Title: Depression Remission at Twelve MonthsFHIR Id: DepressionRemissionatTwelveMonthsFHIR Download cql: DepressionRemissionatTwelveMonthsFHIR.cql Version: 0.0.001 Url: Depression Remission at Twelve MonthsFHIR short-name identifier: CMS159FHIR version-independent identifier: urn:uuid:5df972fb-27e0-4b59-b5f8-b041e6ffc947 version-specific identifier: urn:uuid:2c928084808a9589018094b0efb804a6 endorser (NQF) identifier: 0710e publisher (CMS) identifier: 159FHIR Effective Period: 2024-01-01 ..2024-12-31 Status: draft Date: 2023-08-28 17:12:47+0000 Approval Date: 2023-08-28 Last Review Date: 2023-08-28 Name: DepressionRemissionatTwelveMonthsFHIR Publisher: MN Community Measurement Author: Telligen: https://www.telligen.com/ Description: The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event Use Context: code value program Purpose: UNKNOWN Copyright: Copyright MN Community Measurement, 2023. 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. Mathematica 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 2004-2022 American Medical Association. LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 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 MEASURES 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]. Rationale: Adults: Depression is a common and treatable mental disorder. During 2013-2016, 8.1% of American adults age 20 and over had depression in a given 2 week period. Women (10.4%) were almost twice as likely as men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increased. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Brody, Pratt, and Hughes, 2018). Depression is a risk factor for development of chronic illnesses such as diabetes and coronary heart disease and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression's negative effect on outcomes of chronic illness (Katon, 2011). Adolescents and Adults: The Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year (Pratt and Brody, 2014). Depression is associated with higher mortality rates in all age groups. Depression is also a leading cause of medical disability, and depressed people lose 5.6 hours of productive work every week when they are depressed, 50% of which is due to absenteeism and short-term disability (Stewart et al., 2003). Adolescents: In 2014, an estimated 2.8 million adolescents age 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year (Center for Behavioral Health Statistics and Quality, 2015). The 2013 Youth Risk Behavior Survey of students grades 9 to 12 indicated that during the past 12 months 39.1% (F) and 20.8% (M) indicated feeling sad or hopeless almost every day for at least 2 weeks, planned suicide attempt 16.9% (F) and 10.3% (M), with attempted suicide 10.6% (F) and 5.4% (M) (Kann et al., 2014). Adolescent-onset depression is associated with chronic depression in adulthood. Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors (Mojtabai, Olfson, and Han 2016). Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents (Mojtabai, Olfson, and Han 2016). Clinical recommendation statement: Adults: Recommendations and algorithm notations supporting depression outcomes and duration of treatment according to Institute for Clinical Systems Improvement Health Care Guideline (Trangle et al., 2016): Recommendation: Clinicians should establish and maintain follow-up with patients. Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse (Trangle et al., 2016). Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer et al., 2002). In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi et al., 2006; Unutzer et al., 2002). Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects. Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler et al., 2000; Simon et al., 2000). The Patient Health Questionnaire-9 (PHQ-9) is an effective monitoring and management tool, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy et al., 2008; Lowe et al., 2004). Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission. A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009). The goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function. If using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, 2001). Results from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush et al., 2006). Response and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission. In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology, 50% did so only at or after six weeks of treatment (Trivedi et al., 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission. This can take up to three months. This measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring. Adult Depression in Primary Care - Guideline Aims (Trangle et al., 2016): Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder. Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment. Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed). Adolescents: Recommendations supporting depression outcomes and duration of treatment according to American Academy of Child and Adolescent Psychiatry guideline (Birmaher et al., 2007): Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below). Each phase of treatment should include psychoeducation, supportive management, and family and school involvement. Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment. For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated. Recommendations supporting depression outcomes and duration of treatment according to Guidelines for Adolescent Depression in Primary Care (Zuckerbrot et al., 2018 (Part I), Zuckerbrot et al., 2018 (Part II)): Mild depression: consider a period of active support and monitoring before starting other evidence-based treatment Moderate or severe major clinical depression or complicating factors: -- consultation with mental health specialist with agreed upon roles -- evidence based treatment (cognitive behavioral therapy or interpersonal psychotherapy and/or antidepressant selective serotonin reuptake inhibitors) Monitor for adverse effects during antidepressant therapy -- clinical worsening, suicidality, unusual changes in behavior Systematic and regular tracking of goals and outcomes -- improvement in functioning status and resolution of depressive symptoms Regardless of the length of treatment, all patients should be monitored on a monthly basis for 6 to 12 months after the full resolution of symptoms. Guidance (Usage): When an index assessment is conducted with PHQ-9M, the follow-up assessment can use either a PHQ-9M or PHQ-9. This eCQM is a patient-based measure. This FHIR-based measure has been derived from the QDM-based measure: CMS159v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html). Population Criteria: 638501ed4ba3d47c885c02b0 Initial Population: Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event). Denominator: Equals Initial Population Denominator Exclusion: 1: Patients who died any time prior to the end of the measure assessment period 2: Patients who received hospice or palliative care services between the start of the denominator period and the end of the measurement assessment period 3: Patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period 4: Patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period 5: Patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period 6: Patients with a diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period Numerator: Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by the most recent twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five Numerator Exclusion: None Denominator Exception: None Stratifier Criteria: : Ages 12 to 17 at the time of the index assessment : Ages 18 and older at the time of the index assessment Supplemental Data Guidance : Supplemental Data Elements: SDE Ethnicity SDE Payer SDE Race SDE Sex Libraries: DepressionRemissionatTwelveMonthsFHIR Related Artifact Dependencies: Library/SupplementalDataElements|3.4.000 Library/FHIRHelpers|4.3.000 Library/QICoreCommon|1.5.000 Library/FHIRHelpers|4.3.000 Library/FHIRHelpers|4.3.000 Condition Clinical Status Codes ConditionVerificationStatus SNOMED CT (all versions) LOINC PHQ 9 and PHQ 9M Tools Contact or Office Visit Major Depression Including Remission Dysthymia Payer Encounter Inpatient Hospice Encounter Hospice Care Ambulatory Hospice Diagnosis Palliative Care Diagnosis Palliative Care Encounter Palliative Care Intervention Bipolar Disorder Personality Disorder Emotionally Labile Schizophrenia or Psychotic Disorder Pervasive Developmental Disorder Parameters: name use min max type Measurement Period In 0 1 Period SDE Sex Out 0 1 Coding Numerator Out 0 1 boolean Stratification 2 Out 0 1 boolean Stratification 1 Out 0 1 boolean Denominator Out 0 1 boolean SDE Payer Out 0 * Resource Initial Population Out 0 1 boolean SDE Ethnicity Out 0 1 Resource Denominator Exclusions Out 0 1 boolean SDE Race Out 0 1 Resource DataRequirements: Type Elements Valueset Name Valueset Patient(QICorePatient) Patient(http://hl7.org/fhir/Patient) gender gender.value birthDate birthDate.value deceased Patient(QICorePatient) Observation(QICoreObservation) code value status status.value effective PHQ 9 and PHQ 9M Tools PHQ 9 and PHQ 9M Tools Condition(http://hl7.org/fhir/Condition) clinicalStatus Condition(QICoreCondition) code Major Depression Including Remission Major Depression Including Remission Condition(QICoreCondition) code Dysthymia Dysthymia Encounter(QICoreEncounter) type period status status.value Contact or Office Visit Contact or Office Visit Observation(QICoreObservation) code value status status.value effective PHQ 9 and PHQ 9M Tools PHQ 9 and PHQ 9M Tools Observation(QICoreObservation) code effective status status.value PHQ 9 and PHQ 9M Tools PHQ 9 and PHQ 9M Tools Observation(http://hl7.org/fhir/Observation) value effective Patient(QICorePatient) Coverage(QICoreCoverage) type period Payer Type Payer uri(http://hl7.org/fhir/uri) value Patient(QICorePatient) url extension Patient(QICorePatient) url extension Encounter(QICoreEncounter) type hospitalization