Childhd Immunizatin Status (NQF 0038) EMeasure Name Childhd Immunizatin EMeasure Id Pending Status Versin Number 1 Set Id Pending Available Date N infrmatin Measurement Perid January 1, 20xx thrugh December 31, 20xx Measure Steward Natinal Cmmittee fr Quality Assurance Endrsed by Natinal Quality Frum Descriptin The percentage f children 2 years f age wh had fur diphtheria, tetanus and acellular pertussis (DTaP); three pli (IPV); ne measles, mumps and rubella (MMR); tw H influenza type B (HiB); three hepatitis B (Hep B), ne chicken px (VZV); fur pneumcccal cnjugate (PCV); tw hepatitis A (Hep A); tw r three rtavirus (RV); and tw influenza (flu) vaccines by their secnd birthday. The measure calculates a rate fr each vaccine and tw separate cmbinatin rates. Measure scring Prprtin Measure type Prcess Ratinale This measure mnitrs the apprpriate and timely use f vaccines fr children prir t their secnd birthday. Pediatric vaccines are respnsible fr preventing 10.5 millin diseases per birth chrt in the U.S. and are a cst effective preventive measure. Fr every dllar spent n immunizatins, as many as $29 can be saved in direct and indirect csts. With the develpment and use f vaccines, the prevalence f sme infectius diseases has dramatically reduced; since the beginning f the 20th century, there has been a 99% decline in vaccinepreventable disease mrbidity. Despite the established guidelines and well knwn benefits f vaccinatin, hwever, in 2007, 22.5% f children 19 35 mnths f age had nt received the recmmended immunizatins. General clinical cnsensus ntes that if immunizatin practices ceased, mst infectius diseases currently prevented by vaccinatins wuld reemerge as serius health threats. This measure facilitates effrts tward infectius disease preventin amng a vulnerable subgrup f the ppulatin. Clinical Recmmendatin Statement Current CDC/ACIP Guidelines recmmend infants and tddlers receive the Hepatitis B series, fur DTaP vaccinatins, fur HiB vaccinatins, three IPV vaccinatins, ne MMR vaccinatin, fur pneumcccal cnjugate vaccinatins, and ne varicella vaccinatin. Sme cmbinatin prducts n the market include bth the DTaP and HiB vaccines and shuld nly be administered three times. In these cases, children receive three HiB vaccinatins instead f the fur mentined abve. The recmmendatin is t receive these vaccinatins between birth and 18 mnths f age. The current HEDIS specificatins allw a grace perid by measuring cmpliance with these recmmendatins between birth and age tw.
Reference Definitins Guidance CDC. General Recmmendatins n Immunizatin: Recmmendatins f the Advisry Cmmittee n Immunizatin Practices (ACIP). MMWR 2006; 55(RR15);1 48 http://www.cdc.gv/mmwr/preview/mmwrhtml/rr5515a1.htm Measure 0038 lists 12 numeratrs fr reprting. The first ten numeratrs indicate whether any individual has received the apprpriate number f a specific immunizatin by the age f 2. The 11 th and 12 th numeratrs indicate whether any individual has received all f the expected dses f a grup (r bundle) f immunizatins. Nte that each f the first 10 numeratrs, referring t a single vaccine (r vaccine cmbinatin MMR) has a related (r paired) set f exclusins that apply nly t the respective vaccine. The exclusin criteria are numbered identically t their respective numeratrs (e.g., MMR vaccines in Numeratr 3 and MMR exclusins in Exclusin 3). Numeratrs 11 and 12 cntain multiple vaccines. The exclusins fr numeratrs 11 and 12 shuld be derived frm the exclusins specified fr the individual vaccines within thse bundles. Nte that numeratr 3 is separated int numeratr 3a (MMR vaccine) and numeratr 3b (measles, mumps and rubella vaccines individually). Either 3a r 3b must be satisfied t meet the requirements f numeratr 3. If there is an exclusin fr any f the individual vaccines in numeratr 3b, the patient is remved frm the denminatr. Similarly, fr numeratrs 11 and 12, if there is an exclusin fr any f the individual vaccines, the patient is remved frm the denminatr. Numeratrs 11 and 12 are intended t shw nly thse patients fr whm all f the listed vaccines have been perfrmed. Table f Cntents Ppulatin criteria Data criteria (QDS Data Elements) Summary calculatin Please refer t the spreadsheet fr this measure fr detail regarding data criteria and cde lists. Ppulatin criteria Initial Patient Ppulatin = Patient characteristic: birth date (age) >=1 year and <2 years t capture all patients wh will reach 2 years during the measurement perid ; Denminatr =
