| Title: |
Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection |
| Id: |
BreastCancerMeasureFHIR4 |
| Version: |
1.0.000 |
| Url: |
https://madie.cms.gov/Measure/BreastCancerMeasureFHIR4 |
|
Short Name Identifier:
|
BreastCancerScreeningFollow-up
|
|
Version Independent Identifier:
|
urn:uuid:2ac79a92-7d23-44d2-a937-66f13e41ffc7
|
|
Version Specific Identifier:
|
urn:uuid:e396edba-3eb6-4e7f-97de-5d5faed9498d
|
|
Publisher (CMS) Identifier:
|
1303FHIR
|
| Effective Period: |
2024-01-01..2024-12-31 |
| Publisher: |
Brigham and Womens Health |
| Author: |
Brigham and Womens Health |
| Description: |
This electronic clinical quality measure (eCQM) reports the rate of female patients aged 40-75 years who completed timely diagnostic resolution within 60 days after an index abnormal screening mammogram (i.e., Breast Imaging – Reporting and Data System [BI-RADS] rating of 0 [incomplete], 4 [suspicious], or 5 [highly suggestive of malignancy]) with either follow-up imaging with benign or probably benign results (e.g., diagnostic mammogram with a BI-RADS 1 [negative], 2 [benign], or 3 [probably benign] rating) or diagnostic sample extraction (e.g., biopsy). |
| Purpose: |
UNKNOWN |
| Copyright: |
This eCQM and related data specifications are owned and stewarded by the Brigham and Women's Hospital (BWH). BWH is not responsible for any use of the Measure. BWH makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and BWH has no liability to anyone who relies on such measures or specifications. |
| 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. |
| Rationale: |
Breast cancer is the second most common cause of cancer deaths among women in the United States (American Cancer Society, 2024). Survival is dependent upon cancer stage at diagnosis. Noninvasive mammographic screening is the primary screening modality used to detect cancer. Delays in diagnostic follow-up after abnormal mammographic screening results increase the risk of diagnosing cancer at a more advanced stage (McCarthy AM et al., 2016).
National screening guidelines recommend that women with abnormal screening mammogram results (BI-RADS 0, 4, or 5) undergo additional follow-up imaging, including diagnostic mammography, magnetic resonance imaging (MRI), or ultrasound (ACR, 2017; USPSTF, 2023). While it is recommended that patients with a benign follow-up imaging result return to routine screening, those with abnormal results (BI-RADS 4 or 5) should have diagnostic samples extracted (e.g., percutaneous biopsy, fine needle aspiration, surgical excision) from a suspicious area to evaluate for cancer. Expert-based quality measure programs support the need to establish a reasonable timeframe that encompasses this multi-step process. According to the Center for Disease Control and Prevention’s (CDC) Breast and Cervical Cancer Early Detection Program (BCCEDP), breast cancer screening to diagnostic resolution should occur within 60 days (DeGroff A et al., 2014). Published literature shows that long wait times to diagnostic evaluation are associated with increased tumor size and metastases in patients with delays exceeding 12 weeks (Olivetto IA et al., 2002; Ganry O et al., 2004). Federal requirements instituted by the Mammography Quality Standards Act (MQSA) are limited in their capacity to improve quality performance in different facilities as they do not provide guidelines on how to assess diagnostic timeliness (Rauscher GH et al., 2021). This eCQM can be used to address quality assessment gaps by monitoring timeliness and completeness of care in medical facilities and health systems looking to improve the breast cancer screening diagnostic process. |
| Clinical recommendation statement: |
See measure description. |
| Guidance (Usage): |
A higher score (expressed as a percentage) indicates higher quality care. |
| Population Criteria: |
| 65f87c1e80319060e1fd8738 |
| Initial Population: |
Patient aged between 40-75 with abnormal screening mammogram |
| Denominator: |
None |
| Numerator: |
Patient has a diagnostic mammography within 60 days after the abnormal screening mammogram |
|
| Libraries: |
| https://madie.cms.gov/Library/BreastCancerMeasureFHIR4 |
|
| Terminology and Other Dependencies: |
Library/FHIRHelpers|4.1.000
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1206.65
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1206.61
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.1903
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.1902
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1206.66
|
| Parameters: |
| name |
use |
min |
max |
type |
| Measurement Period |
in |
0 |
1 |
Period |
| Numerator |
out |
0 |
1 |
boolean |
| Denominator |
out |
0 |
1 |
boolean |
| Initial Population |
out |
0 |
1 |
boolean |
|
| DataRequirements: |
| Resource Type |
Resource Elements |
Valueset Name |
Valueset |
| Observation(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation) |
code
status
status.value
value
issued
issued.value
|
Screening Mammogram (Grouping)
|
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1206.61 |
| Observation(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation) |
code
status
status.value
value
issued
issued.value
|
Diagnostic Mammography
|
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1206.65 |
| Observation(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation) |
code
status
status.value
value
issued
issued.value
|
MRI of the Breast
|
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.1903 |
| Observation(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation) |
code
status
status.value
value
issued
issued.value
|
Ultrasound of the Breast
|
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.1902 |
| Observation(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation) |
issued
issued.value
|
|
|
| Procedure(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure) |
