International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

eCQM Title	International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
eCQM Identifier (Measure Authoring Tool)	771	eCQM Version number	1.4.000
NQF Number	Not Applicable	GUID	1c05c6c0-8099-4270-83ce-292cf6e35c51
Measurement Period	January 1, 20XX through December 31, 20XX
Measure Steward	Large Urology Group Practice Association (LUGPA)
Measure Developer	Large Urology Group Practice Association (LUGPA)
Endorsed By	None
Description	Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points
Copyright	Limited proprietary coding is contained in the Measure specifications for user convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Large Urology Group Practice Association (LUGPA) and Oregon Urology Institute (OUI) disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2007- 2018. American Medical Association. LOINC(R) copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organisation. ICD-10 copyright 2018 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	Outcome
Stratification	None
Risk Adjustment	None
Rate Aggregation	None
Rationale	Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting older men, with a prevalence of 50% by age 60 years and 90% by the ninth decade of life (Medina, Parra, & Moore, 1999).The enlarged gland had been proposed to contribute to the overall lower urinary tract symptoms (LUTS) complex (McVary et al., 2014). Although LUTS secondary to BPH is not often a life-threatening condition, the impact of LUTS/BPH on quality of life can be significant (Wei, Calhoun, & Jacobsen, 2005). The American Urological Association Symptom Index (AUA-SI) and the International Prostate Symptom Score (IPSS) were developed to measure outcomes in studies of different treatments for BPH (Wuerstle et al., 2011). The IPSS uses the same questions as the AUA-SI, but also adds a disease-specific quality of life question (OLeary, 2005). The IPSS was adopted in 1993 by the World Health Organization. It is a reproducible, validated index designed to determine disease severity and response to therapy (D’Silva, Dahm, & Wong, 2014). It includes 3 storage symptom questions (frequency, nocturia, urgency) and four voiding symptoms (feeling of incomplete emptying, intermittency, straining, and a weak stream) as well as a Bother question: If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? A three-point improvement in the score is considered meaningful (McVary et al., 2014).
Clinical Recommendation Statement	The symptoms of BPH are LUTS symptoms. There are other disorders with similar symptoms and need to be excluded. History, physical examination, and testing are required prior to a diagnosis of BPH. IPSS by itself is not a reliable diagnostic tool for LUTS suggestive of BPH, but serves as a quantitative measure of LUTS after the diagnosis is established (D’Silva, Dahm, & Wong, 2014).Medical and surgical interventions for BPH recommend a follow up IPSS evaluation to determine effectiveness of treatment. IPSS should be evaluated at the time of diagnosis and after definitive treatment.
Improvement Notation	A meaningful improvement is a negative 3 point change in the urinary symptom score. The quality improves when a higher proportion of people meet the meaningful improvement definition.
Reference	D'Silva, K. A., Dahm, P., & Wong, C. L. (2014). Does this man with lower urinary tract symptoms have bladder outlet obstruction? The Rational Clinical Examination: A systematic review. Journal of the American Medical Association, 312(5), 535-542. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25096693
Reference	McVary, K. T., Roehrborn, C. G., Avins, A. L., et al. (2014). Management of benign prostatic hyperplasia . Retrieved from http://www.auanet.org/guidelines/benign-prostatic-hyperplasia-(2010-reviewed-and-validity-confirmed-2014)
Reference	Medina, J. J., Parra, R. O., & Moore, R. G. (1999). Benign prostatic hyperplasia (the aging prostate). Medical Clinics of North America, 83(5), 1213-1229. Retrieved from http://www.sciencedirect.com/science/article/pii/S0025712505701590
Reference	O’Leary, M. P. (2005). Validity of the Bother Score in the evaluation and treatment of symptomatic benign prostatic hyperplasia. Reviews in Urology, 7(1), 1-10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477553/
Reference	Wei, J., Calhoun, E., & Jacobsen, S. (2005). Urologic diseases in America project: Benign prostatic hyperplasia. Journal of Urology, 173(4), 1256-1261. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15758764
Reference	Wuerstle, M. C., Van Den Eeden, S. K., Poon, K. T., et al. (2011). Contribution of common medications to lower urinary tract symptoms in men. Archives of Internal Medicine, 171(18), 1680-1682. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21987200
Definition	Clinically significant Benign Prostatic Hyperplasia (BPH) is BPH with lower urinary tract symptoms (LUTS). IPSS - International Prostate Symptom Score AUA-SI - American Urological Association Symptom Index QOL - Quality of Life score
Guidance	The IPSS is inclusive of the symptom index score and the quality of life score. The AUA-SI is the symptom index score alone and must be added to the QOL score. The AUA-SI with the QOL equals the IPSS. Both of these are the urinary symptom score. The patient must have a urinary symptom score (USS) within 1 month after initial diagnosis. If more than one USS in the initial one month, then the first USS counts. The patient must have a USS again at 6-12 months after the initial diagnosis and if more than one USS in this time frame, then the last USS counts. Hospitalization within 30 days of Initial BPH Diagnosis refers to a 30 day period between the end of the hospitalization and the clinical office setting BPH diagnosis. This is due to aggravating factors from hospitalization, such as bed rest, medications, surgery, and altered body functions.
Transmission Format	TBD
Initial Population	Male patients with an initial diagnosis of benign prostatic hyperplasia 6 months prior to, or during the measurement period, and a urinary symptom score assessment within 1 month of initial diagnosis and a follow-up urinary symptom score assessment within 6-12 months, who had a qualifying visit during the measurement period.
Denominator	Equals initial population
Denominator Exclusions	Patients with urinary retention that starts within 1 year of initial BPH diagnosis Patients with an initial BPH diagnosis that starts during, or within 30 days of hospitalization Patients with a diagnosis of morbid obesity, or with a BMI Exam >40 before the follow up urinary symptom score.
Numerator	Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period
Numerator Exclusions	None
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

