eCQM Title

Controlling High Blood Pressure

eCQM Identifier (Measure Authoring Tool)

165

eCQM Version Number

10.0.000

NQF Number

Not Applicable

GUID

abdc37cc-bac6-4156-9b91-d1be2c8b7268

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 patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during 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) 2012-2020 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.

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

Intermediate Clinical Outcome

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

High blood pressure (HBP), also known as hypertension, is when the pressure in blood vessels is higher than normal (Centers for Disease Control and Prevention [CDC], 2020). The causes of hypertension are multiple and multifaceted and can be based on genetic predisposition, environmental risk factors, being overweight and obese, sodium intake, potassium intake, physical activity, and alcohol use. High blood pressure is common; according to the American Heart Association, between 2013-2016, approximately 116.4 million US adults >= 20 years of age had HBP and the prevalence of hypertension among US adults 65 and older was 78.2 percent (Benjamin et al, 2019).

HBP, known as the “silent killer,” increases risks of heart disease and stroke which are two of the leading causes of death in the U.S. (Yoon, Fryar, & Carroll, 2015). A person who has HBP is four times more likely to die from a stroke and three times more likely to die from heart disease (CDC, 2012). The National Vital Statistics Systems reported that in 2014 there were approximately 73,300 deaths directly due to HBP and 410,624 deaths with any mention of HBP (CDC, 2014). Between 2006 and 2016 the number of deaths due to HBP rose by 46.3 percent (Benjamin et al, 2019). . Managing and treating HBP would reduce cardiovascular disease mortality for males and females by 30.4 percent and 38.0 percent, respectively (Patel et al., 2015).

The estimated annual average direct and indirect cost of HBP from 2014 to 2015 was $55.9 billion (Benjamin et al, 2019). Total direct costs of HBP is projected to increase to $220.9 billion by 2035 (Benjamin et al, 2019). A study on cost-effectiveness on treating hypertension found that controlling HBP in patients with cardiovascular disease and systolic blood pressures of >= 160 mm Hg could be effective and cost-saving (Moran, 2015). 

Many studies have shown that controlling high blood pressure reduces cardiovascular events and mortality. The Systolic Blood Pressure Intervention Trial (SPRINT) investigated the impact of obtaining a SBP goal of <120 mm Hg compared to a SBP goal of <140 mm Hg among patients 50 and older with established cardiovascular disease and found that the patients with the former goal had reduced cardiovascular events and mortality (SPRINT Research Group et al., 2015). 

Controlling HBP will significantly reduce the risks of cardiovascular disease mortality and lead to better health outcomes like reduction of heart attacks, stroke, and kidney disease (James et al., 2014). Thus, the relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established.

Clinical Recommendation Statement

The U.S. Preventive Services Task Force (2015) recommends screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation.  

American College of Cardiology/American Heart Association (2017) 

-For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a blood pressure target of less than 130/80 mmHg is recommended (Level of evidence: B-R (for systolic blood pressures), Level of evidence: C-EO (for diastolic blood pressure)) 

-For adults with confirmed hypertension, without additional markers of increased CVD risk, a blood pressure target of less than 130/80 mmHg may be reasonable (Note: clinical trial evidence is strongest for a target blood pressure of 140/90 mmHg in this population. However, observational studies suggest that these individuals often have a high lifetime risk and would benefit from blood pressure control earlier in life) (Level of evidence: B-NR (for systolic blood pressure), Level of evidence: C-EO (for diastolic blood pressure)) 

American College of Physicians and the American Academy of Family Physicians (2017):   

-Initiate or intensify pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mmHg (Grade: weak recommendation, Quality of evidence: low) 

-Initiate or intensify pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mmHg to reduce the risk of recurrent stroke (Grade: weak recommendation, Quality of evidence: moderate) 

American Diabetes Association (2019): 

