventive Care Services Initial Office Visit, 18 and Up based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1025): Renamed to Preventive Care Services Established Office Visit, 18 and Up based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Replaced value set Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15) with value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Preventive Care Services Other (2.16.840.1.113883.3.464.1003.101.12.1030) with direct reference code CPT code (99429) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set (2.16.840.1.113883.3.464.1003.101.12.1027): Renamed to Preventive Care Services Group Counseling based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Added direct reference code SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead