eCQM Title | Breast Cancer Screening |
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eCQM Identifier (Measure Authoring Tool) | 125 | eCQM Version Number | 10.0.000 |
NQF Number | Not Applicable | GUID | 19783c1b-4fd1-46c1-8a96-a2f192b97ee0 |
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 women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period |
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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) 2012-2020 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) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved. |
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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]. |
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Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification |
None |
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Risk Adjustment |
None |
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Rate Aggregation |
None |
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Rationale |
Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Noone et al, 2018). In 2015, over 3 million women were estimated to be living with breast cancer in the U.S. and it is estimated that 12 percent of women will be diagnosed with breast cancer at some point during their lifetime (Noone et al, 2018). While there are other factors that affect a woman's risk of developing breast cancer, advancing age is a primary risk factor. Breast cancer is most frequently diagnosed among women ages 55-64; the median age at diagnosis is 62 years (Noone et al, 2018). The chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 68; by age 50 it becomes 1 in 43; by age 60, it is 1 in 29 (American Cancer Society, 2017). |
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Clinical Recommendation Statement |
The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation). (USPSTF, 2016) The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years (C recommendation). (USPSTF, 2016) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older (I statement). (USPSTF, 2016) The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer (I Statement). (USPSTF, 2016) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (I statement). (USPSTF, 2016) |
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Improvement Notation |
Higher score equals better quality |
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Reference |
Reference Type: CITATION Reference Text: 'American Cancer Society. 2017. “Breast Cancer Facts & Figures 2017-2018.” (February 8, 2019). Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf' |
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Reference |
Reference Type: CITATION Reference Text: 'Noone, A.M., Howlader, N., Krapcho, M., Miller, D., Brest, A., Yu, M., Ruhl, J., Tatalovich, Z., Mariotto, A., Lewis, D.R., Chen, H.S., Feuer, E.J., Cronin, K.A. (eds). 2018. “SEER Cancer Statistics Review, 1975-2015.” National Cancer Institute. Bethesda, MD. (February 8, 2019) Retrieved from https://seer.cancer.gov/csr/1975_2015/' |
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Reference |
Reference Type: CITATION Reference Text: 'U.S. Preventive Services Task Force. (2016). Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 164(4), 279-296.' |
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Definition |
None |
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Guidance |
Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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Transmission Format |
TBD |
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Initial Population |
Women 51-74 years of age with a visit during the measurement period |
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Denominator |
Equals Initial Population |
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Denominator Exclusions |
Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following 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 receiving palliative care during the measurement period. |
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Numerator |
Women with one or more mammograms during the 27 months prior to the end of the measurement period |
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Numerator Exclusions |
Not Applicable |
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Denominator Exceptions |
None |
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Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
exists ( ["Patient Characteristic Sex": "Female"] ) and exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[51, 74 ) and exists ( AdultOutpatientEncounters."Qualifying Encounters" union "Telehealth Services" )
"Initial Population"
Hospice."Has Hospice" or ( ( exists ( "Right Mastectomy Diagnosis" ) or exists ( "Right Mastectomy Procedure" ) ) and ( exists ( "Left Mastectomy Diagnosis" ) or exists ( "Left Mastectomy Procedure" ) ) ) or exists "Bilateral Mastectomy Diagnosis" or exists "Bilateral Mastectomy Procedure" or FrailtyLTI."Advanced Illness and Frailty Exclusion Not Including Over Age 80" or ( exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 65 ) and FrailtyLTI."Has Long Term Care Periods Longer Than 90 Consecutive Days" ) or PalliativeCare."Palliative Care in the Measurement Period"
exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends 27 months or less on or before day of end of "Measurement Period" ) )
None
None
None
( ["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"] ) ValidEncounter where ValidEncounter.relevantPeriod during "Measurement Period"
exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 65 and "Has Criteria Indicating Frailty" and ( exists "Two Outpatient Encounters with Advanced Illness on Different Dates of Service" or exists ( "Inpatient Encounter with Advanced Illness" ) or exists "Dementia Medications In Year Before or During Measurement Period" ) )
["Medication, Active": "Dementia Medications"] DementiaMed where Global."NormalizeInterval"(DementiaMed.relevantDatetime, DementiaMed.relevantPeriod) overlaps Interval[( start of "Measurement Period" - 1 year ), end of "Measurement Period"]
