| Measure Information | 2020 Performance Period |
|---|---|
| CMS Measure ID | CMS347v3 |
| NQF Number | Not Applicable |
| Measure Description |
Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: *Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR *Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR *Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL |
| Initial Population | All patients aged 21 years and older at the beginning of the measurement period with a patient encounter during the measurement period |
| Denominator Statement |
All patients who meet one or more of the following criteria (considered at "high risk" for cardiovascular events, under ACC/AHA guidelines): 1) Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD diagnosis 2) Patients aged >= 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C >=190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia 3) Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70-189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period |
| Denominator Exclusions |
Patients who have a diagnosis of pregnancy Patients who are breastfeeding Patients who have a diagnosis of rhabdomyolysis |
| Numerator Statement |
Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period |
| Numerator Exclusions |
None |
| Denominator Exceptions |
Patients with adverse effect, allergy, or intolerance to statin medication Patients who are receiving palliative or hospice care Patients with active liver disease or hepatic disease or insufficiency Patients with end-stage renal disease (ESRD) Patients with diabetes who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) |
| Domain | Effective Clinical Care |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
Higher score indicates better quality |
| Guidance |
Numerator instructions and guidance: -Current statin therapy use must be documented in the patient's current medication list or ordered during the measurement period. -ONLY statin therapy meets the measure Numerator criteria (NOT other cholesterol lowering medications). -Prescription or order does NOT need to be linked to an encounter or visit; it may be called to the pharmacy. -Statin medication "samples" provided to patients can be documented as "current statin therapy" if documented in the medication list in health/medical record. -Patients who meet the denominator criteria for inclusion, but are not prescribed or using statin therapy, will NOT meet performance for this measure. There is only one performance rate calculated for this measure; the weighted average of the three populations. -Adherence to statin therapy is not calculated in this measure. Denominator Guidance: The denominator covers three distinct populations. Use the following process to prevent counting patients more than once. Denominator Population 1: Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD -If YES, meets Denominator Population 1 risk category -If NO, screen for next risk category Denominator Population 2: Patients aged >= 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory test result of LDL-C >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia -If YES, meets Denominator Population 2 risk category -If NO, screen for next risk category Denominator Population 3: Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with a LDL-C result of 70 -189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period -If YES, meets Denominator Population 3 risk category -If NO, patient does NOT meet Denominator criteria and is NOT eligible for measure inclusion Denominator Guidance for Encounter: -In order for the patient to be included in the denominator, the patient must have ONE denominator-eligible visit, defined as follows: --Outpatient encounter visit type --Encounter, performed: initial or established office visit, face-to-face interaction, preventive care services, or annual wellness visit LDL-C Laboratory test result options: The measure can be reported for all patients with a documented fasting or direct LDL-C level recorded as follows: To meet Denominator Population 1: There is no LDL-C result required. To meet Denominator Population 2: If a patient has ANY previous fasting or direct laboratory result of LDL-C >= 190 mg/dL, report the highest value >= 190 mg/dL. To meet Denominator Population 3: If a patient has more than one LDL-C result during the measurement period or during the two years before the start of the measurement period, report the highest level recorded during either time. The Denominator Exception, "Patients with diabetes who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy" applies only to Denominator Population 3. Intensity of statin therapy in primary and secondary prevention: The expert panel of the 2013 ACC/AHA Guidelines (Stone et al., 2014) defines recommended intensity of statin therapy on the basis of the average expected LDL-C response to specific statin and dose. Although intensity of statin therapy is important in managing cholesterol, this measure assesses prescription of ANY statin therapy, irrespective of intensity. Assessment of appropriate intensity and dosage documentation added too much complexity to allow inclusion of statin therapy intensity in the measure at this time. Lifestyle modification coaching: A healthy lifestyle is important for the prevention of cardiovascular disease. However, lifestyle modification monitoring and documentation added too much complexity to allow its inclusion in the measure at this time. |
| MIPS Quality ID | 438 |
| Meaningful Measure | Management of Chronic Conditions |
| Telehealth Eligible | Yes |
| Next Version |
Data Element Repository
Header
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Updated eCQM version number.
Measure Section: eCQM Version number
Source of Change: Measure Lead
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated the rate aggregation statement to provide more specific instruction regarding the performance rate calculation.
Measure Section: Rate Aggregation
Source of Change: Measure Lead
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Updated the rationale to align with the most recent literature.
Measure Section: Rationale
Source of Change: Expert Work Group Review
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Updated references to align with American Psychological Association (APA) style.
Measure Section: Reference
Source of Change: Measure Lead
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Updated references.