( "Patient is Male" )
	and exists ( "Qualifying Encounter" )
	and exists ( "Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period" )
	and "Urinary Symptom Score Within 1 Month after Initial BPH Diagnosis" is not null
	and "Urinary Symptom Score 6 to 12 Months After Initial BPH Diagnosis" is not null

- Denominator
  - "Initial Population"

Denominator Exclusions

exists ( "Urinary Retention Diagnosis Starts Within 1 Year After Initial BPH Diagnosis" )
	or exists ( "Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization" )
	or ( "Morbid Obesity Diagnosis or BMI Exam Result Greater Than 40 Starts On or Before Follow Up USS Assessment" )

Numerator

"Urinary Symptom Score Improvement Greater Than or Equal To 3"

- Numerator Exclusions
  - None
- Denominator Exceptions
  - None
- Stratification
  - None

Definitions

AUA Symptom Index and Quality of Life Assessment Result

from
	["Assessment, Performed": "American Urological Association Symptom Index [AUASI]"] AUASIAssessment,
	["Assessment, Performed": "If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that [IPSS]"] QOLAssessment
	let AUASIAssessmentresult: ( AUASIAssessment.result as Integer ) + ( QOLAssessment.result as Integer )
	where AUASIAssessment.authorDatetime same day as QOLAssessment.authorDatetime
		and AUASIAssessment.result is not null
		and QOLAssessment.result is not null
	return {
		authorDatetime: AUASIAssessment.authorDatetime,
		result: AUASIAssessmentresult
	}

BMI Exam Result Greater Than 40 During Measurement Period and On or Before Follow Up USS Assessment

["Physical Exam, Performed": "Estimated BMI greater than 40"] BMIExam
	with "Urinary Symptom Score 6 to 12 Months After Initial BPH Diagnosis" FollowUpUSSAssessment
		such that ( BMIExam.authorDatetime during "Measurement Period"
				and BMIExam.authorDatetime on or before FollowUpUSSAssessment.authorDatetime
		)
			and BMIExam.result > 40 'kg/m2'

Denominator
- - "Initial Population"

Denominator Exclusions

exists ( "Urinary Retention Diagnosis Starts Within 1 Year After Initial BPH Diagnosis" )
	or exists ( "Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization" )
	or ( "Morbid Obesity Diagnosis or BMI Exam Result Greater Than 40 Starts On or Before Follow Up USS Assessment" )

Documented IPSS Assessment Result

["Assessment, Performed": "International Prostate Symptom Score [IPSS]"] IPSSAssessment
	where IPSSAssessment.result is not null
	return {
		authorDatetime: ( IPSSAssessment.authorDatetime ),
		result: ( IPSSAssessment.result as Integer )
	}

Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization

"Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period" InitialBPHDiagnosis
	with ["Encounter, Performed": "Hospital Services for urology care"] InHospitalServices
		such that InitialBPHDiagnosis.prevalencePeriod starts during Interval[start of InHospitalServices.relevantPeriod, ( 
			end of InHospitalServices.relevantPeriod
		) + 31 days )

Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period

["Diagnosis": "Benign prostatic hyperplasia with lower urinary tract symptoms"] NewBPHDiagnosis
	where NewBPHDiagnosis.prevalencePeriod starts during Interval[start of "Measurement Period" - 6 months, 
	end of "Measurement Period"]

Initial Population

( "Patient is Male" )
	and exists ( "Qualifying Encounter" )
	and exists ( "Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period" )
	and "Urinary Symptom Score Within 1 Month after Initial BPH Diagnosis" is not null
	and "Urinary Symptom Score 6 to 12 Months After Initial BPH Diagnosis" is not null