All patients in the initial patient ppulatin; Encunter: encunter utpatient w/ PCP & bgyn ; Numeratr 1= OR: >= 4 cunt(s) f Medicatin administered: DTaP vaccine, different dates, ccurring >=42 days and <2 years after Patient characteristic: birth date ; OR: >= 4 cunt(s) f Prcedure perfrmed: DTaP vaccinatin, different dates, ccurring >=42 days and <2 years after Patient characteristic: birth date ; Numeratr 2 = OR: >=3 cunt(s) f Medicatin administered: IPV, different dates, ccurring >=42 days and <2 years after Patient characteristic: birth date ; OR: >=3 cunt(s) f Prcedure perfrmed: IPV vaccinatin, different dates, ccurring >=42 days and <2 years after Patient characteristic: birth date ; Numeratr 3 = OR Numeratr 3a: OR: >=1 cunt(s) f Medicatin administered: MMR, ccurring <2 years after the Patient characteristic: birth date ; OR: >=1 cunt(s) Prcedure perfrmed: MMR vaccinatin, ccurring <2 years after the Patient characteristic: birth date ; OR Numeratr 3b: OR: >= 1 cunt(s) f Medicatin administered: rubella vaccine, ccurring <2 years after Patient characteristic: birth date ; OR: >= 1 cunt(s) f Prcedure perfrmed: rubella vaccinatin, ccurring <2 years after Patient characteristic: birth date ; OR: Diagnsis reslved: rubella ; OR: >= 1 cunt(s) f Medicatin administered: measles vaccine, ccurring <2 years after Patient characteristic: birth date ; OR: >= 1 cunt(s) f Prcedure perfrmed: measles vaccinatin, ccurring <2 years after Patient characteristic: birth date ; OR: Diagnsis reslved: measles ;
OR: >= 1 cunt(s) f Medicatin administered: mumps vaccine, ccurring <2 years after Patient characteristic: birth date ; OR: >= 1 cunt(s) f Prcedure perfrmed: mumps vaccinatin, ccurring <2 years after Patient characteristic: birth date ; OR: Diagnsis reslved: mumps ; Numeratr 4 = OR: >=2 cunt(s) f Medicatin administered: HiB, ccurring >=42 days and <2 years after Patient characteristic: birth date ; OR: >=2 cunt(s) f Prcedure perfrmed: HiB vaccinatin, ccurring >=42 days and <2 years after Patient characteristic: birth date ; Numeratr 5 = OR: >=3 cunt(s) f Medicatin administered: hepatitis B vaccine, ccurring < 2 years after Patient characteristic: birth date ; OR: >=3 cunt(s) f Prcedure perfrmed: hepatitis B vaccinatin, ccurring < 2 years after Patient characteristic: birth date ; OR: Diagnsis reslved: hepatitis B diagnsis ; OR: Diagnsis active: hepatitis B diagnsis ; Numeratr 6 = OR: >=1 cunt(s) f Medicatin administered: VZV vaccine, ccurring < 2 years after Patient characteristic: birth date ; OR: >=1 cunt(s) f Prcedure perfrmed: VZV vaccinatin, ccurring < 2 years after Patient characteristic: birth date ; OR: Diagnsis reslved: VZV ; Numeratr 7 = OR: >=4 cunt(s) f Medicatin administered: pneumcccal vaccine, ccurring >=42 days and <2 years after Patient characteristic: birth date ; OR: >=4 cunt(s) f Prcedure perfrmed: pneumcccal vaccinatin, ccurring >=42 days and <2 years after Patient characteristic: birth date ; Numeratr 8 =
OR: >=2 cunt(s) f Medicatin administered: hepatitis A vaccine, ccurring <2 years after Patient characteristic: birth date ; OR: >=2 cunt(s) f Prcedure perfrmed: hepatitis A vaccinatin, ccurring <2 years after Patient characteristic: birth date ; OR: Diagnsis reslved: hepatitis A diagnsis ; Numeratr 9 = OR: >=2 cunt(s) f Medicatin administered: rtavirus vaccine, ccurring >=42 days and <2 years after Patient characteristic: birth date ; OR: >=2 cunt(s) f Prcedure perfrmed: rtavirus vaccinatin, ccurring >=42 days and <2 years after Patient characteristic: birth date ; Numeratr 10 = OR: >=2 cunt(s) f Medicatin administered: influenza vaccine, ccurring >=180 days and <2 years after Patient characteristic: birth date ; OR: >=2 cunt(s) f Prcedure perfrmed: influenza vaccinatin, ccurring >=180 days and <2 years after Patient characteristic: birth date ; Numeratr 11 = All patients in numeratr 1; All patients in numeratr 2; All patients in numeratr 3; All patients in numeratr 4; All patients in numeratr 5; All patients in numeratr 6; Numeratr 12 = All patients in numeratr 1; All patients in numeratr 2; All patients in numeratr 3; All patients in numeratr 4; All patients in numeratr 5; All patients in numeratr 6; All patients in numeratr 7; Exclusin 1= :
