eCQM Title

Breast Cancer Screening

eCQM Identifier (Measure Authoring Tool)

125

eCQM Version Number

12.0.000

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

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.

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

Process

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

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).

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). 

The National Comprehensive Cancer Network (NCCN) and the American College of Radiology (ACR) recommend using conventional mammography or DBT for screening women at low, intermediate or high risk for breast cancer (NCCN, 2021) (ACR, 2017).

Improvement Notation

Higher score equals better quality

Reference

Reference Type: CITATION

Reference Text: 'American Cancer Society. (2017). Breast Cancer Facts & Figures 2017-2018. Retrieved February 8, 2019, 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'

Reference

Reference Type: CITATION

Reference Text: 'American College of Radiology (ACR). (2017). ACR Appropriateness Criteria: Breast Cancer Screening. Retrieved from https://acsearch.acr.org/docs/70910/Narrative/'

Reference

Reference Type: CITATION

Reference Text: 'National Comprehensive Cancer Network (NCCN). (2021). Breast Cancer Screening and Diagnosis. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf'

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. Retrieved February 8, 2019, from https://seer.cancer.gov/csr/1975_2015/'

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.'

Definition

None

Guidance

This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.

Please note the measure may include screenings performed outside the age range of patients referenced in the initial population. Screenings that occur prior to the measurement period are valid to meet measure criteria.

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

Women 52-74 years of age by the end of the measurement period with a visit during the measurement period

Denominator

Equals Initial Population

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 on or before the end of 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 and older 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 receiving palliative care for any part of the measurement period.

Numerator

Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of 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

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

exists ( ["Patient Characteristic Sex": "Female"] )
  and AgeInYearsAt(date from 
    end of "Measurement Period"
  )in Interval[52, 74]
  and exists AdultOutpatientEncounters."Qualifying Encounters"

- Denominator
  - "Initial Population"

Denominator Exclusions

Hospice."Has Hospice Services"
  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 AIFrailLTCF."Is Age 66 or Older with Advanced Illness and 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

exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
    where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period", 
      end of "Measurement Period"]
    )
)

- 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 or Older with Advanced Illness and Frailty

( AgeInYearsAt(date from 
    end of "Measurement Period"
  )>= 66
    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"
    )
)

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"]

Bilateral Mastectomy Diagnosis

["Diagnosis": "History of bilateral mastectomy"] BilateralMastectomyHistory
  where BilateralMastectomyHistory.prevalencePeriod starts on or before 
  end of "Measurement Period"

Bilateral Mastectomy Procedure

["Procedure, Performed": "Bilateral Mastectomy"] BilateralMastectomyPerformed
  where Global."NormalizeInterval" ( BilateralMastectomyPerformed.relevantDatetime, BilateralMastectomyPerformed.relevantPeriod ) ends on or before 
  end of "Measurement Period"

Denominator
- - "Initial Population"

Denominator Exclusions

Hospice."Has Hospice Services"
  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 AIFrailLTCF."Is Age 66 or Older with Advanced Illness and Frailty"
  or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"
  or PalliativeCare."Has Palliative Care in the Measurement Period"

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

exists ( ["Patient Characteristic Sex": "Female"] )
  and AgeInYearsAt(date from 
    end of "Measurement Period"
  )in Interval[52, 74]
  and exists AdultOutpatientEncounters."Qualifying Encounters"

Left Mastectomy Diagnosis

( ["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"

Left Mastectomy Procedure

["Procedure, Performed": "Unilateral Mastectomy Left"] UnilateralMastectomyLeftPerformed
  where Global."NormalizeInterval" ( UnilateralMastectomyLeftPerformed.relevantDatetime, UnilateralMastectomyLeftPerformed.relevantPeriod ) ends on or before 
  end of "Measurement Period"

Numerator

exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
    where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period", 
      end of "Measurement Period"]
    )
)

October 1 Two Years Prior to the Measurement Period

DateTime((year from start of "Measurement Period" - 2), 10, 1, 0, 0, 0, 0, 0)

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"
  )

Right Mastectomy Diagnosis

( ["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"

Right Mastectomy Procedure

["Procedure, Performed": "Unilateral Mastectomy Right"] UnilateralMastectomyRightPerformed
  where Global."NormalizeInterval" ( UnilateralMastectomyRightPerformed.relevantDatetime, UnilateralMastectomyRightPerformed.relevantPeriod ) ends on or before 
  end 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.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 "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
code "Female" ("AdministrativeGender Code (F)")
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 "Left (qualifier value)" ("SNOMEDCT Code (7771000)")
code "Lives in a nursing home (finding)" ("SNOMEDCT Code (160734000)")
code "Medical equipment used" ("LOINC Code (98181-1)")
code "Right (qualifier value)" ("SNOMEDCT Code (24028007)")
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 "Bilateral Mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1005)
valueset "Dementia Medications" (2.16.840.1.113883.3.464.1003.196.12.1510)
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 "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 "History of bilateral mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1068)
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 "Mammography" (2.16.840.1.113883.3.464.1003.108.12.1018)
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 "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 "Status Post Left Mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1069)
valueset "Status Post Right Mastectomy" (2.16.840.1.113883.3.464.1003.198.12.1070)
valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
valueset "Unilateral Mastectomy Left" (2.16.840.1.113883.3.464.1003.198.12.1133)
valueset "Unilateral Mastectomy Right" (2.16.840.1.113883.3.464.1003.198.12.1134)
valueset "Unilateral Mastectomy, Unspecified Laterality" (2.16.840.1.113883.3.464.1003.198.12.1071)

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: Frailty Diagnosis" using "Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074)"
"Diagnosis: History of bilateral mastectomy" using "History of bilateral mastectomy (2.16.840.1.113883.3.464.1003.198.12.1068)"
"Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
"Diagnosis: Palliative Care Diagnosis" using "Palliative Care Diagnosis (2.16.840.1.113883.3.464.1003.1167)"
"Diagnosis: Status Post Left Mastectomy" using "Status Post Left Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1069)"
"Diagnosis: Status Post Right Mastectomy" using "Status Post Right Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1070)"
"Diagnosis: Unilateral Mastectomy, Unspecified Laterality" using "Unilateral Mastectomy, Unspecified Laterality (2.16.840.1.113883.3.464.1003.198.12.1071)"
"Diagnostic Study, Performed: Mammography" using "Mammography (2.16.840.1.113883.3.464.1003.108.12.1018)"
"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: 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: Female" using "Female (AdministrativeGender Code F)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"Procedure, Performed: Bilateral Mastectomy" using "Bilateral Mastectomy (2.16.840.1.113883.3.464.1003.198.12.1005)"
"Procedure, Performed: Unilateral Mastectomy Left" using "Unilateral Mastectomy Left (2.16.840.1.113883.3.464.1003.198.12.1133)"
"Procedure, Performed: Unilateral Mastectomy Right" using "Unilateral Mastectomy Right (2.16.840.1.113883.3.464.1003.198.12.1134)"
"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