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 Generated using version 0.4.9 of the sample-content-ig Liquid templates
Is Between 2 and 17 Years of Age at Start of Measurement Period
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
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"
define "Pharyngitis": ([Condition: code in "Acute Pharyngitis"] union [Condition: code in "Acute Tonsillitis"]) Pharyngitis where Pharyngitis.clinicalStatus ~ Global.active and Pharyngitis.verificationStatus ~ Global.confirmed
define "Antibiotics": [MedicationRequest: medication in "Antibiotic Medications"] Prescription where Prescription.status = 'active' and Prescription.intent = 'order'
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)
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]
define "Numerator": "Strep Test Encounters"
define "Initial Population": "Pharyngitis Encounters With Antibiotics"
define "Denominator": "Initial Population"
define "Pharyngitis With Prior Antibiotics": "Pharyngitis" Pharyngitis with "Antibiotics" Antibiotics such that Antibiotics.authoredOn 30 days or less before Pharyngitis.onset
define "Excluded Encounters": "Pharyngitis Encounters With Antibiotics" Encounters with "Pharyngitis With Prior Antibiotics" Pharyngitis such that Common."Includes Or Starts During"(Pharyngitis, Encounters)
define "Denominator Exclusions": "Excluded Encounters"
/* @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]
define function ToString(value EncounterStatus): value.value
/* @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 }
/* @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 }
define function "Includes Or Starts During"(Condition Condition, Encounter Encounter): Interval[Condition.onset, Condition.abatement] includes Encounter.period or Condition.onset during Encounter.period
define function ToDateTime(value dateTime): value.value
define function ToString(value MedicationRequestStatus): value.value
define function ToString(value MedicationRequestIntent): value.value
Code system ConditionClinicalStatusCodes
Code system ConditionVerificationStatusCodes
EXM146 - Appropriate Testing for Children with Pharyngitis
HL7 International / Clinical Quality Information
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.
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.
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].
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).
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)
This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. If the patient has more than one episode, include all episodes in the measure.