OR: Medicatin allergy: DTaP vaccine ; OR: Diagnsis active: encephalpathy ; OR: Diagnsis active: prgressive neurlgical disrder ; Exclusin 2= OR: Medicatin allergy: IPV ; OR: Medicatin allergy: nemycin ; OR: Medicatin allergy: streptmycin ; OR: Medicatin allergy: plymyxin ; Exclusin 3a= AND : OR: Medicatin allergy: MMR vaccine ; OR: Medicatin allergy: mumps vaccine ; OR: Medicatin allergy: measles vaccine ; OR: Medicatin allergy: rubella vaccine ; OR: Diagnsis active: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis inactive: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis active: HIV disease ; OR: Diagnsis active: multiple myelma ; OR: Diagnsis active: leukemia ; OR: Diagnsis active: immundeficiency ; Exclusin 3b= OR: Medicatin allergy: mumps vaccine ; OR: Medicatin allergy: measles vaccine ; OR: Medicatin allergy: rubella vaccine ; OR: Diagnsis active: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis inactive: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis active: HIV disease ; OR: Diagnsis active: multiple myelma ; OR: Diagnsis active: leukemia ; OR: Diagnsis active: immundeficiency ; Exclusin 4= Medicatin allergy: HiB ; Exclusin 5= OR: Medicatin allergy: Baker s yeast ; OR: Substance allergy: Baker s yeast substance ; OR: Medicatin allergy: hepatitis B vaccine ;
Exclusin 6= OR: Diagnsis active: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis inactive: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis active: HIV disease ; OR: Diagnsis active: multiple myelma ; OR: Diagnsis active: leukemia ; OR: Medicatin allergy: VZV vaccine ; OR: Diagnsis active: immundeficiency ; Exclusin 7= Medicatin allergy: pneumcccal vaccinatin ; Exclusin 8= Medicatin allergy: hepatitis A vaccine ; Exclusin 9= Medicatin allergy: rtavirus vaccine ; Exclusin 10= OR: Diagnsis active: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis inactive: cancer f lymphreticular r histicytic tissue ; OR: Diagnsis active: HIV disease ; OR: Diagnsis active: multiple myelma ; OR: Diagnsis active: leukemia ; OR: Medicatin allergy: influenza vaccine ; OR: Diagnsis active: immundeficiency ; Exclusin 11= OR: Exclusin 1; OR: Exclusin 2; OR: Exclusin 3; OR: Exclusin 4; OR: Exclusin 5; OR: Exclusin 6; Exclusin 12= OR: Exclusin 1; OR: Exclusin 2; OR: Exclusin 3; OR: Exclusin 4; OR: Exclusin 5;
OR: Exclusin 6; OR: Exclusin 7; Data criteria (QDS Data Elements) Initial Patient Ppulatin = "Patient characteristic: Birth date using birth date cde list befre the beginning f the measurement perid ; Denminatr = All patients in the initial patient ppulatin; Encunter: encunter utpatient w/ PCP & bgyn using encunter utpatient w/ PCP & bgyn cde list gruping befre r simultaneusly t Numeratr = Medicatin administered: DTaP vaccine using DTaP vaccine cde list befre the Medicatin administered: IPV using IPV cde list befre the measurement end date ; "Medicatin administered: MMR vaccine using MMR vaccine cde list befre the Medicatin administered: mumps vaccine using mumps vaccine cde list befre the Medicatin administered: measles vaccine using measles vaccine cde list befre the Medicatin administered: rubella vaccine using rubella vaccine cde list befre the "Medicatin administered: HiB using HiB cde list befre the measurement end date ; Medicatin administered: hepatitis B vaccine using hepatitis B vaccine cde list befre the "Medicatin administered: VZV vaccine using VZV vaccine cde list befre the Medicatin administered: influenza vaccine using influenza vaccine cde list befre "Medicatin administered: hepatitis A vaccine using hepatitis A vaccine cde list befre Medicatin administered: rtavirus vaccine using rtavirus vaccine cde list befre "Medicatin administered: pneumcccal vaccinatin using pneumcccal vaccinatin cde list befre Prcedure perfrmed: Dtap vaccinatin using DtaP vaccinatin cde list gruping befre the Prcedure perfrmed: hepatitis B vaccinatin using hepatitis B vaccinatin cde list gruping befre the
