Quality Measure Implementation Guide
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Quality Measure Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-cqm/ and changes regularly. See the Directory of published versions

Measure: EXM146 - Appropriate Testing for Children with Pharyngitis (Experimental)

Official URL: http://hl7.org/fhir/uv/cqm/Measure/EXM146-FHIR Version: 4.0.0
Standards status: Informative Computable Name: EXM146
Other Identifiers: http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm#146 (use: official, ), OID:2.16.840.1.113883.4.642.40.61.29.7

Usage:Clinical Venue: EC

Copyright/Legal: Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. (c) 2008 -2014 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 CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.

Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.

This measure has been developed to support improvement in clinical care.

Metadata
Title EXM146 - Appropriate Testing for Children with Pharyngitis
Version 4.0.0
Identifier 146
Identifier urn:oid:2.16.840.1.113883.4.642.40.61.29.7
Effective Period 2018-01-01 through 2018-12-31
Approval Date 2016-01-01
Last Review Date 2016-09-01
Experimental true
Use Context Clinical Venue = EC
Jurisdiction Global (Whole world)
Topic Health Quality Measure Document
Steward (Publisher) HL7 International / Clinical Quality Information
Description

Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.

Purpose

This measure has been developed to support improvement in clinical care.

Copyright

Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. (c) 2008 -2014 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 CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 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 Basis Encounter
Measure Scoring Proportion
Measure Type Process
Rationale

Group A streptococcal bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (IDSA 2002). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005). A study on antibiotic treatment of children with sore throat found that although only 15 to 36 percent of children with sore throat have Strep A pharyngitis, physicians prescribed antibiotics to 53 percent of children with a chief complaint of sore throat between 1995 and 2003 (Linder et al. 2005).

Clinical Recommendation Statement

Institute for Clinical Systems Improvement (ICSI) (2007) Reduce unnecessary use of antibiotics. Antibiotic treatment should be reserved for a bacterial illness. Diagnosis of group A beta streptococcal Pharyngitis should be made by laboratory testing rather than clinically. Infectious Disease Society of America (Bisno et al. 2002) The signs and symptoms of group A streptococcal and other (most frequently viral) pharyngitides overlap broadly. Therefore, unless the physician is able with confidence to exclude the diagnosis of streptococcal pharyngitis on epidemiological and clinical grounds alone, a laboratory test should be done to determine whether group A streptococci are present in the pharynx. With the exception of very rare infections by certain other pharyngeal bacterial pathogens (eg, Corynebacterium diphtheriae and Neisseria gonorrhoeae), antimicrobial therapy is of no proven benefit as treatment for acute pharyngitis due to bacteria other than group A streptococci. Therefore, it is extremely important that physicians exclude the diagnosis of group A streptococcal pharyngitis to prevent inappropriate administration of antimicrobials to large numbers of patients with pharyngitis. Michigan Quality Improvement Consortium (2007) Probability of group A beta hemolytic streptococci (GABHS): Low; Testing: None; Treatment: Symptomatic treatment only. Avoid antibiotics. Probability of GABHS: Intermediate or High; Testing: Throat Culture (TC) OR Rapid Screen; Treatment: If TC is positive, use antibiotics. If TC is negative, use symptomatic treatment only. Avoid antibiotics. If treatment is started and culture result is negative, stop antibiotics. If Rapid Screen is positive, use antibiotics. If Rapid Screen is negative, culture (Culture is optional for age 16 and over) and only use antibiotics if throat culture is positive. (Michigan, 2007)

