Proportion

Process

increase

define "Initial Population 1":
  exists ( "ASVCD Diagnosis or Procedure before End of Measurement Period"
      union "Myocardial Infarction before End of Measurement Period"
  )
    and exists "Qualifying Encounter during day of Measurement Period"

define "Denominator 1":
  "Initial Population 1"

define "Denominator Exclusions":
  exists ( ( [Condition: "Breastfeeding"]
      union [Condition: "Rhabdomyolysis"] ) ExclusionDiagnosis
      where ( ExclusionDiagnosis.isProblemListItem ( )
          or ExclusionDiagnosis.isHealthConcern ( )
      )
        and ExclusionDiagnosis.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Numerator":
  exists "Statin Therapy Prescribed Anytime during day of Measurement Period"

define "Denominator Exceptions":
  "Has Allergy to Statin"
    or Hospice."Has Hospice Services"
    or PalliativeCare."Has Palliative Care in the Measurement Period"
    or "Has Hepatitis or Liver Disease Diagnosis"
    or "Has Statin Associated Muscle Symptoms"
    or "Has ESRD Diagnosis"
    or "Has Adverse Reaction to Statin"
    or "Has Medical Reason for Not Ordering Statin Therapy"

Proportion

Process

increase

define "Initial Population 2":
  "Patients Aged 20 to 75 with LDL Cholesterol Result Greater than or Equal to 190 or Hypercholesterolemia without ASCVD"
    and exists "Qualifying Encounter during day of Measurement Period"

define "Denominator 2":
  "Initial Population 2"

define "Denominator Exclusions":
  exists ( ( [Condition: "Breastfeeding"]
      union [Condition: "Rhabdomyolysis"] ) ExclusionDiagnosis
      where ( ExclusionDiagnosis.isProblemListItem ( )
          or ExclusionDiagnosis.isHealthConcern ( )
      )
        and ExclusionDiagnosis.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Numerator":
  exists "Statin Therapy Prescribed Anytime during day of Measurement Period"

define "Denominator Exceptions":
  "Has Allergy to Statin"
    or Hospice."Has Hospice Services"
    or PalliativeCare."Has Palliative Care in the Measurement Period"
    or "Has Hepatitis or Liver Disease Diagnosis"
    or "Has Statin Associated Muscle Symptoms"
    or "Has ESRD Diagnosis"
    or "Has Adverse Reaction to Statin"
    or "Has Medical Reason for Not Ordering Statin Therapy"

Proportion

Process

increase

define "Initial Population 3":
  "Patients Aged 40 to 75 Years with Diabetes without ASCVD or LDL Greater than 190 or Hypercholesterolemia"
    and exists "Qualifying Encounter during day of Measurement Period"

define "Denominator 3":
  "Initial Population 3"

define "Denominator Exclusions":
  exists ( ( [Condition: "Breastfeeding"]
      union [Condition: "Rhabdomyolysis"] ) ExclusionDiagnosis
      where ( ExclusionDiagnosis.isProblemListItem ( )
          or ExclusionDiagnosis.isHealthConcern ( )
      )
        and ExclusionDiagnosis.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Numerator":
  exists "Statin Therapy Prescribed Anytime during day of Measurement Period"

define "Denominator Exceptions":
  "Has Allergy to Statin"
    or Hospice."Has Hospice Services"
    or PalliativeCare."Has Palliative Care in the Measurement Period"
    or "Has Hepatitis or Liver Disease Diagnosis"
    or "Has Statin Associated Muscle Symptoms"
    or "Has ESRD Diagnosis"
    or "Has Adverse Reaction to Statin"
    or "Has Medical Reason for Not Ordering Statin Therapy"

Proportion

Process

define "Initial Population 4":
  "Patients Age 40 to 75 Years and have a 10 Year CVD Risk of High without ASCVD and High LDL and Diabetes"
    and exists "Qualifying Encounter during day of Measurement Period"

define "Denominator 4":
  "Initial Population 4"

define "Denominator Exclusions":
  exists ( ( [Condition: "Breastfeeding"]
      union [Condition: "Rhabdomyolysis"] ) ExclusionDiagnosis
      where ( ExclusionDiagnosis.isProblemListItem ( )
          or ExclusionDiagnosis.isHealthConcern ( )
      )
        and ExclusionDiagnosis.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Numerator":
  exists "Statin Therapy Prescribed Anytime during day of Measurement Period"