Prcedure perfrmed: hepatitis A vaccinatin using hepatitis A vaccinatin cde list gruping befre the Prcedure perfrmed: HiB vaccinatin using HiB vaccinatin cde list gruping befre the Prcedure perfrmed: Influenza vaccinatin using Influenza vaccinatin cde list gruping befre the Prcedure perfrmed: IPV vaccinatin using IPV vaccinatin cde list gruping befre the Prcedure perfrmed: MMR vaccinatin using MMR vaccinatin cde list gruping befre the Prcedure perfrmed: measles vaccinatin using measles vaccinatin cde list gruping befre the Prcedure perfrmed: mumps vaccinatin using mumps vaccinatin cde list gruping befre the Prcedure perfrmed: pneumcccal vaccinatin using pneumcccal vaccinatin cde list gruping befre the Prcedure perfrmed: rtavirus vaccinatin using rtavirus vaccinatin cde list gruping befre the Prcedure perfrmed: rubella vaccinatin using rubella vaccinatin cde list gruping befre the Prcedure perfrmed: VZV vaccinatin using VZV vaccinatin cde list gruping befre the Diagnsis reslved: measles using measles cde list gruping befre measurement Diagnsis reslved: mumps using mumps cde list gruping befre measurement Diagnsis reslved: rubella using rubella cde list gruping befre measurement Diagnsis reslved: hepatitis A diagnsis using hepatitis A diagnsis cde list gruping befre Diagnsis reslved: VZV using VZV cde list gruping befre the measurement end date ; Diagnsis reslved: hepatitis B diagnsis using hepatitis B cde list gruping befre Diagnsis active: hepatitis B diagnsis using hepatitis B diagnsis cde list gruping befre Exclusins = Medicatin allergy: DTaP vaccine using DTaP vaccine cde list befre r simultaneusly t the Medicatin allergy: nemycin using nemycin cde list befre measurement end date ; Medicatin allergy: streptmycin using streptmycin cde list befre measurement Medicatin allergy: plymyxin using plymyxin cde list befre measurement end date ;
Medicatin allergy: MMR vaccine using MMR vaccine cde list <=2 years befre Medicatin allergy: mumps vaccine using mumps vaccine cde list befre Medicatin allergy: measles vaccine using measles vaccine cde list befre Medicatin allergy: VZV vaccine using VZV vaccine cde list befre measurement Medicatin allergy: influenza vaccine using influenza vaccine cde list befre Medicatin allergy: Baker s yeast using Baker s yeast cde list befre measurement Substance allergy: Baker s yeast substance using Baker s yeast substance cde list befre Medicatin allergy: hepatitis B vaccine using hepatitis B vaccine cde list befre Medicatin allergy: hepatitis A vaccine using hepatitis A vaccine cde list befre Medicatin allergy: rtavirus vaccine using rtavirus vaccine cde list befre Medicatin allergy: pneumcccal vaccinatin using pneumcccal vaccinatin cde list befre Medicatin allergy: HiB using HiB cde list befre Medicatin allergy: rubella vaccine using rubella vaccine cde list befre Medicatin allergy: IPV using IPV cde list befre Diagnsis active: encephalpathy using encephalpathy cde list gruping befre measurement Diagnsis active: prgressive neurlgical disrder using prgressive neurlgical disrder cde list befre measurement Diagnsis active: cancer f lymphreticular r histicytic tissue using cancer f lymphreticular r histicytic tissue cde list gruping befre measurement Diagnsis inactive: cancer f lymphreticular r histicytic disease using cancer f lymphreticular r histicytic tissue cde list gruping befre measurement Diagnsis active: HIV disease using HIV disease cde list gruping befre measurement Diagnsis active: multiple myelma using multiple myelma cde list gruping befre measurement Diagnsis active: leukemia using leukemia cde list gruping befre measurement Diagnsis active: immundeficiency using immundeficiency cde list gruping befre r simultaneusly t Summary calculatin Calculatin is generic t all measures: Calculate the final denminatr by adding all that meet denminatr criteria.
Subtract frm the final denminatr all that d nt meet numeratr criteria yet als meet exclusin criteria. Nte sme measures d nt have exclusin criteria. The perfrmance calculatin is the number meeting numeratr criteria divided by the final denminatr. Fr measures with multiple patient ppulatins, repeat this prcess fr each patient ppulatin and reprt each result separately. Fr measures with multiple numeratrs, calculate each numeratr separately within each ppulatin using the paired exclusin. Measure set CLINICAL QUALITY MEASURE SET 2011 2012