-For individuals with diabetes and hypertension at higher cardiovascular risk (existing atherosclerotic cardiovascular disease or 10-year atherosclerotic cardiovascular disease risk >15%), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained (Level of evidence: C)-For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year atherosclerotic cardiovascular disease risk <15%), treat to a blood pressure target of <140/90 mmHg (Level of evidence: A)

Improvement Notation

Higher score indicates better quality

Reference

Reference Type: CITATION

Reference Text: 'American Diabetes Association. (2019). 10. Cardiovascular disease and risk management: Standards of medical care in diabetes—2019. Diabetes Care, 42(Suppl. 1), S103-S123. https://doi.org/10.2337/dc19-S010'

Reference

Reference Type: CITATION

Reference Text: 'Benjamin EJ et al., Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation. 2019;139:e56–e528. DOI: 10.1161/CIR.0000000000000659'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. (2012). Vital signs: Getting blood pressure under control. Retrieved from https://www.cdc.gov/vitalsigns/hypertension/index.html'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention. (2020). Facts About Hypertension. Retrieved from https://www.cdc.gov/bloodpressure/facts.htm'

Reference

Reference Type: CITATION

Reference Text: 'Centers for Disease Control and Prevention, National Center for Health Statistics. Mortality multiple cause micro-data files, 2014: public-use data file and documentation: NHLBI tabulations. http://www.cdc.gov/nchs/data_access/Vitalstatsonline.htm#Mortality_Multiple.'

Reference

Reference Type: CITATION

Reference Text: 'Crim, M. T., Yoon, S. S., Ortiz, E., et al. (2012). National surveillance definitions for hypertension prevalence and control among adults. Circulation: Cardiovascular Quality and Outcomes. 2012, ;5(3), :343-–351. doi: 10.1161/ CIRCOUTCOMES.111.963439.'

Reference

Reference Type: CITATION

Reference Text: 'Moran, A. E., Odden, M. C., Thanataveerat, A., et al.Tzong KY, Rasmussen PW, Guzman D, Williams L, Bibbins-Domingo K, Coxson PG, Goldman L. (2015). Cost-effectiveness of hypertension therapy according to 2014 guidelines. [published correction appears in N Engl J. Med. 2015;372:1677]. New England Journal of Medicine. 2015 ;372, 447-455. doi: 10.1056/NEJMsa1406751. [published correction appears on page 1677]'

Reference

Reference Type: CITATION

Reference Text: 'Patel, S. A., Winkel, M., Ali, M. K., et al. (2015). Cardiovascular mortality associated with 5 leading risk factors: National and state preventable fractions estimated from survey data. Annals of Internal Medicine, 163(4), 245-253. doi: 10.7326/M14-1753'

Reference

Reference Type: CITATION

Reference Text: 'Qaseem, A., Wilt, T. J., Rich, R., et al. (2017). Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Annals of Internal Medicine, 166(6), 430-437. Retrieved from https://annals.org/aim/fullarticle/2598413/pharmacologic-treatment-hypertension-adults-aged-60-years-older-higher-versus'

Reference

Reference Type: CITATION

Reference Text: 'SPRINT Research Group, Wright, J. T., Jr., Williamson, J. D., et al. (2015). A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine, 373(22), 2103–2116.'

Reference

Reference Type: CITATION

Reference Text: 'U.S. Preventive Services Task Force. (2015). Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 163(10), 778-787. Retrieved from https://annals.org/aim/fullarticle/2456129/screening-high-blood-pressure-adults-u-s-preventive-services-task'

Reference

Reference Type: CITATION

Reference Text: 'Whelton, P. K., Carey, R. M., Aronow, W. S., et al. (2017). Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. https://doi.org/10.1161/HYP.0000000000000065'

Reference

Reference Type: CITATION

Reference Text: 'Yoon, S. S., Fryar, C. D., & Carroll, M. D. (2015). Hypertension prevalence and control among adults: United States, 2011-2014. NCHS Data Brief No. 220. Hyattsville, MD: National Center for Health Statistics.'