hospitalization.dischargeDisposition period status status.value Encounter Inpatient Encounter Inpatient Encounter(QICoreEncounter) type period status status.value Hospice Encounter Hospice Encounter Observation(QICoreObservation) code value effective status status.value ServiceRequest(QICoreServiceRequest) code authoredOn authoredOn.value status status.value intent intent.value Hospice Care Ambulatory Hospice Care Ambulatory Procedure(QICoreProcedure) code performed status status.value Hospice Care Ambulatory Hospice Care Ambulatory Condition(QICoreCondition) code verificationStatus Hospice Diagnosis Hospice Diagnosis Observation(QICoreObservation) code effective status status.value Condition(QICoreCondition) code verificationStatus Palliative Care Diagnosis Palliative Care Diagnosis Encounter(QICoreEncounter) type period status status.value Palliative Care Encounter Palliative Care Encounter Procedure(QICoreProcedure) code performed status status.value Palliative Care Intervention Palliative Care Intervention Condition(QICoreCondition) code Bipolar Disorder Bipolar Disorder Condition(QICoreCondition) code Personality Disorder Emotionally Labile Personality Disorder Emotionally Labile Condition(QICoreCondition) code Schizophrenia or Psychotic Disorder Schizophrenia or Psychotic Disorder Condition(QICoreCondition) code Pervasive Developmental Disorder Pervasive Developmental Disorder Patient(QICorePatient) url extension Patient(QICorePatient) url extension Coverage(QICoreCoverage) type period Payer Type Payer Patient(QICorePatient) url extension Patient(QICorePatient) url extension Direct Reference Codes: display code system active http://terminology.hl7.org/CodeSystem/condition-clinical recurrence http://terminology.hl7.org/CodeSystem/condition-clinical relapse http://terminology.hl7.org/CodeSystem/condition-clinical unconfirmed http://terminology.hl7.org/CodeSystem/condition-ver-status refuted http://terminology.hl7.org/CodeSystem/condition-ver-status entered-in-error http://terminology.hl7.org/CodeSystem/condition-ver-status Discharge to home for hospice care (procedure) 428361000124107 http://snomed.info/sct Discharge to healthcare facility for hospice care (procedure) 428371000124100 http://snomed.info/sct Hospice care [Minimum Data Set] 45755-6 http://loinc.org Yes (qualifier value) 373066001 http://snomed.info/sct Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) 71007-9 http://loinc.org Logic Definitions: Group Scoring Population Criteria Expression 638501ed4ba3d47c885c02b0 Group scoring: proportion Initial Population define "Initial Population": AgeInYearsAt(start of("Index Depression Assessment".effective.toInterval())) >= 12 Denominator define "Denominator": "Initial Population" Denominator Exclusion define "Denominator Exclusions": "Has Hospice Services in the Measure Assessment Period" or "Has Palliative Care in the Measure Assessment Period" or "Patient Expired" or "Has Mental Health Disorder Diagnoses" Numerator define "Numerator": Last([Observation: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment where ToDate(start of DepressionAssessment.effective.toInterval()) during "Measure Assessment Period" and DepressionAssessment.status in { 'final', 'amended', 'corrected' } sort by start of effective.toInterval() ).value < 5 Numerator Exclusion None Denominator Exception None Library Name Name SupplementalDataElements SDE Sex define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end Library Name Name DepressionRemissionatTwelveMonthsFHIR SDE Sex define "SDE Sex": SDE."SDE Sex" Library Name Name DepressionRemissionatTwelveMonthsFHIR Depression Assessments Greater than 9 define "Depression Assessments Greater than 9": [Observation: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment where DepressionAssessment.value > 9 and DepressionAssessment.status in { 'final', 'amended', 'corrected' } Library Name Name DepressionRemissionatTwelveMonthsFHIR Depression Diagnoses define "Depression Diagnoses": ( [Condition: "Major Depression Including Remission"] union [Condition: "Dysthymia"] ) Depression where Depression.isActive ( ) and not ( Depression.verificationStatus ~ QICoreCommon."unconfirmed" or Depression.verificationStatus ~ QICoreCommon."refuted" or Depression.verificationStatus ~ QICoreCommon."entered-in-error" ) Library Name Name DepressionRemissionatTwelveMonthsFHIR Denominator Identification Period define "Denominator Identification Period": Interval[start of "Measurement Period" - 14 months, start of "Measurement Period" - 2 months ) Library Name Name DepressionRemissionatTwelveMonthsFHIR Depression Encounter define "Depression Encounter": [Encounter: "Contact or Office Visit"] ValidEncounter with "Depression Diagnoses" Depression such that ValidEncounter.period overlaps Depression.prevalenceInterval ( ) and ValidEncounter.period ends during "Denominator Identification Period" and ValidEncounter.status = 'finished' Library Name Name DepressionRemissionatTwelveMonthsFHIR Index Depression Assessment define "Index