Diagnosis and Treatment Asthma: Review of the Performance Measures by the Performance Measurement Committee of the American College of Physicians

Performance Measurement Diagnosis and Treatment Asthma: Review of the Performance Measures by the Performance Measurement Committee of the American College of Physicians Writing Committee Amir Qaseem, MD, J. Thomas Cross, MD, Eve A. Kerr, MD, Susan Thompson Hingle, MD, Kesavan Kutty, MD, and Sarah West, RN ACP Performance Measurement Committee Members* Eve A. Kerr, MD, MPH (Chair); Catherine MacLean, MD, PhD (Vice Chair); Eileen D. Barrett, MD, MPH; J. Thomas Cross, MD, MPH; Andrew Dunn, MD; Nick Fitterman, MD; Robert A. Gluckman, MD; Susan Thompson Hingle, MD; Kesavan Kutty, MD; Ana Maria López, MD, MPH; Stephen D. Persell, MD, MPH; and Terrence Shaneyfelt, MD, MPH Corresponding author: A. Qaseem 190 N. Independence Mall West Philadelphia, PA 19106 Email aqaseem@acponline.org * Individuals who served on the Performance Measurement Committee from initiation of the project until its approval

Introduction An estimated 300 million people worldwide suffer from asthma, and it is estimated that by 2025, the prevalence will grow by more than 100 million (1). Proper disease management along with increased access to quality care could reduce emergency department visits, decrease inpatient admissions, and save costs of $5 billion nationally (2). However; nearly one third of children and adults are not receiving appropriate medication to control their symptoms (2). Furthermore, inappropriate medication management contributes to increased medical costs which totaled $56 billion for asthma care in 2007 (3). In-spite of global efforts to improve care management in patients with asthma, international surveys provide on-going indication of suboptimal asthma control (4). Measure reporting from the National Committee for Quality Assurance s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) also shows room for improvement. In 2014, healthcare plan rates of appropriate medications for people with asthma ranged from 70% to 97% (5). The ACP Performance Measurement Committee (PMC) reviewed performance measures related to the diagnosis and treatment of asthma to assess whether the measures are evidence-based, methodologically sound, and clinically meaningful. Methods We performed a search to identify relevant performance measures from the National Quality Forum (NQF), and National Quality Measures Clearinghouse (NQMC) websites. The inclusion criteria were performance measures currently used in the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) or currently used in the CMS Electronic Health Record (EHR) Incentive Program. The PMC identified and reviewed 7 performance measures.

Recommendation ACP supports NQF 0028: Preventive Care and Screening: Tobacco Use: Screening & Cessation Intervention. Rationale Reduction of tobacco use has been proven to slow the progression of respiratory disease and is a key element in the management of pulmonary disease (6). The ACP/ACCP/ ATS/ERS* guideline states that a history of heavy smoking (greater than 40 pack-years) is a strong predictor of airflow obstruction (6). The United States Preventive Services Task Force also recommends that clinicians ask all their adult patients about tobacco use and offer cessation interventions (7). Tobacco use is a modifiable risk factor and clinical evidence suggests that patient counseling and re-counseling by physicians increase attempts to quit (8). *American College of Physicians (ACP)/American College of Chest Physicians (ACCP), American Thoracic Society (ATS)/European Respiratory Society (ERS) Measure Specifications NQF 0028: Preventive Care and Screening: Tobacco Use: Screening & Cessation Intervention Status: NQF Endorsed, Last Updated Jul 01, 2014 (2015 PQRS Measure # 226) Measure American Medical Association-Physician Consortium for Performance Steward: Description: Numerator Denominator Exclusions: Type of Measure: Level of Analysis: Care Setting: Improvement (AMA-PCPI) Percentage of patients 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user. Patients who were screened* for tobacco use at least once during the twoyear measurement period AND who received cessation counseling intervention** if identified as a tobacco user. *Includes use of any type of tobacco **Cessation counseling intervention includes brief counseling (3 minutes or less) and/or pharmacotherapy. All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two year measurement period. Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy) Process Clinician : Group/Practice, Clinician : Individual, Clinician : Team Ambulatory Care: Clinician Office/Clinic, Behavioral Health/Psychiatric: Outpatient, Other Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data : Electronic Health Record, Electronic Clinical Data : Registry, Paper Medical Records