define "Denominator Exceptions":
  "Has Allergy to Statin"
    or Hospice."Has Hospice Services"
    or PalliativeCare."Has Palliative Care in the Measurement Period"
    or "Has Hepatitis or Liver Disease Diagnosis"
    or "Has Statin Associated Muscle Symptoms"
    or "Has ESRD Diagnosis"
    or "Has Adverse Reaction to Statin"
    or "Has Medical Reason for Not Ordering Statin Therapy"

define "ASVCD Diagnosis or Procedure before End of Measurement Period":
  ( ( [Condition: "Myocardial Infarction"]
      union [Condition: "Cerebrovascular Disease Stroke or TIA"]
      union [Condition: "Atherosclerosis and Peripheral Arterial Disease"]
      union [Condition: "Ischemic Heart Disease or Other Related Diagnoses"]
      union [Condition: "Stable and Unstable Angina"] ) ASCVDDiagnosis
      where ( ASCVDDiagnosis.isProblemListItem ( )
          or ASCVDDiagnosis.isHealthConcern ( )
      )
        and ASCVDDiagnosis.prevalenceInterval ( ) starts on or before day of end of "Measurement Period"
  )
    union ( ( [Procedure: "PCI"]
        union [Procedure: "CABG Surgeries"]
        union [Procedure: "Carotid Intervention"]
        union [Procedure: "CABG or PCI Procedure"] ) ASCVDProcedure
        where ASCVDProcedure.performed.toInterval ( ) starts on or before day of end of "Measurement Period"
          and ASCVDProcedure.status = 'completed'
    )

define "Myocardial Infarction before End of Measurement Period":
  [Condition: "Subsequent non-ST elevation (NSTEMI) myocardial infarction"] SubsequentMI
    where ( SubsequentMI.isProblemListItem ( )
        or SubsequentMI.isHealthConcern ( )
    )
      and SubsequentMI.prevalenceInterval ( ) starts on or before day of end of "Measurement Period"

define "Qualifying Encounter during day of Measurement Period":
  ( [Encounter: "Annual Wellness Visit"]
    union [Encounter: "Office Visit"]
    union [Encounter: "Outpatient Consultation"]
    union [Encounter: "Outpatient Encounters for Preventive Care"]
    union [Encounter: "Preventive Care Services Established Office Visit, 18 and Up"]
    union [Encounter: "Preventive Care Services Individual Counseling"]
    union [Encounter: "Preventive Care Services Initial Office Visit, 18 and Up"]
    union [Encounter: "Preventive Care Services Other"] ) QualifyingEncounter
    where QualifyingEncounter.period during day of "Measurement Period"
      and QualifyingEncounter.status = 'finished'

define "Initial Population 1":
  exists ( "ASVCD Diagnosis or Procedure before End of Measurement Period"
      union "Myocardial Infarction before End of Measurement Period"
  )
    and exists "Qualifying Encounter during day of Measurement Period"

define "Patients Aged 20 to 75 at Start of Measurement Period":
  AgeInYearsAt(date from start of "Measurement Period") in Interval[20, 75]

define "LDL Result Greater Than or Equal To 190":
  [Observation: "LDL Cholesterol"] LDL190
    where LDL190.value as Quantity >= 190 'mg/dL'
      and LDL190.effective.toInterval ( ) starts on or before day of end of "Measurement Period"
      and LDL190.status in { 'final', 'amended', 'corrected', 'appended' }

define "Hypercholesterolemia Diagnosis":
  ( [Condition: "Familial Hypercholesterolemia"] Hypercholesterolemia
      where ( Hypercholesterolemia.isProblemListItem ( )
          or Hypercholesterolemia.isHealthConcern ( )
      )
        and Hypercholesterolemia.prevalenceInterval ( ) starts on or before day of end of "Measurement Period"
  )

define "Patients Aged 20 to 75 with LDL Cholesterol Result Greater than or Equal to 190 or Hypercholesterolemia without ASCVD":
  "Patients Aged 20 to 75 at Start of Measurement Period"
    and exists ( "LDL Result Greater Than or Equal To 190"
        union "Hypercholesterolemia Diagnosis"
    )
    and not exists ( "ASVCD Diagnosis or Procedure before End of Measurement Period" )

define "Initial Population 2":
  "Patients Aged 20 to 75 with LDL Cholesterol Result Greater than or Equal to 190 or Hypercholesterolemia without ASCVD"
    and exists "Qualifying Encounter during day of Measurement Period"