Depression Assessment": First("Depression Assessments Greater than 9" DepressionAssessment with "Depression Encounter" DepressionEncounter such that DepressionAssessment.effective.toInterval() during day of Interval[ToDate((start of DepressionEncounter.period) - 7 days), end of DepressionEncounter.period] sort by start of effective.toInterval() ) Library Name Name DepressionRemissionatTwelveMonthsFHIR Measure Assessment Period define "Measure Assessment Period": "Index Depression Assessment" FirstIndexAssessment let YearAfterIndexAssessment: date from start of FirstIndexAssessment.effective.toInterval ( ) + 12 months return Interval[YearAfterIndexAssessment - 60 days, YearAfterIndexAssessment + 60 days] Library Name Name DepressionRemissionatTwelveMonthsFHIR Numerator define "Numerator": Last([Observation: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment where ToDate(start of DepressionAssessment.effective.toInterval()) during "Measure Assessment Period" and DepressionAssessment.status in { 'final', 'amended', 'corrected' } sort by start of effective.toInterval() ).value < 5 Library Name Name DepressionRemissionatTwelveMonthsFHIR Stratification 2 define "Stratification 2": "Index Depression Assessment" IndexAssessment return AgeInYearsAt(date from start of IndexAssessment.effective.toInterval()) >= 18 Library Name Name DepressionRemissionatTwelveMonthsFHIR Stratification 1 define "Stratification 1": "Index Depression Assessment" IndexAssessment return AgeInYearsAt(date from start of IndexAssessment.effective.toInterval()) in Interval[12, 17] Library Name Name DepressionRemissionatTwelveMonthsFHIR Initial Population define "Initial Population": AgeInYearsAt(start of("Index Depression Assessment".effective.toInterval())) >= 12 Library Name Name DepressionRemissionatTwelveMonthsFHIR Denominator define "Denominator": "Initial Population" Library Name Name SupplementalDataElements SDE Payer define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period } Library Name Name DepressionRemissionatTwelveMonthsFHIR SDE Payer define "SDE Payer": SDE."SDE Payer" Library Name Name SupplementalDataElements SDE Ethnicity define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text } Library Name Name DepressionRemissionatTwelveMonthsFHIR SDE Ethnicity define "SDE Ethnicity": SDE."SDE Ethnicity" Library Name Name DepressionRemissionatTwelveMonthsFHIR Has Hospice Services in the Measure Assessment Period define "Has Hospice Services in the Measure Assessment Period": exists ( [Encounter: "Encounter Inpatient"] InpatientEncounter where ( InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)" or InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" ) and InpatientEncounter.period ends during day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and InpatientEncounter.status = 'finished' ) or exists ( [Encounter: "Hospice Encounter"] HospiceEncounter where HospiceEncounter.period overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and not ( HospiceEncounter.status in { 'cancelled', 'entered-in-error', 'unknown' } ) ) or exists ( [Observation: "Hospice care [Minimum Data Set]"] HospiceAssessment where HospiceAssessment.value ~ "Yes (qualifier value)" and HospiceAssessment.effective.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and HospiceAssessment.status in { 'final', 'amended', 'corrected' } ) or exists ( [ServiceRequest: code in "Hospice Care Ambulatory"] HospiceOrder where HospiceOrder.authoredOn during day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and HospiceOrder.status in { 'active', 'completed' } and HospiceOrder.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' } ) or exists ( [Procedure: "Hospice Care Ambulatory"] HospicePerformed where HospicePerformed.performed.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and not ( HospicePerformed.status in { 'not-done', 'entered-in-error', 'unknown' } ) ) or exists ( [Condition: "Hospice Diagnosis"] HospiceCareDiagnosis where HospiceCareDiagnosis.prevalenceInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and HospiceCareDiagnosis.isActive ( ) and not ( HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."unconfirmed" or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."refuted" or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."entered-in-error" ) ) Library Name Name DepressionRemissionatTwelveMonthsFHIR Has Palliative Care in the Measure Assessment Period define "Has Palliative Care in the Measure Assessment Period": exists ( [Observation: "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment where PalliativeAssessment.effective.toInterval ( ) overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and PalliativeAssessment.status in { 'final', 'amended', 'corrected' } ) or exists ( [Condition: "Palliative Care Diagnosis"] PalliativeDiagnosis where PalliativeDiagnosis.prevalenceInterval ( ) overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and PalliativeDiagnosis.isActive ( ) and not ( PalliativeDiagnosis.verificationStatus ~ QICoreCommon."unconfirmed" or PalliativeDiagnosis.verificationStatus ~ QICoreCommon."refuted" or PalliativeDiagnosis.verificationStatus ~ QICoreCommon."entered-in-error" ) ) or exists ( [Encounter: "Palliative Care Encounter"] PalliativeEncounter where PalliativeEncounter.period overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and PalliativeEncounter.status = 'finished' ) or exists ( [Procedure: "Palliative Care Intervention"] PalliativeIntervention where PalliativeIntervention.performed.toInterval ( ) overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and not ( PalliativeIntervention.status in { 'not-done', 'entered-in-error', 'unknown' } ) ) Library Name Name DepressionRemissionatTwelveMonthsFHIR Patient Expired define "Patient Expired": Patient.deceased on or before end of "Measure Assessment Period" Library Name Name DepressionRemissionatTwelveMonthsFHIR Has Mental Health Disorder Diagnoses define "Has Mental Health Disorder Diagnoses": exists ( ( [Condition: "Bipolar Disorder"] union [Condition: "Personality Disorder Emotionally Labile"] union [Condition: "Schizophrenia or Psychotic Disorder"] union [Condition: "Pervasive Developmental Disorder"] ) MentalHealthDisorderDiagnoses where ToDate(start of MentalHealthDisorderDiagnoses.prevalenceInterval()) on or before end of "Measure Assessment Period" and MentalHealthDisorderDiagnoses.isActive ( ) and not ( MentalHealthDisorderDiagnoses.verificationStatus ~ QICoreCommon."unconfirmed" or MentalHealthDisorderDiagnoses.verificationStatus ~ QICoreCommon."refuted" or MentalHealthDisorderDiagnoses.verificationStatus ~ QICoreCommon."entered-in-error" ) ) Library Name Name DepressionRemissionatTwelveMonthsFHIR Denominator Exclusions define "Denominator Exclusions": "Has Hospice Services in the Measure Assessment Period" or "Has Palliative Care in the Measure Assessment Period" or "Patient Expired" or "Has Mental Health Disorder Diagnoses" Library Name Name SupplementalDataElements SDE Race define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text } Library Name Name DepressionRemissionatTwelveMonthsFHIR SDE Race define "SDE Race": SDE."SDE Race"
Discharge to home for hospice care (procedure)
Discharge to healthcare facility for hospice care (procedure)
Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)
define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end
define "Depression Assessments Greater than 9": [Observation: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment where DepressionAssessment.value > 9 and DepressionAssessment.status in { 'final', 'amended', 'corrected' }
define "Depression Diagnoses": ( [Condition: "Major Depression Including Remission"] union [Condition: "Dysthymia"] ) Depression where Depression.isActive ( ) and not ( Depression.verificationStatus ~ QICoreCommon."unconfirmed" or Depression.verificationStatus ~ QICoreCommon."refuted" or Depression.verificationStatus ~ QICoreCommon."entered-in-error" )
define "Denominator Identification Period": Interval[start of "Measurement Period" - 14 months, start of "Measurement Period" - 2 months )
define "Depression Encounter": [Encounter: "Contact or Office Visit"] ValidEncounter with "Depression Diagnoses" Depression such that ValidEncounter.period overlaps Depression.prevalenceInterval ( ) and ValidEncounter.period ends during "Denominator Identification Period" and ValidEncounter.status = 'finished'
define "Index Depression Assessment": First("Depression Assessments Greater than 9" DepressionAssessment with "Depression Encounter" DepressionEncounter such that DepressionAssessment.effective.toInterval() during day of Interval[ToDate((start of DepressionEncounter.period) - 7 days), end of DepressionEncounter.period] sort by start of effective.toInterval() )
define "Measure Assessment Period": "Index Depression Assessment" FirstIndexAssessment let YearAfterIndexAssessment: date from start of FirstIndexAssessment.effective.toInterval ( ) + 12 months return Interval[YearAfterIndexAssessment - 60 days, YearAfterIndexAssessment + 60 days]
define "Numerator": Last([Observation: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment where ToDate(start of DepressionAssessment.effective.toInterval()) during "Measure Assessment Period" and DepressionAssessment.status in { 'final', 'amended', 'corrected' } sort by start of effective.toInterval() ).value < 5
define "Stratification 2": "Index Depression Assessment" IndexAssessment return AgeInYearsAt(date from start of IndexAssessment.effective.toInterval()) >= 18
define "Stratification 1": "Index Depression Assessment" IndexAssessment return AgeInYearsAt(date from start of IndexAssessment.effective.toInterval()) in Interval[12, 17]
define "Initial Population": AgeInYearsAt(start of("Index Depression Assessment".effective.toInterval())) >= 12
define "Denominator": "Initial Population"
define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period }
define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text }