Reference

Reference Type: CITATION

Reference Text: 'Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the US by improvements in the use of clinical preventive services. Am J Prev Med. 2010;38:600-9. Retrieved from https://www.ajpmonline.org/article/S0749-3797(10)00207-2/fulltext'

Definition

None

Guidance

In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by a remote monitoring device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the remote monitoring device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record.

Do not include BP readings:
-Taken during an acute inpatient stay or an ED visit
-Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests.
-Taken by the patient using a non-digital device such as with a manual blood pressure cuff and a stethoscope.

If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."

If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.

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.

Transmission Format

TBD

Initial Population

Patients 18-85 years of age who had a visit and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period.

Denominator

Equals Initial Population

Denominator Exclusions

Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period.

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 81 and older with an indication of frailty for any part of the measurement period.

Exclude patients receiving palliative care during the measurement period.

Numerator

Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during 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 Birthdate": "Birth date"] BirthDate
  where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[18, 85 )
    and exists "Essential Hypertension Diagnosis"
    and ( exists AdultOutpatientEncounters."Qualifying Encounters"
        or exists ( ( ["Encounter, Performed": "Telephone Visits"]
            union ["Encounter, Performed": "Online Assessments"] ) Telehealth
            where Telehealth.relevantPeriod during "Measurement Period"
        )
    )

- Denominator
  - "Initial Population"

Denominator Exclusions

Hospice."Has Hospice"
  or exists ( "Pregnancy Or Renal Diagnosis Exclusions" )
  or exists ( "End Stage Renal Disease Procedures" )
  or exists ( "End Stage Renal Disease Encounter" )
  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 FrailtyLTI."Advanced Illness and Frailty Exclusion Including Over Age 80"
  or PalliativeCare."Palliative Care in the Measurement Period"

Numerator

"Has Diastolic Blood Pressure Less Than 90"
  and "Has Systolic Blood Pressure Less Than 140"

- 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"] ) ValidEncounter
  where ValidEncounter.relevantPeriod during "Measurement Period"

FrailtyLTI.Advanced Illness and Frailty Exclusion Including Over Age 80

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[65, 79])
      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"
      )
)
  or exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
      where ( Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 80 )
        and "Has Criteria Indicating Frailty"
  )

FrailtyLTI.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"]

FrailtyLTI.Has Criteria Indicating Frailty

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"
  )

FrailtyLTI.Has Long Term Care Periods Longer Than 90 Consecutive Days
- - "Max Long Term Care Period Length" > 90

FrailtyLTI.Inpatient Encounter with Advanced Illness

["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"

FrailtyLTI.Long Term Care Adjacent Periods

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]

FrailtyLTI.Long Term Care Overlapping Periods

collapse("Long Term Care Periods During Measurement Period")

FrailtyLTI.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"

FrailtyLTI.Max Long Term Care Period Length

Max((collapse("Long Term Care Overlapping Periods"
      union "Long Term Care Adjacent Periods"
  ))LTCPeriods
    return duration in days of LTCPeriods
)

FrailtyLTI.Outpatient Encounters with Advanced Illness

( ["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"

FrailtyLTI.Two Outpatient Encounters with Advanced Illness on Different Dates of Service

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

Blood Pressure Days

( "Qualifying Diastolic Blood Pressure Reading" DBPExam
    return date from Global."LatestOf" ( DBPExam.relevantDatetime, DBPExam.relevantPeriod )
)
  intersect ( "Qualifying Systolic Blood Pressure Reading" SBPExam
      return date from Global."LatestOf" ( SBPExam.relevantDatetime, SBPExam.relevantPeriod )
  )

Denominator
- - "Initial Population"

Denominator Exclusions

Hospice."Has Hospice"
  or exists ( "Pregnancy Or Renal Diagnosis Exclusions" )
  or exists ( "End Stage Renal Disease Procedures" )
  or exists ( "End Stage Renal Disease Encounter" )
  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 FrailtyLTI."Advanced Illness and Frailty Exclusion Including Over Age 80"
  or PalliativeCare."Palliative Care in the Measurement Period"