Morbid Obesity Diagnosis On or Before Follow Up USS Assessment

["Diagnosis": "Morbid Obesity"] MorbidObesity
	with "Urinary Symptom Score 6 to 12 Months After Initial BPH Diagnosis" FollowUpUSSAssessment
		such that ( MorbidObesity.prevalencePeriod overlaps "Measurement Period"
				and MorbidObesity.authorDatetime on or before FollowUpUSSAssessment.authorDatetime
		)

Morbid Obesity Diagnosis or BMI Exam Result Greater Than 40 Starts On or Before Follow Up USS Assessment

exists "Morbid Obesity Diagnosis On or Before Follow Up USS Assessment"
	or exists "BMI Exam Result Greater Than 40 During Measurement Period and On or Before Follow Up USS Assessment"

Numerator

"Urinary Symptom Score Improvement Greater Than or Equal To 3"

Patient is Male

exists ["Patient Characteristic Sex": "Male"]

Qualifying Encounter

["Encounter, Performed": "Office Visit"] ValidEncounter
	where ValidEncounter.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"]

Urinary Retention Diagnosis Starts Within 1 Year After Initial BPH Diagnosis

["Diagnosis": "Urinary retention"] UrinaryRetention
	with "Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period" InitialBPHDiagnosis
		such that UrinaryRetention.prevalencePeriod starts 1 year or less on or after day of start of InitialBPHDiagnosis.prevalencePeriod

Urinary Symptom Score

"Documented IPSS Assessment Result"
	union "AUA Symptom Index and Quality of Life Assessment Result"

Urinary Symptom Score 6 to 12 Months After Initial BPH Diagnosis

Last("Urinary Symptom Score" LastUSSAssessment
		with "Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period" InitialBPHDiagnosis
			such that months between start of InitialBPHDiagnosis.prevalencePeriod and LastUSSAssessment.authorDatetime in Interval[6, 12]
		sort by authorDatetime
)

Urinary Symptom Score Improvement

from
	"Urinary Symptom Score Within 1 Month after Initial BPH Diagnosis" FirstUSSAssessment,
	"Urinary Symptom Score 6 to 12 Months After Initial BPH Diagnosis" FollowUpUSSAssessment
	let USSChange: FirstUSSAssessment.result - FollowUpUSSAssessment.result
	return USSChange

Urinary Symptom Score Improvement Greater Than or Equal To 3

( "Urinary Symptom Score Improvement" USSImprovement
		where USSImprovement >= 3
) is not null

Urinary Symptom Score Within 1 Month after Initial BPH Diagnosis

First("Urinary Symptom Score" InitialUSSAssessment
		with "Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period" InitialBPHDiagnosis
			such that InitialUSSAssessment.authorDatetime 1 month or less on or after day of start of InitialBPHDiagnosis.prevalencePeriod
		sort by authorDatetime
)

Functions

None

Terminology

code "American Urological Association Symptom Index [AUASI]" ("LOINC Code (80883-2)")
code "Benign prostatic hyperplasia with lower urinary tract symptoms" ("ICD10CM Code (N40.1)")
code "Estimated BMI greater than 40" ("LOINC Code (88087-2)")
code "If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that [IPSS]" ("LOINC Code (81090-3)")
code "International Prostate Symptom Score [IPSS]" ("LOINC Code (80976-4)")
code "Male" ("AdministrativeGender Code (M)")
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Hospital Services for urology care" (2.16.840.1.113762.1.4.1164.64)
valueset "Morbid Obesity" (2.16.840.1.113762.1.4.1164.65)
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 "Payer" (2.16.840.1.114222.4.11.3591)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Urinary retention" (2.16.840.1.113762.1.4.1164.52)

Data Criteria (QDM Data Elements)

"Diagnosis: Morbid Obesity" using "Morbid Obesity (2.16.840.1.113762.1.4.1164.65)"
"Diagnosis: Urinary retention" using "Urinary retention (2.16.840.1.113762.1.4.1164.52)"
"Encounter, Performed: Hospital Services for urology care" using "Hospital Services for urology care (2.16.840.1.113762.1.4.1164.64)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"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)"
"Assessment, Performed: American Urological Association Symptom Index [AUASI]" using "American Urological Association Symptom Index [AUASI] (LOINC Code 80883-2)"
"Assessment, Performed: If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that [IPSS]" using "If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that [IPSS] (LOINC Code 81090-3)"
"Assessment, Performed: International Prostate Symptom Score [IPSS]" using "International Prostate Symptom Score [IPSS] (LOINC Code 80976-4)"
"Diagnosis: Benign prostatic hyperplasia with lower urinary tract symptoms" using "Benign prostatic hyperplasia with lower urinary tract symptoms (ICD10CM Code N40.1)"
"Patient Characteristic Sex: Male" using "Male (AdministrativeGender Code M)"
"Physical Exam, Performed: Estimated BMI greater than 40" using "Estimated BMI greater than 40 (LOINC Code 88087-2)"

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