define "SDE Race":
  Patient.race R
    return Tuple {
      codes: R.ombCategory union R.detailed,
      display: R.text
    }

define "SDE Race":
  SDE."SDE Race"

define "Has Diabetes Diagnosis":
  exists ( [Condition: "Diabetes"] Diabetes
      where ( Diabetes.isProblemListItem ( )
          or Diabetes.isHealthConcern ( )
      )
        and Diabetes.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Patients Aged 40 to 75 Years with Diabetes without ASCVD or LDL Greater than 190 or Hypercholesterolemia":
  AgeInYearsAt(date from start of "Measurement Period") >= 40
    and AgeInYearsAt(date from start of "Measurement Period") <= 75
    and "Has Diabetes Diagnosis"
    and ( not exists "ASVCD Diagnosis or Procedure before End of Measurement Period"
        and not exists "LDL Result Greater Than or Equal To 190"
        and not exists "Hypercholesterolemia Diagnosis"
    )

define "Initial Population 3":
  "Patients Aged 40 to 75 Years with Diabetes without ASCVD or LDL Greater than 190 or Hypercholesterolemia"
    and exists "Qualifying Encounter during day of Measurement Period"

define "Ten Year CVD Risk is High":
  ( exists ( [Observation: "Cardiovascular disease 10Y risk [Likelihood]"]
      union [Observation: "Cardiovascular disease 10Y risk [Likelihood] ACC-AHA Pooled Cohort by Goff 2013"] ) AtRiskCVD
      where AtRiskCVD.value as Quantity >= 20 '%'
        and AtRiskCVD.effective.toInterval ( ) during day of "Measurement Period"
  )

define "Patients Age 40 to 75 Years and have a 10 Year CVD Risk of High without ASCVD and High LDL and Diabetes":
  AgeInYearsAt(date from start of "Measurement Period") in Interval[40, 75]
    and "Ten Year CVD Risk is High"
    and not ( exists "ASVCD Diagnosis or Procedure before End of Measurement Period"
        or exists "Hypercholesterolemia Diagnosis"
        or exists "LDL Result Greater Than or Equal To 190"
        or "Has Diabetes Diagnosis"
    )

define "Initial Population 4":
  "Patients Age 40 to 75 Years and have a 10 Year CVD Risk of High without ASCVD and High LDL and Diabetes"
    and exists "Qualifying Encounter during day of Measurement Period"

define "SDE Sex":
  case
    when Patient.gender = 'male' then "M"
    when Patient.gender = 'female' then "F"
    else null
  end

define "SDE Sex":
  SDE."SDE Sex"

define "Denominator 3":
  "Initial Population 3"

define "Statin Therapy Prescribed Anytime during day of Measurement Period":
  ( [MedicationRequest: "Low Intensity Statin Therapy"]
    union [MedicationRequest: "Moderate Intensity Statin Therapy"]
    union [MedicationRequest: "High Intensity Statin Therapy"] ) StatinPrescribed
    where StatinPrescribed.status in { 'active', 'completed' }
      and StatinPrescribed.intent ~ 'order'
      and ( StatinPrescribed.authoredOn during day of "Measurement Period"
          or exists ( StatinPrescribed.dosageInstruction.timing T
              where T.repeat.bounds.toInterval ( ) overlaps day of "Measurement Period"
          )
      )

define "Numerator":
  exists "Statin Therapy Prescribed Anytime during day of Measurement Period"

define "Denominator 2":
  "Initial Population 2"

define "Denominator 4":
  "Initial Population 4"

define "SDE Payer":
  [Coverage: type in "Payer Type"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }

define "SDE Payer":
  SDE."SDE Payer"

define "SDE Ethnicity":
  Patient.ethnicity E
    return Tuple {
      codes: { E.ombCategory } union E.detailed,
      display: E.text
    }

define "SDE Ethnicity":
  SDE."SDE Ethnicity"

define "Denominator Exclusions":
  exists ( ( [Condition: "Breastfeeding"]
      union [Condition: "Rhabdomyolysis"] ) ExclusionDiagnosis
      where ( ExclusionDiagnosis.isProblemListItem ( )
          or ExclusionDiagnosis.isHealthConcern ( )
      )
        and ExclusionDiagnosis.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Denominator 1":
  "Initial Population 1"