Measure Section: Reference
Source of Change: Measure Lead
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Updated guidance statement to clarify the calculation of the performance rate is the weighted average of the three populations.
Measure Section: Guidance
Source of Change: Expert Work Group Review
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Updated denominator exceptions statement for 'Patients receiving palliative care' to 'Patients receiving palliative or hospice care' to align with the measure intent.
Measure Section: Denominator Exceptions
Source of Change: ONC Project Tracking System (JIRA): CQM-3022
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Updated parenthetical citations to align with American Psychological Association (APA) style.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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Modified the 'Has Diabetes' definition to use the 'overlaps' operator, instead of 'starts before end of.'
Measure Section: Definitions
Source of Change: Measure Lead
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Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.
Measure Section: Definitions and Functions
Source of Change: Standards Update
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Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).
Measure Section: Multiple Sections
Source of Change: Standards Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value set Moderate intensity statin therapy (2.16.840.1.113762.1.4.1047.98): Added 2 RxNorm codes (1790679, 1944264).
Measure Section: Terminology
Source of Change: Annual Update
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Value set Low intensity statin therapy (2.16.840.1.113762.1.4.1047.107): Added 2 RxNorm codes (1790679, 1944264).
Measure Section: Terminology
Source of Change: Annual Update
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Value set Outpatient Encounters for Preventive Care (2.16.840.1.113762.1.4.1047.9): Deleted 2 SNOMED CT codes (30346009, 37894004).
Measure Section: Terminology
Source of Change: Annual Update
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Value set Carotid Intervention (2.16.840.1.113883.3.117.1.7.1.204): Deleted 4 SNOMED CT codes (209760000, 25007007, 55493009, 75538004).
Measure Section: Terminology
Source of Change: Annual Update
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Value set CABG Surgeries (2.16.840.1.113883.3.666.5.694): Added 4 SNOMED CT codes (736970002, 736971003, 736972005, 736973000).
Measure Section: Terminology
Source of Change: Annual Update
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Value set Hepatitis A (2.16.840.1.113883.3.464.1003.110.12.1024): Added 5 SNOMED CT codes (105801000119103, 165997004, 278971009, 310875001, 428030001).
Measure Section: Terminology
Source of Change: Annual Update
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Value set Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Added 32 SNOMED CT codes and deleted 69 SNOMED CT codes.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Statin Allergen (2.16.840.1.113762.1.4.1110.42): Added Statin Allergen.
Measure Section: Terminology
Source of Change: Annual Update
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Value set LDL-c (2.16.840.1.113883.3.117.1.7.1.215): Added LDL-c.
Measure Section: Terminology
Source of Change: Annual Update
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Value set LDL Test (2.16.840.1.113883.3.464.1003.198.11.1029): Removed LDL Test.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Statin Allergen (2.16.840.1.113883.3.117.1.7.1.423): Removed Statin Allergen.
Measure Section: Terminology
Source of Change: Annual Update
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Changed the value set name from 'Palliative Care' to 'Palliative or Hospice Care' (2.16.840.1.113883.3.600.1.1579) to align with measure intent.
Measure Section: Terminology
Source of Change: ONC Project Tracking System (JIRA): CQM-3022
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Created Statin Allergen (2.16.840.1.113762.1.4.1110.41) with 1 SNOMED code (372912004) and combined with Statin Allergen (2.16.840.1.113883.3.117.1.7.1.423) to create the grouping value set Statin Allergen (2.16.840.1.113762.1.4.1110.42).
Measure Section: Terminology
Source of Change: Measure Lead
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Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.
Measure Section: Terminology
Source of Change: Annual Update
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Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001): Deleted three extensional value sets (2.16.840.1.113883.3.464.1003.103.11.1001 (ICD-9-CM), 2.16.840.1.113883.3.464.1003.103.11.1002 (ICD-10-CM), and 2.16.840.1.113883.3.464.1003.103.11.1003 (SNOMED CT)). Added eight extensional value sets (2.16.840.1.113883.3.464.1003.103.11.1025 (ICD-9-CM), 2.16.840.1.113883.3.464.1003.103.11.1026 (ICD-10-CM), 2.16.840.1.113883.3.464.1003.103.11.1027 (SNOMED CT), 2.16.840.1.113883.3.464.1003.103.11.1030 (SNOMED CT), 2.16.840.1.113883.3.464.1003.103.11.1031 (ICD-10-CM), 2.16.840.1.113883.3.464.1003.103.11.1032 (ICD-10-CM), 2.16.840.1.113883.3.464.1003.103.11.1033 (ICD-9-CM), 2.16.840.1.113883.3.464.1003.103.11.1034 (ICD-9-CM)).
Measure Section: Terminology
Source of Change: Measure Lead