exists ( ["Device, Order": "Frailty Device"] FrailtyDeviceOrder where FrailtyDeviceOrder.authorDatetime during "Measurement Period" ) or exists ( ["Device, Applied": "Frailty Device"] FrailtyDeviceApplied where Global."NormalizeInterval" ( FrailtyDeviceApplied.relevantDatetime, FrailtyDeviceApplied.relevantPeriod ) overlaps "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" )
"Max Long Term Care Period Length" > 90
["Encounter, Performed": "Acute Inpatient"] InpatientEncounter where exists ( InpatientEncounter.diagnoses Diagnosis where Diagnosis.code in "Advanced Illness" ) and InpatientEncounter.relevantPeriod starts 2 years or less on or before end of "Measurement Period"
from "Long Term Care Overlapping Periods" LTCPeriod1, "Long Term Care Overlapping Periods" LTCPeriod2 where end of LTCPeriod1 within 1 day of start of LTCPeriod2 return Interval[start of LTCPeriod1, end of LTCPeriod2]
collapse("Long Term Care Periods During Measurement Period")
( ["Encounter, Performed": "Care Services in Long-Term Residential Facility"] union ["Encounter, Performed": "Nursing Facility Visit"] ) LongTermFacilityEncounter where LongTermFacilityEncounter.relevantPeriod overlaps "Measurement Period" return LongTermFacilityEncounter.relevantPeriod intersect "Measurement Period"
Max((collapse("Long Term Care Overlapping Periods" union "Long Term Care Adjacent Periods" ))LTCPeriods return duration in days of LTCPeriods )
( ["Encounter, Performed": "Outpatient"] union ["Encounter, Performed": "Observation"] union ["Encounter, Performed": "Emergency Department Visit"] union ["Encounter, Performed": "Nonacute Inpatient"] ) OutpatientEncounter where exists ( OutpatientEncounter.diagnoses Diagnosis where Diagnosis.code in "Advanced Illness" ) and OutpatientEncounter.relevantPeriod starts 2 years or less on or before end of "Measurement Period"
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
["Diagnosis": "History of bilateral mastectomy"] BilateralMastectomyHistory where BilateralMastectomyHistory.prevalencePeriod starts on or before end of "Measurement Period"
["Procedure, Performed": "Bilateral Mastectomy"] BilateralMastectomyPerformed where Global."NormalizeInterval" ( BilateralMastectomyPerformed.relevantDatetime, BilateralMastectomyPerformed.relevantPeriod ) ends on or before end of "Measurement Period"
"Initial Population"
Hospice."Has Hospice" or ( ( exists ( "Right Mastectomy Diagnosis" ) or exists ( "Right Mastectomy Procedure" ) ) and ( exists ( "Left Mastectomy Diagnosis" ) or exists ( "Left Mastectomy Procedure" ) ) ) or exists "Bilateral Mastectomy Diagnosis" or exists "Bilateral Mastectomy Procedure" or FrailtyLTI."Advanced Illness and Frailty Exclusion Not Including Over Age 80" or ( exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 65 ) and FrailtyLTI."Has Long Term Care Periods Longer Than 90 Consecutive Days" ) or PalliativeCare."Palliative Care in the Measurement Period"
exists ( ["Encounter, Performed": "Encounter Inpatient"] DischargeHospice where ( DischargeHospice.dischargeDisposition ~ "Discharge to home for hospice care (procedure)" or DischargeHospice.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" ) and DischargeHospice.relevantPeriod ends during "Measurement Period" ) or exists ( ["Intervention, Order": "Hospice care ambulatory"] HospiceOrder where HospiceOrder.authorDatetime during "Measurement Period" ) or exists ( ["Intervention, Performed": "Hospice care ambulatory"] HospicePerformed where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period" )
exists ( ["Patient Characteristic Sex": "Female"] ) and exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[51, 74 ) and exists ( AdultOutpatientEncounters."Qualifying Encounters" union "Telehealth Services" )
( ["Diagnosis": "Status Post Left Mastectomy"] union ( ["Diagnosis": "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis where UnilateralMastectomyDiagnosis.anatomicalLocationSite ~ "Left (qualifier value)" ) ) LeftMastectomy where LeftMastectomy.prevalencePeriod starts on or before end of "Measurement Period"
["Procedure, Performed": "Unilateral Mastectomy Left"] UnilateralMastectomyLeftPerformed where Global."NormalizeInterval" ( UnilateralMastectomyLeftPerformed.relevantDatetime, UnilateralMastectomyLeftPerformed.relevantPeriod ) ends on or before end of "Measurement Period"
exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends 27 months or less on or before day of end of "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 "Measurement Period" ) or exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter where PalliativeEncounter.relevantPeriod overlaps "Measurement Period" ) or exists ( ["Intervention, Performed": "Palliative Care Intervention"] PalliativeIntervention where Global."NormalizeInterval"(PalliativeIntervention.relevantDatetime, PalliativeIntervention.relevantPeriod) overlaps "Measurement Period" )
( ["Diagnosis": "Status Post Right Mastectomy"] RightMastectomyProcedure union ( ["Diagnosis": "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis where UnilateralMastectomyDiagnosis.anatomicalLocationSite ~ "Right (qualifier value)" ) ) RightMastectomy where RightMastectomy.prevalencePeriod starts on or before end of "Measurement Period"
["Procedure, Performed": "Unilateral Mastectomy Right"] UnilateralMastectomyRightPerformed where Global."NormalizeInterval" ( UnilateralMastectomyRightPerformed.relevantDatetime, UnilateralMastectomyRightPerformed.relevantPeriod ) ends on or before end of "Measurement Period"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
( ["Encounter, Performed": "Online Assessments"] union ["Encounter, Performed": "Telephone Visits"] ) TelehealthEncounter where TelehealthEncounter.relevantPeriod during "Measurement Period"
years between ToDate(BirthDateTime)and ToDate(AsOf)
if pointInTime is not null then Interval[pointInTime, pointInTime] else if period is not null then period else null as Interval<DateTime>
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |
None |
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