define "Has Allergy to Statin":
  exists ( [AllergyIntolerance: "Statin Allergen"] StatinAllergy
      where StatinAllergy.onset.toInterval ( ) overlaps day of "Measurement Period"
        and StatinAllergy.clinicalStatus ~ QICoreCommon."allergy-active"
  )

define "Has Hospice Services":
  exists ((([Encounter: "Encounter Inpatient"]).isEncounterPerformed()) 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.toInterval() ends during day of "Measurement Period"
  )
    or exists ((([Encounter: "Hospice Encounter"]).isEncounterPerformed()) HospiceEncounter
        where HospiceEncounter.period.toInterval() overlaps day of "Measurement Period"
    )
    or exists ((([Observation: "Hospice care [Minimum Data Set]"]).isAssessmentPerformed()) HospiceAssessment
        where HospiceAssessment.value ~ "Yes (qualifier value)"
          and HospiceAssessment.effective.toInterval() overlaps day of "Measurement Period"
    )
    or exists ((([ServiceRequest: "Hospice Care Ambulatory"]).isInterventionOrder()) HospiceOrder
        where HospiceOrder.authoredOn.toInterval() during day of "Measurement Period"
        // and HospiceOrder.doNotPerform is not true
        // https://oncprojectracking.healthit.gov/support/browse/CQLIT-447
    )
    or exists ((([Procedure: "Hospice Care Ambulatory"]).isInterventionPerformed()) HospicePerformed
        where HospicePerformed.performed.toInterval() overlaps day of "Measurement Period"
    )
    or exists (([Condition: "Hospice Diagnosis"]) HospiceCareDiagnosis
        where HospiceCareDiagnosis.prevalenceInterval() overlaps day of "Measurement Period"
    )

define "Has Palliative Care in the Measurement Period":
  exists ((([Observation: "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"]).isAssessmentPerformed()) PalliativeAssessment
      where PalliativeAssessment.effective.toInterval() overlaps day of "Measurement Period"
  )
    or exists ([Condition: "Palliative Care Diagnosis"] PalliativeDiagnosis
        where PalliativeDiagnosis.prevalenceInterval() overlaps day of "Measurement Period"
    )
    or exists ((([Encounter: "Palliative Care Encounter"]).isEncounterPerformed()) PalliativeEncounter
        where PalliativeEncounter.period.toInterval() overlaps day of "Measurement Period"
    )
    or exists ((([Procedure: "Palliative Care Intervention"]).isInterventionPerformed()) PalliativeIntervention
        where PalliativeIntervention.performed.toInterval() overlaps day of "Measurement Period"
    )

define "Has Hepatitis or Liver Disease Diagnosis":
  exists ( ( [Condition: "Hepatitis A"]
      union [Condition: "Hepatitis B"]
      union [Condition: "Liver Disease"] ) HepatitisLiverDisease
      where ( HepatitisLiverDisease.isProblemListItem ( )
          or HepatitisLiverDisease.isHealthConcern ( )
      )
        and HepatitisLiverDisease.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Has Statin Associated Muscle Symptoms":
  exists ( [Condition: "Statin Associated Muscle Symptoms"] StatinMuscleSymptom
      where ( StatinMuscleSymptom.isProblemListItem ( )
          or StatinMuscleSymptom.isHealthConcern ( )
      )
        and StatinMuscleSymptom.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Has ESRD Diagnosis":
  exists ( [Condition: "End Stage Renal Disease"] ESRD
      where ( ESRD.isProblemListItem ( )
          or ESRD.isHealthConcern ( )
      )
        and ESRD.prevalenceInterval ( ) overlaps day of "Measurement Period"
  )

define "Has Adverse Reaction to Statin":
  exists ( [AdverseEvent: event in "Statin Allergen"] StatinReaction
      where StatinReaction.recordedDate during day of "Measurement Period"
  )

define "Has Medical Reason for Not Ordering Statin Therapy":
  exists ( ( [MedicationNotRequested: "Low Intensity Statin Therapy"]
      union [MedicationNotRequested: "Moderate Intensity Statin Therapy"]
      union [MedicationNotRequested: "High Intensity Statin Therapy"] ) NoStatinTherapyOrdered
      with "Qualifying Encounter during day of Measurement Period" QualifyingEncounter
        such that NoStatinTherapyOrdered.authoredOn during QualifyingEncounter.period
          and NoStatinTherapyOrdered.status = 'completed'
          and NoStatinTherapyOrdered.reasonCode in "Medical Reason"
  )

define "Denominator Exceptions":
  "Has Allergy to Statin"
    or Hospice."Has Hospice Services"
    or PalliativeCare."Has Palliative Care in the Measurement Period"
    or "Has Hepatitis or Liver Disease Diagnosis"
    or "Has Statin Associated Muscle Symptoms"
    or "Has ESRD Diagnosis"
    or "Has Adverse Reaction to Statin"
    or "Has Medical Reason for Not Ordering Statin Therapy"