Improvement Notation Increased score indicates improvement
Measure Group (Rate) (ID: primary)
Initial Population ID: primary-exm146-initial-population
Description: No description provided Criteria: Initial Population
Numerator ID: primary-exm146-numerator
Description: No description provided Criteria: Numerator
Denominator ID: primary-exm146-denominator
Description: No description provided Criteria: Denominator
Denominator Exclusion ID: primary-exm146-denominator-exclusion
Description: No description provided Criteria: Denominator Exclusions
Measure Logic
Primary Library EXM146 - Example Proportion Measure Library
Contents Population Criteria
Logic Definitions
Terminology
Dependencies
Data Requirements
Population Criteria
Measure Group (Rate) (ID: primary)
Initial Population
define "Initial Population":
   "Pharyngitis Encounters With Antibiotics"
Definition
Numerator
define "Numerator":
   "Strep Test Encounters"
Definition
Denominator
define "Denominator":
   "Initial Population"
Definition
Denominator Exclusion
define "Denominator Exclusions":
  "Excluded Encounters"
Definition
Logic Definitions
Logic Definition Library Name: EXM146
define "Is Between 2 and 17 Years of Age at Start of Measurement Period":
   AgeInYearsAt(start of "Measurement Period") >= 2
      and AgeInYearsAt(start of "Measurement Period") <= 17
Logic Definition Library Name: EXM146
define "Measurement Period Encounters":
   [Encounter: "Ambulatory/ED Visit"] Encounter
      where Encounter.period during "Measurement Period"
        and Encounter.status = 'finished'
        and "Is Between 2 and 17 Years of Age at Start of Measurement Period"
Logic Definition Library Name: EXM146
define "Pharyngitis":
   ([Condition: code in "Acute Pharyngitis"]
     union [Condition: code in "Acute Tonsillitis"]) Pharyngitis
     where Pharyngitis.clinicalStatus ~ Global.active
       and Pharyngitis.verificationStatus ~ Global.confirmed
Logic Definition Library Name: EXM146
define "Antibiotics":
   [MedicationRequest: medication in "Antibiotic Medications"] Prescription
     where Prescription.status = 'active'
       and Prescription.intent = 'order'
Logic Definition Library Name: EXM146
define "Pharyngitis Encounters With Antibiotics":
   "Measurement Period Encounters" Encounters
      with "Pharyngitis" Pharyngitis such that
         Common."Includes Or Starts During"(Pharyngitis, Encounters)
      with "Antibiotics" Antibiotics such that Antibiotics.authoredOn
         3 days or less after FHIRHelpers.ToInterval(Encounters.period)
Logic Definition Library Name: EXM146
define "Strep Test Encounters":
   "Pharyngitis Encounters With Antibiotics" Encounters
      with [Observation: code in "Group A Streptococcus Test"] Tests
         such that Tests.value is not null
            and Tests.effective starts during
               Interval[start of FHIRHelpers.ToInterval(Encounters.period) - 3 days,
                 end of FHIRHelpers.ToInterval(Encounters.period) + 3 days]
Logic Definition Library Name: EXM146
define "Numerator":
   "Strep Test Encounters"
Logic Definition Library Name: EXM146
define "Initial Population":
   "Pharyngitis Encounters With Antibiotics"
Logic Definition Library Name: EXM146
define "Denominator":
   "Initial Population"
Logic Definition Library Name: EXM146
define "Pharyngitis With Prior Antibiotics":
   "Pharyngitis" Pharyngitis
      with "Antibiotics" Antibiotics such that
         Antibiotics.authoredOn 30 days or less before Pharyngitis.onset
Logic Definition Library Name: EXM146
define "Excluded Encounters":
   "Pharyngitis Encounters With Antibiotics" Encounters
      with "Pharyngitis With Prior Antibiotics" Pharyngitis such that
         Common."Includes Or Starts During"(Pharyngitis, Encounters)
Logic Definition Library Name: EXM146
define "Denominator Exclusions":
  "Excluded Encounters"
Logic Definition Library Name: Common
define function
   "Includes Or Starts During"(Condition Condition, Encounter Encounter):
      Interval[Condition.onset, Condition.abatement] includes Encounter.period
         or Condition.onset during Encounter.period
Logic Definition Library Name: FHIRHelpers
/*
@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
value to a CQL DateTime Interval
@comment: If the start value of the given period is unspecified, the starting