End Stage Renal Disease Encounter

["Encounter, Performed": "ESRD Monthly Outpatient Services"] ESRDEncounter
  where ESRDEncounter.relevantPeriod starts on or before 
  end of "Measurement Period"

End Stage Renal Disease Procedures

( ["Procedure, Performed": "Kidney Transplant"]
  union ["Procedure, Performed": "Dialysis Services"] ) ESRDProcedure
  where 
  end of Global."NormalizeInterval" ( ESRDProcedure.relevantDatetime, ESRDProcedure.relevantPeriod ) on or before 
  end of "Measurement Period"

Essential Hypertension Diagnosis

["Diagnosis": "Essential Hypertension"] Hypertension
  where Hypertension.prevalencePeriod overlaps Interval[start of "Measurement Period", start of "Measurement Period" + 6 months )

Has Diastolic Blood Pressure Less Than 90

"Lowest Diastolic Reading on Most Recent Blood Pressure Day".result < 90 'mm[Hg]'

Has Systolic Blood Pressure Less Than 140

"Lowest Systolic Reading on Most Recent Blood Pressure Day".result < 140 'mm[Hg]'

Hospice.Has Hospice

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"
  )

Initial Population

exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate
  where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) in Interval[18, 85 )
    and exists "Essential Hypertension Diagnosis"
    and ( exists AdultOutpatientEncounters."Qualifying Encounters"
        or exists ( ( ["Encounter, Performed": "Telephone Visits"]
            union ["Encounter, Performed": "Online Assessments"] ) Telehealth
            where Telehealth.relevantPeriod during "Measurement Period"
        )
    )

Lowest Diastolic Reading on Most Recent Blood Pressure Day

First("Qualifying Diastolic Blood Pressure Reading" DBPReading
    where Global."LatestOf"(DBPReading.relevantDatetime, DBPReading.relevantPeriod)same day as "Most Recent Blood Pressure Day"
    sort by(result as Quantity)
)

Lowest Systolic Reading on Most Recent Blood Pressure Day

First("Qualifying Systolic Blood Pressure Reading" SBPReading
    where Global."LatestOf"(SBPReading.relevantDatetime, SBPReading.relevantPeriod)same day as "Most Recent Blood Pressure Day"
    sort by(result as Quantity)
)

Most Recent Blood Pressure Day

Last("Blood Pressure Days" BPDays
    sort ascending
)

Numerator

"Has Diastolic Blood Pressure Less Than 90"
  and "Has Systolic Blood Pressure Less Than 140"

PalliativeCare.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 "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"
  )

Pregnancy Or Renal Diagnosis Exclusions

( ["Diagnosis": "Pregnancy"]
  union ["Diagnosis": "End Stage Renal Disease"]
  union ["Diagnosis": "Kidney Transplant Recipient"]
  union ["Diagnosis": "Chronic Kidney Disease, Stage 5"] ) PregnancyESRDDiagnosis
  where PregnancyESRDDiagnosis.prevalencePeriod overlaps "Measurement Period"

Qualifying Diastolic Blood Pressure Reading

["Physical Exam, Performed": "Diastolic blood pressure"] DiastolicBP
  without ( ["Encounter, Performed": "Encounter Inpatient"]
    union ["Encounter, Performed": "Emergency Department Visit"] ) DisqualifyingEncounter
    such that Global."LatestOf" ( DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod ) during DisqualifyingEncounter.relevantPeriod
  where DiastolicBP.result.unit = 'mm[Hg]'
    and Global."LatestOf" ( DiastolicBP.relevantDatetime, DiastolicBP.relevantPeriod ) during "Measurement Period"