define "SDE Ethnicity": SDE."SDE Ethnicity"
Has Hospice Services in the Measure Assessment Period
define "Has Hospice Services in the Measure Assessment Period": exists ( [Encounter: "Encounter Inpatient"] InpatientEncounter where ( InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)" or InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" ) and InpatientEncounter.period ends during day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and InpatientEncounter.status = 'finished' ) or exists ( [Encounter: "Hospice Encounter"] HospiceEncounter where HospiceEncounter.period overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and not ( HospiceEncounter.status in { 'cancelled', 'entered-in-error', 'unknown' } ) ) or exists ( [Observation: "Hospice care [Minimum Data Set]"] HospiceAssessment where HospiceAssessment.value ~ "Yes (qualifier value)" and HospiceAssessment.effective.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and HospiceAssessment.status in { 'final', 'amended', 'corrected' } ) or exists ( [ServiceRequest: code in "Hospice Care Ambulatory"] HospiceOrder where HospiceOrder.authoredOn during day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and HospiceOrder.status in { 'active', 'completed' } and HospiceOrder.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' } ) or exists ( [Procedure: "Hospice Care Ambulatory"] HospicePerformed where HospicePerformed.performed.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and not ( HospicePerformed.status in { 'not-done', 'entered-in-error', 'unknown' } ) ) or exists ( [Condition: "Hospice Diagnosis"] HospiceCareDiagnosis where HospiceCareDiagnosis.prevalenceInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and HospiceCareDiagnosis.isActive ( ) and not ( HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."unconfirmed" or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."refuted" or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."entered-in-error" ) )
Has Palliative Care in the Measure Assessment Period
define "Has Palliative Care in the Measure Assessment Period": exists ( [Observation: "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment where PalliativeAssessment.effective.toInterval ( ) overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and PalliativeAssessment.status in { 'final', 'amended', 'corrected' } ) or exists ( [Condition: "Palliative Care Diagnosis"] PalliativeDiagnosis where PalliativeDiagnosis.prevalenceInterval ( ) overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and PalliativeDiagnosis.isActive ( ) and not ( PalliativeDiagnosis.verificationStatus ~ QICoreCommon."unconfirmed" or PalliativeDiagnosis.verificationStatus ~ QICoreCommon."refuted" or PalliativeDiagnosis.verificationStatus ~ QICoreCommon."entered-in-error" ) ) or exists ( [Encounter: "Palliative Care Encounter"] PalliativeEncounter where PalliativeEncounter.period overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and PalliativeEncounter.status = 'finished' ) or exists ( [Procedure: "Palliative Care Intervention"] PalliativeIntervention where PalliativeIntervention.performed.toInterval ( ) overlaps Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"] and not ( PalliativeIntervention.status in { 'not-done', 'entered-in-error', 'unknown' } ) )
define "Patient Expired": Patient.deceased on or before end of "Measure Assessment Period"
define "Has Mental Health Disorder Diagnoses": exists ( ( [Condition: "Bipolar Disorder"] union [Condition: "Personality Disorder Emotionally Labile"] union [Condition: "Schizophrenia or Psychotic Disorder"] union [Condition: "Pervasive Developmental Disorder"] ) MentalHealthDisorderDiagnoses where ToDate(start of MentalHealthDisorderDiagnoses.prevalenceInterval()) on or before end of "Measure Assessment Period" and MentalHealthDisorderDiagnoses.isActive ( ) and not ( MentalHealthDisorderDiagnoses.verificationStatus ~ QICoreCommon."unconfirmed" or MentalHealthDisorderDiagnoses.verificationStatus ~ QICoreCommon."refuted" or MentalHealthDisorderDiagnoses.verificationStatus ~ QICoreCommon."entered-in-error" ) )
define "Denominator Exclusions": "Has Hospice Services in the Measure Assessment Period" or "Has Palliative Care in the Measure Assessment Period" or "Patient Expired" or "Has Mental Health Disorder Diagnoses"
define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text }
Code system ConditionClinicalStatusCodes
Code system ConditionVerificationStatusCodes
Value set Major Depression Including Remission
Value set Personality Disorder Emotionally Labile
Value set Schizophrenia or Psychotic Disorder
Value set Pervasive Developmental Disorder
Depression Remission at Twelve MonthsFHIR
The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event
When an index assessment is conducted with PHQ-9M, the follow-up assessment can use either a PHQ-9M or PHQ-9. This eCQM is a patient-based measure. This FHIR-based measure has been derived from the QDM-based measure: CMS159v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).