Recommendation ACP supports NQF 0036 with modifications: Use of Appropriate Medications for People with Asthma (ASM). Rationale Appropriate medication management for patients with asthma can prevent, and in some cases reverse the disease process (9). Evidence shows that therapeutic approaches allow most people who have asthma to participate fully in activities they choose (9). ACP supports this measure with modifications because the numerator specifications include medications that are not commonly used in practice such as theophylline, potassium iodide, and guaifenesin. Although sustained release theophylline is a mild to moderate bronchodilator, it is used as a non-preferred adjunctive alternative therapy to inhaled corticosteroids (10). If theophylline is prescribed as adjunctive therapy, providers should document patient exclusions for alternative treatment and monitor its serum concentration (10). Additionally, while this measure is straight forward to calculate at the health plan level for patients with pharmacy benefits, it will be more difficult to calculate at the physician group level without medical record review. Measure Specifications NQF 0036: Use of Appropriate Medications for People with Asthma (ASM) Status: NQF Endorsed, Last Updated Dec 23, 2014 (Not reported in PQRS) Measure National Committee for Quality Assurance Steward: Description: The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. Numerator The number of patients who were dispensed at least one prescription for an asthma controller medication during the measurement year. Denominator Patients 5-64 years of age by the end of the measurement year who were identified as having persistent asthma. Exclusions: Exclude patients who had any diagnosis of Emphysema (Emphysema Value Set, Other Emphysema Value Set), COPD (COPD Value Set), Chronic Bronchitis (Obstructive Chronic Bronchitis Value Set, Chronic Respiratory Conditions Due to Fumes/Vapors Value Set), Cystic Fibrosis (Cystic Fibrosis Value Set) or Acute Respiratory Failure (Acute Respiratory Failure Value Set) any time during the patient s history through the end of the measurement year (e.g., December 31). Type of Process Measure: Level of Analysis: Health Plan, Integrated Delivery System Care Setting: Ambulatory Care: Clinician Office/Clinic, Pharmacy Data Source: Administrative Claims, Electronic Clinical Data, Electronic Clinical Data: Pharmacy, Paper Medical Records

Recommendation ACP supports NQF 0041: Influenza Immunization. Rationale ACP supports this measure because it aligns with the current recommendation on influenza vaccination from the Centers for Disease Control and Prevention (CDC) Advisory Committee (11). Measure Specifications NQF 0041: Influenza Immunization Status: NQF Endorsed, Last Updated Oct 01, 2014 (2015 PQRS Measure #110) Measure American Medical Association-Physician Consortium for Performance Steward: Description: Numerator Denominator Exclusions: Improvement (AMA-PCPI) The percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 The PCPI exception methodology uses three categories of reasons for which a patient may be removed from the denominator of an individual measure. These measure exception categories are not uniformly relevant across all measures; there must be a clear rationale to permit an exception for a medical, patient, or system reason. Examples are provided in the measure exception language of instances that may constitute an exception and are intended to serve as a guide to clinicians. For measure 0041, exceptions may include medical reason(s) (e.g., patient allergy, other medical reasons), patient reason(s) (e.g., patient declined, other patient reasons), or system reason(s) for the patient not receiving influenza immunization (e.g., vaccine not available, other system reasons). Where examples of exceptions are included in the measure language, value sets for these examples are developed and included in the emeasure. Although this methodology does not require the external reporting of more detailed exception data, the PCPI recommends that physicians document the specific reasons for exception in patients medical records for purposes of optimal patient management and audit-readiness. The PCPI also advocates the systematic review and analysis of each physician s exceptions data to identify practice patterns and opportunities for quality improvement. Additional details by data source are as follows: Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons) Documentation of patient reason(s) for not receiving influenza

Type of Measure: Level of Analysis: Care Setting: Data Source: immunization (e.g., patient declined, other patient reason) Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons) Process Clinician: Group/Practice, Clinician: Individual, Clinician: Team Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Urgent Care, Dialysis Facility, Home Health, Other, Post-Acute/Long Term Care Facility: Nursing Home/Skilled Nursing Facility Administrative claims, Electronic Clinical Data, Electronic Clinical Data: Pharmacy