boundary of the resulting interval will be open (meaning the start of the interval
is unknown, as opposed to interpreted as the beginning of time).
*/
define function ToInterval(period FHIR.Period):
    if period is null then
        null
    else
        if period."start" is null then
            Interval(period."start".value, period."end".value]
        else
            Interval[period."start".value, period."end".value]
Logic Definition Library Name: FHIRHelpers
define function ToString(value EncounterStatus): value.value
Logic Definition Library Name: FHIRHelpers
/*
@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
*/
define function ToConcept(concept FHIR.CodeableConcept):
    if concept is null then
        null
    else
        System.Concept {
            codes: concept.coding C return ToCode(C),
            display: concept.text.value
        }
Logic Definition Library Name: FHIRHelpers
/*
@description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
*/
define function ToCode(coding FHIR.Coding):
    if coding is null then
        null
    else
        System.Code {
          code: coding.code.value,
          system: coding.system.value,
          version: coding.version.value,
          display: coding.display.value
        }
Logic Definition Library Name: FHIRHelpers
define function ToDateTime(value dateTime): value.value
Logic Definition Library Name: FHIRHelpers
define function ToString(value MedicationRequestStatus): value.value
Logic Definition Library Name: FHIRHelpers
define function ToString(value MedicationRequestIntent): value.value
Terminology
Code System Description: Code system ConditionClinicalStatusCodes
Resource: Condition Clinical Status Codes
Canonical URL: http://terminology.hl7.org/CodeSystem/condition-clinical
Code System Description: Code system ConditionVerificationStatusCodes
Resource: ConditionVerificationStatus
Canonical URL: http://terminology.hl7.org/CodeSystem/condition-ver-status
Value Set Description: Value set Ambulatory/ED Visit
Resource: Ambulatory/ED Visit
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061
Value Set Description: Value set Acute Pharyngitis
Resource: Acute Pharyngitis
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011
Value Set Description: Value set Acute Tonsillitis
Resource: Acute Tonsillitis
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012
Value Set Description: Value set Antibiotic Medications
Resource: Antibiotic Medications for Pharyngitis
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001
Value Set Description: Value set Group A Streptococcus Test
Resource: Group A Streptococcus Test
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012
Direct Reference Code Code: active
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Code: confirmed
System: http://terminology.hl7.org/CodeSystem/condition-ver-status
Dependencies
Dependency Description: Library FHIRHelpers
Resource: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
Dependency Description: Library Global
Resource: MAT Global Common Functions FHIR Libraryversion: null5.0.000)
Canonical URL: http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000
Dependency Description: Library Common
Resource: Common Libraryversion: null2.0.0)
Canonical URL: http://hl7.org/fhir/uv/cqm/Library/Common|2.0.0
Data Requirements
Data Requirement Type: Patient
Profile(s): Patient
Data Requirement Type: Encounter
Profile(s): Encounter
Must Support Elements: type, period, status
Code Filter(s):
Path: type
ValueSet: Ambulatory/ED Visit
Data Requirement Type: Condition
Profile(s): Condition
Must Support Elements: code, clinicalStatus, verificationStatus, onset
Code Filter(s):
Path: code
ValueSet: Acute Pharyngitis
Data Requirement Type: Condition
Profile(s): Condition
Must Support Elements: code, clinicalStatus, verificationStatus, onset
Code Filter(s):
Path: code
ValueSet: Acute Tonsillitis
Data Requirement Type: MedicationRequest
Profile(s): MedicationRequest
Must Support Elements: medication, status, intent, authoredOn
Code Filter(s):
Path: medication
ValueSet: Antibiotic Medications for Pharyngitis
Data Requirement Type: Observation
Profile(s): Observation
Must Support Elements: code, value, effective
Code Filter(s):
Path: code
ValueSet: Group A Streptococcus Test
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