eCQM Title

Appropriate Treatment for Upper Respiratory Infection (URI)

eCQM Identifier (Measure Authoring Tool)

154

eCQM Version Number

13.0.000

CBE Number

Not Applicable

GUID

e455fac0-f2cb-4074-a351-1e68a90fb7cf

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 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

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) 2012-2024 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 2024. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS restrictions apply to government use.

Some measure specifications contain coding from LOINC(R) (http://loinc.org). The LOINC table, LOINC codes, LOINC panels and form file, LOINC linguistic variants file, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright 2004-2024 Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee, and are available at no cost under the license at http://loinc.org/terms-of-use.

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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].

Measure Scoring

Proportion

Measure Type

Process

Stratification

- 3 months-17 years
- 18-64 years
- 65 years and older

Risk Adjustment

None

Rate Aggregation

None

Rationale

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).

Clinical Recommendation Statement

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.

Improvement Notation

Higher score indicates better quality

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2020). Be Antibiotics Aware: Smart Use, Best Care. Retrieved from https://www.cdc.gov/patientsafety/features/be-antibiotics-aware.html'

Reference

Reference Type: CITATION

Reference Text: 'Fashner, J., Ericson, K., & Werner, S. (2012). Treatment of the Common Cold in Children and Adults. American Family Physician, 86(2), 153-159.'

Reference

Reference Type: JUSTIFICATION

Reference Text: 'Harris, A.M., Hicks, L.A., & Qaseem, A. (2016.) Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 164(6),425-434.'

Reference

Reference Type: CITATION

Reference Text: 'Short, S., Bashir, H., Marshall, P., Miller, N., Olmschenk, D., Prigge, K., & Solyntjes, L. (2017). Institute for Clinical Systems Improvement. Diagnosis and Treatment of Respiratory Illness in Children and Adults. Updated September 2017. Retrieved from https://www.icsi.org/wp-content/uploads/2019/01/RespIllness.pdf.'

Definition

None

Guidance

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 eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission Format

TBD

Initial Population

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

Denominator Exclusions

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.

Numerator

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

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

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInMonthsAt(date from start of "Measurement Period") >= 3
  return EncounterWithURI

- Denominator
  - "Initial Population"

Denominator Exclusions

"Encounters and Assessments with Hospice Patient"
  union "Encounter with Comorbid Condition for Upper Respiratory Infection Prior"
  union "Encounter with Upper Respiratory Infection and Antibiotics Active In 30 Days Prior to the Episode Date"
  union "Encounter with Competing Diagnosis for Upper Respiratory Infection"

Numerator

"Encounter with Upper Respiratory Infection" EncounterWithURI
  without ["Medication, Order": "Antibiotic Medications for Upper Respiratory Infection"] OrderedAntibiotic
    such that OrderedAntibiotic.authorDatetime 3 days or less on or after start of EncounterWithURI.relevantPeriod
  return EncounterWithURI

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

Stratification 1

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInMonthsAt(date from start of "Measurement Period") >= 3
    and AgeInYearsAt(date from start of "Measurement Period") <= 17
  return EncounterWithURI

Stratification 2

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInYearsAt(date from start of "Measurement Period") in Interval[18, 64]
  return EncounterWithURI

Stratification 3

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInYearsAt(date from start of "Measurement Period") >= 65
  return EncounterWithURI

Definitions

Denominator
- - "Initial Population"

Denominator Exclusions

"Encounters and Assessments with Hospice Patient"
  union "Encounter with Comorbid Condition for Upper Respiratory Infection Prior"
  union "Encounter with Upper Respiratory Infection and Antibiotics Active In 30 Days Prior to the Episode Date"
  union "Encounter with Competing Diagnosis for Upper Respiratory Infection"

Encounter with Comorbid Condition for Upper Respiratory Infection Prior

( "Encounter with Upper Respiratory Infection" EncounterWithURI
    with ["Diagnosis": "Comorbid Conditions for Respiratory Conditions"] ComorbidCondition
      such that start of ComorbidCondition.prevalencePeriod in day of Interval[start of EncounterWithURI.relevantPeriod - 1 year, start of EncounterWithURI.relevantPeriod]
    return EncounterWithURI
)

Encounter with Competing Diagnosis for Upper Respiratory Infection

( "Encounter with Upper Respiratory Infection" EncounterWithURI
    with ( ["Diagnosis": "Competing Conditions for Respiratory Conditions"]
      union ["Diagnosis": "Acute Pharyngitis"]
      union ["Diagnosis": "Acute Tonsillitis"] ) CompetingDiagnosis
      such that CompetingDiagnosis.prevalencePeriod starts 3 days or less on or after day of start of EncounterWithURI.relevantPeriod
    return EncounterWithURI
)

Encounter with Upper Respiratory Infection

from
  "Qualifying Encounters" QualifyingEncounters,
  ["Diagnosis": "Upper Respiratory Infection"] URI
  where URI.prevalencePeriod starts during day of QualifyingEncounters.relevantPeriod
    or URI.prevalencePeriod overlaps before QualifyingEncounters.relevantPeriod
  return QualifyingEncounters

Encounter with Upper Respiratory Infection and Antibiotics Active In 30 Days Prior to the Episode Date

"Encounter with Upper Respiratory Infection" EncounterWithURI
  with ["Medication, Active": "Antibiotic Medications for Upper Respiratory Infection"] ActiveAntibiotic
    such that ( Global."NormalizeInterval" ( ActiveAntibiotic.relevantDatetime, ActiveAntibiotic.relevantPeriod ) overlaps day of Interval[start of EncounterWithURI.relevantPeriod - 30 days, start of EncounterWithURI.relevantPeriod - 1 day])
  return EncounterWithURI

