Quality Measures

Overview

Code on Github

The Quality Measures data mart is where we are building publicly available quality measures. The following measures are currently built into the data mart, in addition to readmission and AHRQ QIs which are their own data mart.

Measure Name	Measure ID	Specification	Status
Documentation of Current Medications in the Medical Record	CMS Star C06, MIPS CQM 130	Link	Released
Hospital-Wide All-Cause Readmission (HWR)	CMS Star C15, MIPS CQM 479	Link	Released (Readmissions mart)
Medication Adherence for Cholesterol (Statins)	CMS Star D10, NQF 0541	Link	Released
Medication Adherence for Diabetes Medications	CMS Star D08, NQF 0541	Link	Released
Medication Adherence for Hypertension (RAS antagonists)	CMS Star D09, NQF 0541	Link	Released
Pain Assessment and Follow-Up	CMS Star C07, MIPS CQM 131	Link	Released
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS Star C16, MIPS CQM 438	Link	Released
Statin Use in Persons with Diabetes (SUPD)	CMS Star D12	Link	Released

The data mart includes logic that allows you to choose a measurement period end date.

• quality_measures_period_end defaults to the current year-end
• snapshots_enabled is an optional variable that can be enabled to allow running the mart for multiple years

To run the data mart without the default, simply add the quality_measures_period_end variable to your dbt_project.yml file or use the --vars dbt command. See examples below.

dbt_project.yml:

vars:
    quality_measures_period_end: "2020-12-31"
    snapshots_enabled: true

Quality measures have many standard sections:

• Measure ID: Measures can have several different identifiers. These are created by the measure steward (i.e., the organization that authored and maintains the measure). For example, the identifiers for Breast Cancer Screening are NQF 2372, MIPS CQM Quality ID #112, and eCQM CMS125.
• Measure Description: A brief description of the purpose of the measure.
• Denominator: The population to which the measure applies (i.e., the number of people who should have received a service or action such as a screening). The denominator is the lower part of a fraction used to calculate a rate.
• Numerator: The portion of the denominator population that received the service or action for which the measure is quantifying. The numerator is the upper part of a fraction used to calculate a rate.
• Exclusions/Exceptions: An exclusion is a reason that removes a patient from both the numerator and denominator because the measure would not appropriately apply to them. Exceptions are due to medical reasons (e.g., patient is comatose), patient reasons (e.g., patient refuses), and system reasons (e.g., shortage of a vaccine).
• Measure Period: The timeframe in which the service or action should have occurred.
• Value Sets: The healthcare codes used to define the clinical concepts used in the measure. These codes are from standard systems such as ICD-10, CPT, LOINC, RxNorm, SNOMED, etc.

Data Dictionary

summary_counts

Column Name	Data Type	Primary Key	Description

summary_long

Column Name	Data Type	Primary Key	Description

summary_wide

Column Name	Data Type	Primary Key	Description

Example SQL

Quality Measure Performance

select
      measure_id
    , measure_name
    , performance_period_end
    , performance_rate
from quality_measures.summary_counts
order by performance_rate desc

Exclusion Reason Breakdown

select
      measure_id
    , exclusion_reason
    , count(person_id) as patient_count
from quality_measures.summary_long
where exclusion_flag = 1
group by
      measure_id
    , exclusion_reason
order by
      measure_id
    , exclusion_reason

Patient Pivot

select * from quality_measures.summary_wide