/*
@description: Returns true if the given condition is a problem list item.
*/
define fluent function isProblemListItem(condition Condition):
  exists (condition.category C
    where C ~ "problem-list-item"
  )

/*
@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: Returns true if the given condition is a health concern
*/
define fluent function isHealthConcern(condition Condition):
  exists (condition.category C
    where C ~ "health-concern"
  )

/*
@description: Returns an interval representing the normalized prevalence period of a given Condition.
@comment: Uses the ToInterval and ToAbatementInterval functions to determine the widest potential interval from
onset to abatement as specified in the given Condition. If the condition is active, or has an abatement date the resulting 
interval will have a closed ending boundary. Otherwise, the resulting interval will have an open ending boundary.
*/
define fluent function prevalenceInterval(condition Condition):
if condition.clinicalStatus ~ "active"
  or condition.clinicalStatus ~ "recurrence"
  or condition.clinicalStatus ~ "relapse" then
  Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]
else
    (end of condition.abatementInterval()) abatementDate
    return if abatementDate is null then
      Interval[start of condition.onset.toInterval(), abatementDate)
    else
      Interval[start of condition.onset.toInterval(), abatementDate]

define function ToString(value uri): value.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
        }

//Encounter, Performed
//General usage unless required otherwise by measure intent (e.g., follow-up encounters)
define fluent function isEncounterPerformed(Enc List<Encounter>):
  Enc E
    where E.status in {'finished', 'arrived', 'triaged', 'in-progress', 'onleave'}

/*
@description: Normalizes a value that is a choice of timing-valued types to an equivalent interval
@comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types
to an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible
representations for timing-valued elements in QICore, allowing this function to be used across any resource.
The input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.
The intent of this function is to provide a clear and concise mechanism to treat single
elements that have multiple possible representations as intervals so that logic doesn't have to account
for the variability. More complex calculations (such as medication request period or dispense period
calculation) need specific guidance and consideration. That guidance may make use of this function, but
the focus of this function is on single element calculations where the semantics are unambiguous.
If the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.
If the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,
and the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.
If the input is a DateTime Interval, the result is the input.
If the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result
is a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending
immediately before one year later than the date the patient turned the age given as the end of the quantity interval.
If the input is a Timing, an error will be thrown indicating that Timing calculations are not implemented. Any other input will reslt in a null DateTime Interval
*/
define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>, Timing>):
  case
	  when choice is DateTime then
    	Interval[choice as DateTime, choice as DateTime]
		when choice is Interval<DateTime> then
  		choice as Interval<DateTime>
		when choice is Quantity then
		  Interval[Patient.birthDate + (choice as Quantity),
			  Patient.birthDate + (choice as Quantity) + 1 year)
		when choice is Interval<Quantity> then
		  Interval[Patient.birthDate + (choice.low as Quantity),
			  Patient.birthDate + (choice.high as Quantity) + 1 year)
		when choice is Timing then
      Message(null, true, 'NOT_IMPLEMENTED', 'Error', 'Calculation of an interval from a Timing value is not supported') as Interval<DateTime>
		else
			null as Interval<DateTime>
	end

//This library contains functions that are based on QDM 5.6 to QICore 4.1.1 March 2023 (https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns---QICore-v4.1.1). The functions may appear similar to some QICoreCommon functions but different in that they have constraints that are relevant for measures authored by NCQA.

//Assessment, Performed
define fluent function isAssessmentPerformed(Obs List<Observation>):
  Obs O
    where O.status in { 'final', 'amended', 'corrected' }
          and exists ( O.category ObservationCategory
          where ( ObservationCategory ) ~ "survey"
      )

//Intervention, Order: active and completed only    
define fluent function isInterventionOrder(ServiceRequest List<ServiceRequest>):
  ServiceRequest S
    where S.status in { 'active', 'completed' }
      and S.intent = 'order'

//Intervention, Performed
define fluent function isInterventionPerformed(Proc List<Procedure>):
  Proc P
    where P.status ~ 'completed'