Copyright MN Community Measurement, 2023. 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. Mathematica 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 2004-2022 American Medical Association. LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.
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 MEASURES 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].
Adults: Depression is a common and treatable mental disorder. During 2013-2016, 8.1% of American adults age 20 and over had depression in a given 2 week period. Women (10.4%) were almost twice as likely as men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increased. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Brody, Pratt, and Hughes, 2018). Depression is a risk factor for development of chronic illnesses such as diabetes and coronary heart disease and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression's negative effect on outcomes of chronic illness (Katon, 2011). Adolescents and Adults: The Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year (Pratt and Brody, 2014). Depression is associated with higher mortality rates in all age groups. Depression is also a leading cause of medical disability, and depressed people lose 5.6 hours of productive work every week when they are depressed, 50% of which is due to absenteeism and short-term disability (Stewart et al., 2003). Adolescents: In 2014, an estimated 2.8 million adolescents age 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year (Center for Behavioral Health Statistics and Quality, 2015). The 2013 Youth Risk Behavior Survey of students grades 9 to 12 indicated that during the past 12 months 39.1% (F) and 20.8% (M) indicated feeling sad or hopeless almost every day for at least 2 weeks, planned suicide attempt 16.9% (F) and 10.3% (M), with attempted suicide 10.6% (F) and 5.4% (M) (Kann et al., 2014). Adolescent-onset depression is associated with chronic depression in adulthood. Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors (Mojtabai, Olfson, and Han 2016). Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents (Mojtabai, Olfson, and Han 2016).
Adults: Recommendations and algorithm notations supporting depression outcomes and duration of treatment according to Institute for Clinical Systems Improvement Health Care Guideline (Trangle et al., 2016): Recommendation: Clinicians should establish and maintain follow-up with patients. Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse (Trangle et al., 2016). Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer et al., 2002). In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi et al., 2006; Unutzer et al., 2002). Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects. Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler et al., 2000; Simon et al., 2000). The Patient Health Questionnaire-9 (PHQ-9) is an effective monitoring and management tool, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy et al., 2008; Lowe et al., 2004). Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission. A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009). The goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function. If using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, 2001). Results from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush et al., 2006). Response and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission. In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology, 50% did so only at or after six weeks of treatment (Trivedi et al., 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission. This can take up to three months. This measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring. Adult Depression in Primary Care - Guideline Aims (Trangle et al., 2016): - Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder. - Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment. - Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed). Adolescents: Recommendations supporting depression outcomes and duration of treatment according to American Academy of Child and Adolescent Psychiatry guideline (Birmaher et al., 2007): - Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below). - Each phase of treatment should include psychoeducation, supportive management, and family and school involvement. - Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment. - For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated. Recommendations supporting depression outcomes and duration of treatment according to Guidelines for Adolescent Depression in Primary Care (Zuckerbrot et al., 2018 (Part I), Zuckerbrot et al., 2018 (Part II)): - Mild depression: consider a period of active support and monitoring before starting other evidence-based treatment - Moderate or severe major clinical depression or complicating factors: -- consultation with mental health specialist with agreed upon roles -- evidence based treatment (cognitive behavioral therapy or interpersonal psychotherapy and/or antidepressant selective serotonin reuptake inhibitors) - Monitor for adverse effects during antidepressant therapy -- clinical worsening, suicidality, unusual changes in behavior - Systematic and regular tracking of goals and outcomes -- improvement in functioning status and resolution of depressive symptoms Regardless of the length of treatment, all patients should be monitored on a monthly basis for 6 to 12 months after the full resolution of symptoms.
Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event).
1: Patients who died any time prior to the end of the measure assessment period 2: Patients who received hospice or palliative care services between the start of the denominator period and the end of the measurement assessment period 3: Patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period 4: Patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period 5: Patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period 6: Patients with a diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period
Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by the most recent twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five
Ages 12 to 17 at the time of the index assessment
Ages 18 and older at the time of the index assessment