Encounters and Assessments with Hospice Patient

"Initial Population" InitialPopulation
  where Hospice."Has Hospice Services"

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

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInMonthsAt(date from start of "Measurement Period") >= 3
  return EncounterWithURI

Numerator

"Encounter with Upper Respiratory Infection" EncounterWithURI
  without ["Medication, Order": "Antibiotic Medications for Upper Respiratory Infection"] OrderedAntibiotic
    such that OrderedAntibiotic.authorDatetime 3 days or less on or after start of EncounterWithURI.relevantPeriod
  return EncounterWithURI

Qualifying Encounters

( ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"]
  union ["Encounter, Performed": "Home Healthcare Services"]
  union ["Encounter, Performed": "Medical Disability Exam"]
  union ["Encounter, Performed": "Office Visit"]
  union ["Encounter, Performed": "Outpatient Consultation"]
  union ["Encounter, Performed": "Preventive Care Services Group Counseling"]
  union ["Encounter, Performed": "Preventive Care Services Individual Counseling"]
  union ["Encounter, Performed": "Preventive Care Services, Initial Office Visit, 0 to 17"]
  union ["Encounter, Performed": "Preventive Care, Established Office Visit, 0 to 17"]
  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": "Telephone Visits"]
  union ["Encounter, Performed": "Virtual Encounter"]
  union ["Encounter, Performed": "Unlisted preventive medicine service"] ) ValidEncounters
  where ValidEncounters.relevantPeriod ends during day of Interval[start of "Measurement Period", end of "Measurement Period" - 3 days]

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer Type"]

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

SDE Sex

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

Stratification 1

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInMonthsAt(date from start of "Measurement Period") >= 3
    and AgeInYearsAt(date from start of "Measurement Period") <= 17
  return EncounterWithURI

Stratification 2

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInYearsAt(date from start of "Measurement Period") in Interval[18, 64]
  return EncounterWithURI

Stratification 3

"Encounter with Upper Respiratory Infection" EncounterWithURI
  where AgeInYearsAt(date from start of "Measurement Period") >= 65
  return EncounterWithURI

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 "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
code "Unlisted preventive medicine service" ("CPT Code (99429)")
code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
valueset "Acute Pharyngitis" (2.16.840.1.113883.3.464.1003.102.12.1011)
valueset "Acute Tonsillitis" (2.16.840.1.113883.3.464.1003.102.12.1012)
valueset "Antibiotic Medications for Upper Respiratory Infection" (2.16.840.1.113883.3.464.1003.1190)
valueset "Comorbid Conditions for Respiratory Conditions" (2.16.840.1.113883.3.464.1003.102.12.1025)
valueset "Competing Conditions for Respiratory Conditions" (2.16.840.1.113883.3.464.1003.102.12.1017)
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 "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 "Medical Disability Exam" (2.16.840.1.113883.3.464.1003.101.12.1073)
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 "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
valueset "Payer Type" (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 Group Counseling" (2.16.840.1.113883.3.464.1003.101.12.1027)
valueset "Preventive Care Services Individual Counseling" (2.16.840.1.113883.3.464.1003.101.12.1026)
valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
valueset "Preventive Care Services, Initial Office Visit, 0 to 17" (2.16.840.1.113883.3.464.1003.101.12.1022)
valueset "Preventive Care, Established Office Visit, 0 to 17" (2.16.840.1.113883.3.464.1003.101.12.1024)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
valueset "Upper Respiratory Infection" (2.16.840.1.113883.3.464.1003.102.12.1022)
valueset "Virtual Encounter" (2.16.840.1.113883.3.464.1003.101.12.1089)

Data Criteria (QDM Data Elements)

"Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
"Diagnosis: Acute Pharyngitis" using "Acute Pharyngitis (2.16.840.1.113883.3.464.1003.102.12.1011)"
"Diagnosis: Acute Tonsillitis" using "Acute Tonsillitis (2.16.840.1.113883.3.464.1003.102.12.1012)"
"Diagnosis: Comorbid Conditions for Respiratory Conditions" using "Comorbid Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1025)"
"Diagnosis: Competing Conditions for Respiratory Conditions" using "Competing Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1017)"
"Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
"Diagnosis: Upper Respiratory Infection" using "Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.102.12.1022)"
"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: 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: Medical Disability Exam" using "Medical Disability Exam (2.16.840.1.113883.3.464.1003.101.12.1073)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
"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 Group Counseling" using "Preventive Care Services Group Counseling (2.16.840.1.113883.3.464.1003.101.12.1027)"
"Encounter, Performed: Preventive Care Services Individual Counseling" using "Preventive Care Services Individual Counseling (2.16.840.1.113883.3.464.1003.101.12.1026)"
"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: Preventive Care Services, Initial Office Visit, 0 to 17" using "Preventive Care Services, Initial Office Visit, 0 to 17 (2.16.840.1.113883.3.464.1003.101.12.1022)"
"Encounter, Performed: Preventive Care, Established Office Visit, 0 to 17" using "Preventive Care, Established Office Visit, 0 to 17 (2.16.840.1.113883.3.464.1003.101.12.1024)"
"Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
"Encounter, Performed: Unlisted preventive medicine service" using "Unlisted preventive medicine service (CPT Code 99429)"
"Encounter, Performed: Virtual Encounter" using "Virtual Encounter (2.16.840.1.113883.3.464.1003.101.12.1089)"
"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)"
"Medication, Active: Antibiotic Medications for Upper Respiratory Infection" using "Antibiotic Medications for Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.1190)"
"Medication, Order: Antibiotic Medications for Upper Respiratory Infection" using "Antibiotic Medications for Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.1190)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer Type" using "Payer Type (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)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer Type"]

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

SDE Sex

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

Risk Adjustment Variables

None

Measure Set

None