Recommendation ACP supports NQF 0047 with modifications: Asthma: Pharmacologic Therapy for Persistent Asthma. Rationale Appropriate medication management for patients with asthma can prevent, and in some cases reverse the disease process (9). Evidence shows that therapeutic approaches allow most people who have asthma to participate fully in activities they choose (9). While the evidence supports the concept behind this measure, we are concerned with the process of electronic data extraction. Further clarification of appropriate medications and an explanation of data collection methods are needed. Also, the specifications of the denominator (persistent asthma) are not specific enough to ensure the measure is being collected for the correct population. This measure will be well served by revision, once ICD-10 is operationalized. Measure Specifications NQF 0047: Asthma: Pharmacologic Therapy for Persistent Asthma Status: NQF Endorsed, Last Updated February Apr 01, 2014, (2015 PQRS Measure #53) Measure American Medical Association-Physician Consortium for Performance Steward: Improvement (AMA-PCPI) Description: Percentage of patient aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication Three rates are reported for this measure: 1. Patients prescribed inhaled corticosteroids (ICS) as their long term control medication 2. Patients prescribed other alternative long term control medications (non-ics) 3. Total patients prescribed long-term control medication Numerator Patients who were prescribed long-term control medication Denominator All patients aged 5 through 64 years with a diagnosis of persistent asthma Exclusions: The PCPI distinguishes between measure exceptions and measure exclusions. Exclusions arise when patients who are included in the initial patient or eligible population for a measure do not meet the denominator criteria specific to the intervention required by the numerator. Exclusions are absolute and apply to all patients and, therefore, are not part of clinical judgement within a measure. Exceptions are used to remove patients from the denominator of a performance measure when a patient does not receive a therapy or service AND that therapy or service would not be appropriate due to specific reasons; otherwise, the patient would meet the denominator criteria.

Exceptions are not absolute, and the application of exceptions is based on clinical judgement, individual patient characteristics, or patient preferences. The PCPI exception methodology uses three categories of exception reasons for which a patient may be removed from the denominator of an individual measure. These measure exception categories are not uniformly relevant across all measures; for each measure, there must be a clear rationale to permit an exception for a medical, patient, or system reason. Examples are provided in the measure exception language of instances that may constitute and exception and are intended to serve as a guide to clinicians. For this measure, exceptions may include patient reason(s) (e.g., patient declined). Where examples of exceptions are included in the measures language, value sets for these examples are developed and are included in the especifications. Although this methodology does not require the external reporting in patients medical records for purposes of optimal patient management and auditreadiness. The PCPI also advocates the systematic review and analysis of each physician s exceptions data to identify practice patterns and opportunities for quality improvement. Type of Measure: Level of Analysis: Care Setting: Data Source: Denominator exceptions: Documentation of patient reason(s) for not prescribing inhaled corticosteroids or alternative long-term control medication (e.g., patient declined, other patient reason) Process Clinician: Group/Practice, Clinician: Individual, Clinician: Team, Ambulatory Care: Clinician Office/Clinic Administrative claims, Electronic Clinical Data, Electronic Clinical Data: Electronic Registry, Paper Medical Records

Recommendation ACP does not support NQF 0419: Documentation of Current Medications in the Medical Record. Rationale Although we support the concept behind this measure, independent patient, system, and practice variables (incomplete patient information, unavailable drug information, miscommunication of drug orders, and insufficient information flow) can impede the physician s ability to document complete and accurate medication lists (12-13). Consequently, clinical judgements may be based on incomplete clinical information (12). Further, the burden of collecting this information for all visits, even brief acute care visits when medications were documented on a recent visit, likely exceeds benefit. Attestation for these visits may become routine but does not add value. Measure Specifications NQF 0419: Documentation of Current Medications in the Medical Record Status: NQF Endorsed, Last Updated Jul 01, 2014, (2015 PQRS Measure #130) Measure Centers for Medicare & Medicaid Services Steward: Description: Numerator Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counter, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. All measure specification details reference the 2014 Physician Quality Reporting System measure specification. Eligible professional attests to documenting, updating or reviewing a patient s current medications using all immediate resources available on the date of the encounter. This list must include ALL prescriptions, overthe-counters, herbals, vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route. Denominator NUMERATOR NOTE: The eligible professional must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible professionals reporting this measure may document medication information received from the patient, authorized representatives(s), caregiver(s), or other available healthcare resources. G8427 should be reported if the eligible professional documented that the patient is not currently taking any medications. All measure specification details reference the 2014 Physician Quality Reporting System measure specification.

