Brief Description of Measure:
CMS117: Childhood Immunization Status:
Percentage
of children 2 years of age who had four diphtheria, tetanus and
acellular pertussis (DTaP); three polio (IPV), one measles, mumps
and rubella (MMR); three or four H influenza type B (Hib); three
hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal
conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus
(RV); and two influenza (flu) vaccines by their second birthday
Description of Issue:
Currently, the measure contains numerator inclusion
criteria for
immunodeficiency, immunodeficiency, HIV, lymphoreticular
cancer, multiple myeloma or leukemia, and intussusception
before their second birthday. After reviewing our HEDIS MY22
measure, we decided this approach does not support the actual
intent of the measure and the desired measure calculation.
Therefore, NCQA is proposing moving the numerator inclusion
criteira to the denominator exclusions for children
that have severe
combined immunodeficiency, immunodeficiency, HIV, lymphoreticular
cancer, multiple myeloma or leukemia, and intussusception before
their second birthday.
Proposed Solution:
Current Denominator Exclusions header language:
Exclude
patients who are in hospice care for any part of the measurement
period.
Proposed Denominator Exclusions header langauge:
Exclude
children with any of the following on or before the child’s
second birthday:
•Severe combined
immunodeficiency.
•Immunodeficiency.
•HIV.
•Lymphoreticular
cancer, multiple myeloma or leukemia.
•Intussusception.
Exclude
children who are in hospice care for any part of the measurement
period.
Current Denominator Exclusions logic and affected
defintions:
Denominator Exclusions
Hospice."Has
Hospice"
Numerator
( exists ( "Four DTaP Vaccinations"
)
or exists ( "DTaP Numerator Inclusion
Conditions" ))
and ( exists ( "Three Polio
Vaccinations" )
or exists ( "Polio
Numerator Inclusion Conditions" ) )
and (
exists ( "One MMR Vaccination" )
or exists ( "MMR Numerator Inclusion Conditions" )
or ( exists ( "Measles Indicators" )
and exists ( "Mumps Indicators"
)
and exists ( "Rubella
Indicators" ) ) )
and ( "Has Appropriate
Number of Hib Immunizations"
or
exists ( "Hib Numerator Inclusion Conditions" )
)
and ( exists ( "Three Hepatitis B Vaccinations"
)
or exists ( "Hepatitis B
Numerator Inclusion Conditions" ) )
and (
exists ( "One Chicken Pox Vaccination" )
or exists ( "Varicella Zoster Numerator Inclusion
Conditions" ) )
and ( exists ( "Four
Pneumococcal Conjugate Vaccinations" )
or exists ( "Pneumococcal Conjugate Numerator Inclusion
Conditions" ) )
and ( exists ( "One
Hepatitis A Vaccinations" )
or
exists ( "Hepatitis A Numerator Inclusion Conditions" )
)
and ( "Has Appropriate Number of Rotavirus
Immunizations"
or exists (
"Rotavirus Numerator Inclusion Conditions" ) )
and ( exists ( "Two Influenza Vaccinations" )
or ( "Two Influenza Vaccinations Including One
LAIV Vaccination" )
or exists (
"Influenza Numerator Inclusion Conditions" ))
Influenza Numerator Inclusion Conditions
( ["Diagnosis":
"Adverse reaction to vaccine product containing Influenza
virus antigen (disorder)"]
union ["Diagnosis":
"Malignant Neoplasm of Lymphatic and Hematopoietic Tissue"]
union ["Diagnosis": "Neomycin adverse reaction
(disorder)"]
union ["Diagnosis":
"HIV"]
union ["Diagnosis":
"Disorders of the Immune System"] )
InfluenzaConditions
where start of
InfluenzaConditions.prevalencePeriod during "First Two Years"
MMR Numerator Inclusion Conditions
( ["Diagnosis":
"Disorders of the Immune System"]
union
["Diagnosis": "HIV"]
union
["Diagnosis": "Malignant Neoplasm of Lymphatic and
Hematopoietic Tissue"]
union ["Diagnosis":
"Neomycin adverse reaction (disorder)"] )
MMRConditions
where ( start of
MMRConditions.prevalencePeriod during
Interval[Patient.birthDatetime, "Date of Second Birthday"])
Rotavirus Numerator Inclusion Conditions
( ( ["Diagnosis":
"Anaphylaxis due to rotavirus vaccine (disorder)"]
union ["Diagnosis": "Severe Combined
Immunodeficiency"]
union ["Diagnosis":
"Intussusception"] ) RotavirusConditions
where start of RotavirusConditions.prevalencePeriod during "First
Two Years")
Varicella Zoster Numerator Inclusion
Conditions
( ( ["Laboratory Test, Performed":
"Varicella Zoster Antibody Test (IgG Antibody Titer)"]
ChickenPoxTiter
where ChickenPoxTiter.result >=
1.10)
union ( ["Laboratory Test, Performed":
"Varicella Zoster Antibody Test (IgG Antibody Presence)"]
ChickenPoxIgGPresence
where
ChickenPoxIgGPresence.result as Code in "Positive Finding"
)
union ( ["Diagnosis": "Disorders of
the Immune System"] ImmuneDisorder
return "Laboratory Test, Performed" { relevantDatetime:
start of ImmuneDisorder.prevalencePeriod } )
union ( ["Diagnosis": "HIV"] HIV
return "Laboratory Test, Performed" {
relevantDatetime: start of HIV.prevalencePeriod } )