code
status
status.value
performed
|
Breast Cancer Biopsy and Surgical Excision
|
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1206.66 |
| Patient(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient) |
gender
gender.value
|
|
|
|
| Logic Definitions: |
| Group |
Scoring |
Population Criteria |
Expression |
| 65f87c1e80319060e1fd8738 |
Group scoring:
proportion
|
| Type: |
Process
|
| Improvement Notation: |
increase
|
|
|
Initial Population |
define "Initial Population":
AgeInYearsAt(start of "Measurement Period") in Interval[40, 75]
and Patient.gender = 'female'
and exists "Mammogram Screening with Abnormal Result"
|
|
|
Denominator |
define "Denominator":
"Initial Population"
|
|
|
Numerator |
define "Numerator":
"Has Follow-up Diagnostic Mammogram Within 60 Days of The Index Abnormal Screening Mammogram"
or "Has Follow-up MRI of the Breast Within 60 Days of The Index Abnormal Screening Mammogram"
or "Has Follow-up Ultrasound of the Breast Within 60 Days of The Index Abnormal Screening Mammogram"
or "Has Breast Biopsy Within 60 Days of The Index Abnormal Screening Mammogram"
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Follow-up Diagnostic Mammogram |
|
define "Follow-up Diagnostic Mammogram":
/***
* BI-RAD 1 means Negative
* BI-RAD 2 means Benign (non-cancerous) finding
* BI-RAD 3 Probably benign finding – Follow-up in a short time frame is suggested
***/
[Observation: "Diagnostic Mammography"] MammogramScreening
where MammogramScreening.status in { 'final', 'amended', 'corrected' }
and MammogramScreening.value in { '1', '2', '3' }
and MammogramScreening.value is not null
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Mammogram Screening with Abnormal Result |
|
define "Mammogram Screening with Abnormal Result":
/***
* BI-RAD 0 means Incomplete and additional imaging evaluation is needed
* BI-RAD 4 means Suspicious abnormality and biopsy should be considered
* BI-RAD 5 means Highly suggestive of malignancy
***/
[Observation: "Screening Mammogram (Grouping)"] MammogramScreening
where MammogramScreening.status in { 'final', 'amended', 'corrected' }
and MammogramScreening.value in { '0', '4', '4A', '4B', '4C', '5' }
and MammogramScreening.issued during "Measurement Period"
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Index Abnormal Screening Mammogram |
|
define "Index Abnormal Screening Mammogram":
First("Mammogram Screening with Abnormal Result" MS
sort by issued
)
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Has Follow-up Diagnostic Mammogram Within 60 Days of The Index Abnormal Screening Mammogram |
|
define "Has Follow-up Diagnostic Mammogram Within 60 Days of The Index Abnormal Screening Mammogram":
exists ( "Follow-up Diagnostic Mammogram" Mammogram
where Mammogram.issued 60 days or less after "Index Abnormal Screening Mammogram".issued
)
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Follow-up MRI of the Breast |
|
define "Follow-up MRI of the Breast":
/***
* BI-RAD 1 means Negative
* BI-RAD 2 means Benign (non-cancerous) finding
* BI-RAD 3 Probably benign finding – Follow-up in a short time frame is suggested
***/
[Observation: "MRI of the Breast"] mri
where mri.status in { 'final', 'amended', 'corrected' }
and mri.value in { '1', '2', '3' }
and mri.value is not null
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Has Follow-up MRI of the Breast Within 60 Days of The Index Abnormal Screening Mammogram |
|
define "Has Follow-up MRI of the Breast Within 60 Days of The Index Abnormal Screening Mammogram":
exists ( "Follow-up MRI of the Breast" MRI
where MRI.issued 60 days or less after "Index Abnormal Screening Mammogram".issued
)
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Follow-up Ultrasound of the Breast |
|
define "Follow-up Ultrasound of the Breast":
/***
* BI-RAD 1 means Negative
* BI-RAD 2 means Benign (non-cancerous) finding
* BI-RAD 3 Probably benign finding – Follow-up in a short time frame is suggested
***/
[Observation: "Ultrasound of the Breast"] ultrasound
where ultrasound.status in { 'final', 'amended', 'corrected' }
and ultrasound.value in { '1', '2', '3' }
and ultrasound.value is not null
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Has Follow-up Ultrasound of the Breast Within 60 Days of The Index Abnormal Screening Mammogram |
|
define "Has Follow-up Ultrasound of the Breast Within 60 Days of The Index Abnormal Screening Mammogram":
exists ( "Follow-up Ultrasound of the Breast" Ultrasound
where Ultrasound.issued 60 days or less after "Index Abnormal Screening Mammogram".issued
)
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Has Breast Biopsy Within 60 Days of The Index Abnormal Screening Mammogram |
|
define "Has Breast Biopsy Within 60 Days of The Index Abnormal Screening Mammogram":
exists ( [Procedure: "Breast Cancer Biopsy and Surgical Excision"] BreastBiopsyPerformed
where BreastBiopsyPerformed.status = 'completed'
and BreastBiopsyPerformed.performed starts 60 days or less on or after "Index Abnormal Screening Mammogram".issued
)
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Numerator |
|
define "Numerator":
"Has Follow-up Diagnostic Mammogram Within 60 Days of The Index Abnormal Screening Mammogram"
or "Has Follow-up MRI of the Breast Within 60 Days of The Index Abnormal Screening Mammogram"
or "Has Follow-up Ultrasound of the Breast Within 60 Days of The Index Abnormal Screening Mammogram"
or "Has Breast Biopsy Within 60 Days of The Index Abnormal Screening Mammogram"
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Initial Population |
|
define "Initial Population":
AgeInYearsAt(start of "Measurement Period") in Interval[40, 75]
and Patient.gender = 'female'
and exists "Mammogram Screening with Abnormal Result"
|
| Library Name |
Name |
| BreastCancerMeasureFHIR4 |
Denominator |
|
define "Denominator":
"Initial Population"
|
|