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  • Measure Summary
  • NQMC:009931
  • Nov 2014
  • NQF-Endorsed Measure

Breast cancer screening: percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer.

National Committee for Quality Assurance (NCQA). HEDIS 2015 technical specifications for ACO measurement. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

This is the current release of the measure.

This measure updates a previous version: National Committee for Quality Assurance (NCQA). HEDIS 2013 technical specifications for ACO measurement. Washington (DC): National Committee for Quality Assurance (NCQA); 2012. various p.

The measure developer reaffirmed the currency of this measure in February 2017.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer.

Note from the National Quality Measures Clearinghouse (NQMC): For this measure, there are both Electronic and Hybrid Specifications. This NQMC measure summary is based on the Electronic specification. Refer to the original measure documentation for details pertaining to the Hybrid specification.

Rationale

Breast cancer is the second most common type of cancer among American women, with approximately 178,000 new cases reported each year (American Cancer Society [ACS], 2007). It is most common in women over 50. Women whose breast cancer is detected early have more treatment choices and better chances for survival. Mammography screening has been shown to reduce mortality by 20 to 30 percent among women 40 and older. A mammogram can reveal tumors too small to be felt by hand; it can also show other changes in the breast that may suggest cancer

The U.S. Preventive Services Task Force (USPSTF), the American Academy of Family Physicians (AAFP), and the American College of Preventive Medicine recommend mammograms as the most effective method for detecting breast cancer when it is most treatable (USPSTF, 2002; "AAFP periodic," 2005; Ferrini et al., 1996). When high-quality equipment is used and well-trained radiologists read the x-rays, 85 to 90 percent of cancers are detectable.

Evidence for Rationale

AAFP periodic health examinations: summary of AAFP policy recommendations & age charts. [internet]. [updated 2005 Apr 01]; [accessed 2005 Jun 01].

American Cancer Society (ACS). Cancer facts & figures 2007. Atlanta (GA): American Cancer Society (ACS); 2007. 52 p.

Ferrini R, Mannino E, Ramsdell E, Hill L. Screening mammography for breast cancer: American College of Preventive Medicine practice policy statement. Am J Prev Med. 1996 Sep-Oct;12(5):340-1. [14 references] PubMed External Web Site Policy

National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

U.S. Preventive Services Task Force (USPSTF). Screening for breast cancer. [internet]. 2002 Feb [accessed 2005 Jun 24].

Primary Health Components

Breast cancer; screening mammography

Denominator Description

Women 52 to 74 years as of December 31 of the measurement year (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

One or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

All HEDIS measures undergo systematic assessment of face validity with review by measurement advisory panels, expert panels, a formal public comment process and approval by the National Committee for Quality Assurance's (NCQA) Committee on Performance Measurement and Board of Directors. Once NCQA establishes national benchmarks for accountable care organization (ACO) performance, all measures will undergo formal reliability testing of the performance measure score using beta-binomiol statistical analysis. Where applicable, measures also are assessed for construct validity using the Pearson correlation test.

Evidence for Extent of Measure Testing

Rehm B. (Assistant Vice President, Performance Measurement, National Committee for Quality Assurance, Washington, DC). Personal communication. 2015 Apr 8.  1 p.

State of Use

Current routine use

Current Use

Accreditation

Collaborative inter-organizational quality improvement

Decision-making by consumers about health plan/provider choice

Decision-making by health plans about provider contracting

Internal quality improvement

Pay-for-performance

Public reporting

Measurement Setting

Accountable Care Organizations

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Allied Health Personnel

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Multisite Health Care or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age 50 to 74 years

Target Population Gender

Female (only)

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

December 31 of the measurement year

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window precedes index event

Denominator Inclusions/Exclusions

Inclusions
Women 52 to 74 years of age as of December 31 of the measurement year

Exclusions
Bilateral mastectomy any time during the patient's history through December 31 of the measurement year. Any of the following meet criteria for bilateral mastectomy:

  • Bilateral mastectomy (Bilateral Mastectomy Value Set)
  • Unilateral mastectomy (Unilateral Mastectomy Value Set) with a bilateral modifier (Bilateral Modifier Value Set)
  • Two unilateral mastectomies (Unilateral Mastectomy Value Set) with service dates 14 days or more apart.
  • Both of the following (on the same or a different date of service):
    • Unilateral mastectomy (Unilateral Mastectomy Value Set) with a right-side modifier (Right Modifier Value Set) (same date of service)
    • Unilateral mastectomy (Unilateral Mastectomy Value Set) with a left-side modifier (Left Modifier Value Set) (same date of service)

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS 2015 Technical Specifications for ACO Measurement, which includes the Value Set Directory.

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
One or more mammograms (Mammography Value Set) any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year

Exclusions
The purpose of this measure is to evaluate primary screening. Do not count biopsies, breast ultrasounds or magnetic resonance images (MRIs) because they are not appropriate methods for primary breast cancer screening.

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS 2015 Technical Specifications for ACO Measurement, which includes the Value Set Directory.

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Analysis by subgroup (stratification by individual factors, geographic factors, etc.)

Description of Allowance for Patient or Population Factors

The Accountable Care Organization (ACO) aggregate population is reported as a whole, with an option to report Medicaid separately for measures for which HEDIS Health Plan Measurement offers Medicaid specifications.

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Breast cancer screening (ABCS).

Measure Collection Name

HEDIS 2015: Accountable Care Organization (ACO) Collection

Measure Set Name

Effectiveness of Care

Measure Subset Name

Prevention and Screening

Submitter

National Committee for Quality Assurance - Health Care Accreditation Organization

Developer

National Committee for Quality Assurance - Health Care Accreditation Organization

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

National Committee for Quality Assurance's (NCQA's) Measurement Advisory Panels (MAPs) are composed of clinical and research experts with an understanding of quality performance measurement in the particular clinical content areas.

Financial Disclosures/Other Potential Conflicts of Interest

In order to fulfill National Committee for Quality Assurance's (NCQA's) mission and vision of improving health care quality through measurement, transparency and accountability, all participants in NCQA's expert panels are required to disclose potential conflicts of interest prior to their participation. The goal of this Conflict Policy is to ensure that decisions which impact development of NCQA's products and services are made as objectively as possible, without improper bias or influence.

Endorser

National Quality Forum

NQF Number

2372

Date of Endorsement

2016 Jun 10

Core Quality Measures

Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), and Primary Care

Adaptation

This measure was adapted from the HEDIS Technical Specifications for Health Plans ("HEDIS Health Plan Measurement") and HEDIS Physician Measurement.

Date of Most Current Version in NQMC

2014 Nov

Measure Maintenance

Annual

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: National Committee for Quality Assurance (NCQA). HEDIS 2013 technical specifications for ACO measurement. Washington (DC): National Committee for Quality Assurance (NCQA); 2012. various p.

The measure developer reaffirmed the currency of this measure in February 2017.

Source(s)

National Committee for Quality Assurance (NCQA). HEDIS 2015 technical specifications for ACO measurement. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

Measure Availability

Source available for purchase from the National Committee for Quality Measurement (NCQA) Web site External Web Site Policy.

For more information, contact NCQA at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 1, 2014.

This NQMC summary was updated by ECRI Institute on February 10, 2015.

The information was reaffirmed by the measure developer on February 6, 2017.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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