Qualifying Systolic Blood Pressure Reading

["Physical Exam, Performed": "Systolic blood pressure"] SystolicBP
  without ( ["Encounter, Performed": "Encounter Inpatient"]
    union ["Encounter, Performed": "Emergency Department Visit"] ) DisqualifyingEncounter
    such that Global."LatestOf" ( SystolicBP.relevantDatetime, SystolicBP.relevantPeriod ) during DisqualifyingEncounter.relevantPeriod
  where SystolicBP.result.unit = 'mm[Hg]'
    and Global."LatestOf" ( SystolicBP.relevantDatetime, SystolicBP.relevantPeriod ) during "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.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)
- - years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.HasEnd(period Interval<DateTime>)

not ( 
  end of period is null
    or 
    end of period = maximum DateTime
)

Global.Latest(period Interval<DateTime>)

if ( HasEnd(period)) then 
end of period 
  else start of period

Global.LatestOf(pointInTime DateTime, period Interval<DateTime>)
- - Latest(NormalizeInterval(pointInTime, period))

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>

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

code "Birth date" ("LOINC Code (21112-8)")
code "Diastolic blood pressure" ("LOINC Code (8462-4)")
code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
code "Systolic blood pressure" ("LOINC Code (8480-6)")
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 "Care Services in Long-Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014)
valueset "Chronic Kidney Disease, Stage 5" (2.16.840.1.113883.3.526.3.1002)
valueset "Dementia Medications" (2.16.840.1.113883.3.464.1003.196.12.1510)
valueset "Dialysis Services" (2.16.840.1.113883.3.464.1003.109.12.1013)
valueset "Emergency Department 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 "End Stage Renal Disease" (2.16.840.1.113883.3.526.3.353)
valueset "ESRD Monthly Outpatient Services" (2.16.840.1.113883.3.464.1003.109.12.1014)
valueset "Essential Hypertension" (2.16.840.1.113883.3.464.1003.104.12.1011)
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 "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
valueset "Hospice care ambulatory" (2.16.840.1.113762.1.4.1108.15)
valueset "Kidney Transplant" (2.16.840.1.113883.3.464.1003.109.12.1012)
valueset "Kidney Transplant Recipient" (2.16.840.1.113883.3.464.1003.109.12.1029)
valueset "Nonacute Inpatient" (2.16.840.1.113883.3.464.1003.101.12.1084)
valueset "Nursing Facility Visit" (2.16.840.1.113883.3.464.1003.101.12.1012)
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 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 "Pregnancy" (2.16.840.1.113883.3.526.3.378)
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 "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)

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)"
"Device, Applied: Frailty Device" using "Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300)"
"Device, Order: Frailty Device" using "Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300)"
"Diagnosis: Chronic Kidney Disease, Stage 5" using "Chronic Kidney Disease, Stage 5 (2.16.840.1.113883.3.526.3.1002)"
"Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease (2.16.840.1.113883.3.526.3.353)"
"Diagnosis: Essential Hypertension" using "Essential Hypertension (2.16.840.1.113883.3.464.1003.104.12.1011)"
"Diagnosis: Frailty Diagnosis" using "Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074)"
"Diagnosis: Kidney Transplant Recipient" using "Kidney Transplant Recipient (2.16.840.1.113883.3.464.1003.109.12.1029)"
"Diagnosis: Pregnancy" using "Pregnancy (2.16.840.1.113883.3.526.3.378)"
"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: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department 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: ESRD Monthly Outpatient Services" using "ESRD Monthly Outpatient Services (2.16.840.1.113883.3.464.1003.109.12.1014)"
"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: Nonacute Inpatient" using "Nonacute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1084)"
"Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012)"
"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 (2.16.840.1.113762.1.4.1108.15)"
"Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15)"
"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 Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)"
"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: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"Physical Exam, Performed: Diastolic blood pressure" using "Diastolic blood pressure (LOINC Code 8462-4)"
"Physical Exam, Performed: Systolic blood pressure" using "Systolic blood pressure (LOINC Code 8480-6)"
"Procedure, Performed: Dialysis Services" using "Dialysis Services (2.16.840.1.113883.3.464.1003.109.12.1013)"
"Procedure, Performed: Kidney Transplant" using "Kidney Transplant (2.16.840.1.113883.3.464.1003.109.12.1012)"
"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