union ( ["Diagnosis": "Malignant Neoplasm of
Lymphatic and Hematopoietic Tissue"]
LymphaticMalignantNeoplasm
return
"Laboratory Test, Performed" { relevantDatetime: start
of LymphaticMalignantNeoplasm.prevalencePeriod } )
union ( ["Diagnosis": "Neomycin adverse reaction
(disorder)"] NeomycinReaction
return "Laboratory Test, Performed" { relevantDatetime:
start of NeomycinReaction.prevalencePeriod } )
union ( ["Diagnosis": "Varicella Zoster"]
VaricellaZoster
return "Laboratory
Test, Performed" { relevantDatetime: start of
VaricellaZoster.prevalencePeriod } ) )
VaricellaZosterConditions
where
Global."NormalizeInterval" (
VaricellaZosterConditions.relevantDatetime,
VaricellaZosterConditions.relevantPeriod ) ends during "First
Two Years"
Proposed Denominator Exclusions logic and affected
defintions:
Denominator Exclusions:
Hospice."Has
Hospice Services"
or "Has Severe Combined
Immunodeficiency"
or "Has
Immunodeficiency"
or "Has HIV"
or "Has Lymphoreticular Cancer, Multiple Myeloma or
Leukemia"
or "Has Intussusception"
Has Severe Combined Immunodeficiency
(["Diagnosis":
"Severe Combined Immunodeficiency"])
SevereImmuneDisorder
where day of start of
SevereImmuneDisorder.prevalencePeriod during "First Two
Years"
Has Immunodeficiency
(["Diagnosis": "Disorders
of the Immune System"]) ImmuneDisorder
where day
of start of ImmuneDisorder.prevalencePeriod during "First
Two Years"
Has HIV
(["Diagnosis": "HIV"]) HIV
where day of start of HIV.prevalencePeriod during "First
Two Years"
Has Has Lymphoreticular Cancer, Multiple Myeloma or
Leukemia
(["Diagnosis": "Malignant Neoplasm of
Lymphatic and Hematopoietic Tissue"])
LymphaticMalignantNeoplasm
where day of start of
LymphaticMalignantNeoplasm.prevalencePeriod during "First Two
Years"
Has Intussusception
(["Diagnosis":
"Intussusception"]) IntussusceptionDisorder
where day of start of
IntussusceptionDisorder.prevalencePeriod during "First Two
Years"
Numerator
( exists ( "Four DTaP Vaccinations"
)
or exists ( "DTaP Numerator Inclusion
Conditions" ))
and ( exists ( "Three Polio
Vaccinations" )
or exists ( "Polio
Numerator Inclusion Conditions" ) )
and (
exists ( "One MMR Vaccination" )
or ( exists ( "Measles Indicators" )
and exists ( "Mumps Indicators" )
and exists ( "Rubella Indicators"
) ) )
and ( "Has Appropriate
Number of Hib Immunizations"
or
exists ( "Hib Numerator Inclusion Conditions" )
)
and ( exists ( "Three Hepatitis B Vaccinations"
)
or exists ( "Hepatitis B
Numerator Inclusion Conditions" ) )
and (
exists ( "One Chicken Pox Vaccination" )
or exists ( "Varicella Zoster Numerator Inclusion
Conditions" ) )
and ( exists ( "Four
Pneumococcal Conjugate Vaccinations" )
or exists ( "Pneumococcal Conjugate Numerator Inclusion
Conditions" ))
and ( exists ( "One Hepatitis
A Vaccinations" )
or exists (
"Hepatitis A Numerator Inclusion Conditions" ) )
and ( "Has Appropriate Number of Rotavirus Immunizations"
or exists ( "Rotavirus Numerator Inclusion
Conditions" ) )
and ( exists ( "Two
Influenza Vaccinations" )
or ( "Two
Influenza Vaccinations Including One LAIV Vaccination" ))
Rotavirus Numerator Inclusion Conditions
( ( ["Diagnosis":
"Anaphylaxis due to rotavirus vaccine (disorder)"] )
RotavirusConditions
where start of
RotavirusConditions.prevalencePeriod during "First Two
Years")
Varicella Zoster Numerator Inclusion Conditions
( (
["Laboratory Test, Performed": "Varicella Zoster
Antibody Test (IgG Antibody Titer)"] ChickenPoxTiter
where ChickenPoxTiter.result >= 1.10)
union
( ["Laboratory Test, Performed": "Varicella Zoster
Antibody Test (IgG Antibody Presence)"]
ChickenPoxIgGPresence
where
ChickenPoxIgGPresence.result as Code in "Positive Finding"
)
union ( ["Diagnosis": "Neomycin
adverse reaction (disorder)"] NeomycinReaction
return "Laboratory Test, Performed" {
relevantDatetime: start of NeomycinReaction.prevalencePeriod }
)
union ( ["Diagnosis": "Varicella
Zoster"] VaricellaZoster
return
"Laboratory Test, Performed" { relevantDatetime: start
of VaricellaZoster.prevalencePeriod } ) )
VaricellaZosterConditions
where
Global."NormalizeInterval" (
VaricellaZosterConditions.relevantDatetime,
VaricellaZosterConditions.relevantPeriod ) ends during "First
Two Years"
Rationale for Change:
We plan to move the numerator inclusion
criteria to denominator exclusions. We are moving
this criteria to exclude children that have
severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular
cancer, multiple myeloma or leukemia, and intussusception
before their second birthday. We believe it is more appropriate to
specify immunocompromising conditions as denominator exclusions,
rather than as numerator inclusion statements, as this measure is
intended to focus on routine vaccination for children. This change
also aligns with NCQA's HEDIS equivalent measure.
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