Exclusions: Type of Measure: Level of Analysis: Care Setting: Data Source: All visits for patients aged 18 years and older All measure specification details reference the 2014 Physician Quality Reporting System measure specification. A patient is not eligible or excluded (B) from the performance denominator (PD) if one or more of the following reason exists: Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Process Clinician: Individual, Population: National Ambulatory Care: Clinician Office/Clinic, Behavioral Health/Psychiatric: Outpatient, Dialysis Facility, Home Health, Other, Post-Acute/Long Term Care Facility: Inpatient Rehabilitation Facility, Post-Acute/Long Term Care Facility: Nursing Home/Skilled Nursing Facility Administrative claims, Electronic Clinical Data: Registry

Recommendation ACP does not support NQF 1800: Asthma Medication Ratio (AMR). Rationale Although we agree that all patients with persistent asthma should be prescribed a controller medication, there is a lack of evidence to suggest that the ratio of controller medications to total asthma medications should be 0.50 or greater. Also, it is unclear what constitutes this half. For example, is it the number of prescriptions or the medication dosage? Evidence indicates that the combination of controller and rescue medications in adults leads to improvements in lung function and symptoms in patients with asthma, however; the efficacy of long-term therapy is determined by a dose-response curve (10). Furthermore, the doseresponse rate to controller medications may vary, thus some patients experience therapeutic effects at lower doses (10). Therefore, the potential for adverse effects must be weighed against the risk of uncontrolled asthma on an individual patient basis (10). Furthermore, to the extent that this is calculated by using dispensed medications, it may not reflect actual usage. Measure Specifications NQF 1800: Asthma Medication Ratio (AMR) Status: NQF Endorsed, Last Updated Dec 23, 2014 (Not reported in PQRS) Measure National Committee for Quality Assurance Steward: Description: The percentage of patients who have a medication ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. Numerator The number of patients who have a medication ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. Denominator Patients 5-64 years of age during the measurement year who were Exclusions: Type of Measure: Level of Analysis: Care Setting: identified as having persistent asthma. 1) Exclude patients who had any diagnosis of Emphysema (emphysema value set), COPD (COPD value set), Chronic Bronchitis (Obstructive Chronic Bronchitis value set), Cystic Fibrosis (Cystic Fibrosis value set) or Acute Respiratory Failure (Acute Respiratory Failure value set) any time during the patient s history through the end of the measurement year (e.g., December 31). 2) Exclude any patients who have no asthma controller medications (Table AMR-A) dispensed during the measurement year. Process Health Plan, Integrated Delivery System Ambulatory Care: Clinician Office/Clinic, Post-Acute/Long Term Care Facility: Long Term Acute Care Hospital, Post-Acute/Long Term Care Facility: Nursing Home/Skilled Nursing Facility

Data Source: Administrative claims, Electronic Clinical Data, Paper Medical Records Recommendation ACP does not support NQF 0275 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 5). Rationale There is a lack of evidence on the impact of admission rate measures for this population. This measure could prevent necessary admissions in the absence of proper outpatient care. Lack of medication adherence-due to cost, or multiple competing priorities for the patient, may contribute to less than optimal use of preventive therapy and create disparities in care for asthma (10, 15). We also support separating asthma and COPD into discrete measures due to the different etiologies and risk factors for hospitalization. Rates of admission for reasons outside of established criteria may be appropriate. Measure Specifications NQF 0275: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 5) Status: NQF Endorsed, Last Updated Jan 05, 2015 (Not reported in PQRS) Measure Agency for Healthcare Research and Quality Steward: Description: Numerator Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 100,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions. (NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population). Discharges, for patients ages 40 years and older, with either: A principal ICD-9-CM diagnosis code for COPD (excluding acute bronchitis); or A principal ICD-9-CM diagnosis code for asthma; or A principal ICD-9-CM diagnosis code for acute bronchitis and any secondary ICD-9-CM diagnosis codes for COPD (excluding acute bronchitis) Denominator NOTE: By definition, discharges with a principal diagnosis of COPD, asthma, or acute bronchitis are precluded from an assignment of MDC 14 by grouper software. Thus, obstetric discharges should not be considered in the PQI rate, though the AHRQ QITM software does not explicitly exclude obstetric cases. Population ages 40 years and older in metropolitan area or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan

area or county of the hospital where the discharge occurred. Exclusions: Type of Measure: Level of Analysis: Care Setting: Data Source: The term metropolitan area (MA) was adopted by the U.S. Census in 1990 and referred collectively to metropolitan statistical areas (MSAs), consolidated metropolitan statistical areas (CMSAs) and primary metropolitan statistical areas (PMSAs). In addition, area could refer to either 1) FIPS county, 2) modified FIPS county, 3) 1999 OMB Metropolitan Statistical Area or 4) 2003 OMB Metropolitan Statistical Area. Metropolitan Statistical Areas are not used in the QI software Exclude cases: Transferring from another institution (SID ASOURCE=2) MDC 14 (pregnancy, childbirth, and puerperium) MDC 15 (newborn and other neonates) Outcome Population: County or City Hospital/Acute Care Facility Administrative Claims Gaps in Performance Measurement Opportunities to Promote High-Value Care There is a need for research on promising interventions in tobacco use cessation and prevention among children and adolescents (14). Given the large number of children and adolescents who have experimented with, yet not become regular smokers, there is a need to evaluate interventions and messages designed to reach this group (14).

References 1. World Health Organization. Global surveillance, prevention, and control of chronic respiratory diseases: a comprehensive approach. 2007. 2. American Lung Association. Trends in Asthma Morbidity and Mortality. American Lung Association Epidemiology and Statistics Unit Research and Health Education Division. September 2012. 3. Centers for Disease Control and Preventions (CDC). 2011. CDC Vital Signs: Asthma in the US. Accessed at: http://www.cdc.gov/vitalsigns/pdf/2011-05-vitalsigns.pdf (April 15, 2015). 4. Global Initiative for Asthma (GINA). 2014. Global Strategy for Asthma Management and Prevention. Accessed at: http://www.ginasthma.org/documents/ (July 10, 2014) 5. National Committee for Quality Assurance. Use of appropriate medications for people with asthma and medication management for people with asthma. 2014. Accessed at: http://www.ncqa.org/reportcards/healthplans/stateofhealthcarequality/2014tableof Content/Asthma.aspx (April 15, 2015). 6. Qaseem A, Wilt TJ, Weinberger S, Hanania NA, Criner G, Van der Molen T, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011; 155(3):179-191. 7. U.S. Preventive Services Task Force. Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med. 2009; 150:551-555. 8. Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient behavior? Evidence for a priming effect. Arch Fam Med. 2000; 9(5):426-433. 9. U.S. Department of Health and Human Services National Institutes of Health. National Heart, Lung, and Blood Institute. National asthma education and prevention program. Expert panel 3: Guidelines for the diagnosis and management of asthma. August 28, 2007. 10. National Heart, Blood and Lung Institute (NHLBI), National Asthma Education and Prevention Program (NAEPP), National Institutes of Health. August 2007. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report 2007. NIH Publication No. 07-4051.

11. CDC. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR. 2010; 59:1-47. 12. American Medical Association: The physician s role in medication reconciliation. Accessed at:http://www.amaassn.org/ama1/pub/upload/mm/370/med-recmonograph.pdf (May 5, 2015) 13. American Medical Association: The physician s role in medication reconciliation. Accessed June 26, 2015. http://www.amaassn.org/ama1/pub/upload/mm/370/medrec-monograph.pdf 14. Patnode CD, O Connor E, Whitlock EP, Perdue LA, Soh C. Primary Care Relevant Interventions for Tobacco Use Prevention and Cessation in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 97. AHRQ Publication No. 12-05175-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; December 2012 15. Halterman JS, Aligne CA, Auinger P, McBride JT, Szilagyi PG. Inadequate therapy for asthma among children in the United States. Pediatrics. 2000; 105 (1 Pt 3):272-276.

Financial Financial support for the Performance Measurement Committee comes exclusively from the ACP operating budget. Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. A record of conflicts of interest is kept for each PMC meeting and conference call and can be viewed at: http://www.acponline.org/running_practice/performance_measurement/pmc/conflicts_pmc.h tm APPROVED BY THE ACP BOARD OF REGENTS ON: July 26, 2015 Members of the PMC: Individuals who served on the Performance Measurement Committee from initiation of the project until its approval: Eileen D. Barrett, MD, MPH J. Thomas Cross, Jr., MD, MPH Andrew Dunn, MD Nick Fitterman, MD Robert A. Gluckman, MD Susan Thompson Hingle, MD Kesavan Kutty, MD Eve Askanas Kerr, MD, MPH Ana María López, MD, MPH Catherine MacLean, MD, PhD Stephen D. Persell, MD, MPH Terrence Shaneyfelt, MD, MPH Requests and inquiries: Amir Qaseem, MD, PhD, MHA, FACP, American College of Physicians, 190. N Independence Mall West, Philadelphia, PA 19106: email, aqaseem@acponline.org