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ToxIC QCDR Measure Specifications

 

ACMT1: Screening for risk of opioid misuse/overuse

Description: Percentage of patients aged 12 years or older who were screened for the potential risk of opioid misuse/overuse

Numerator: Patients who were screened for the potential risk of opioid misuse/overuse with a standardized tool (e.g., DAST, ASSIST) or assessed for the presence of any of the following risk factors:

  • Patient survived an opioid overdose
  • Patient is taking more than prescribed
  • Patient is taking drugs prescribed for someone else
  • Patient currently prescribed both a benzodiazepine and opioid
  • Patient prescribed more than 50 mg morphine equivalents/day

Denominator: Patients aged 12 years or older.

Exclusions: None

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Measure Rationale: Opioid use and overdose deaths represent a significant public health issue, which has reached epidemic proportions (US DOJ, DEA 2015 National Drug Threat Assessment). Between 1999-2015, more than half a million Americans died from opioid poisoning, including a record number of more than 33,000 opioid-related overdose deaths in 2015. During 2015, an estimated 12,462,000 persons aged 12 years or older in the U.S. misused prescription pain relievers, and an estimated 828,000 persons in the U.S. aged 12 years or older used heroin (https://www.cdc.gov/drugoverdose/). These persons, with high-risk opioid use, have higher mortality than their matched counterparts (Drug & Alcohol Depend 2017;177:307-314, Am. J. Psychiatry 2012;169,:64–70 , J. Subst. Abuse Treat. 2012;43:221–230). These patients present in significant numbers to the healthcare system and incur significant healthcare costs. In 2014, nonfatal, unintentional opioid poisoning accounted for 92,262 emergency department visits and 53,000 hospitalizations (https://www.cdc.gov/drugoverdose/) This represents a 99.5% increase in opioid-related ED visits from 2005-2014 (Healthcare Cost and Utilization Project Statistical Briefs 2016; #216).

Measure Type: Process

Specialities measures applies to: Medical Toxicology; Emergency Medicine; Pediatrics; Internal Medicine; Family Practice

 

ACMT2: Pregnancy test in women who receive a toxicologic consult

Description: Percentage of women of childbearing age (12-60 years) who are seen by a medical toxicologist in the emergency department or inpatient setting and receive a pregnancy test prior to emergency department discharge or within 24 hours of hospital admission.

Numerator: Patients who receive a pregnancy test prior to emergency department discharge or within 24 hours of hospital admission.

Denominator: Women of childbearing age (12-60 years) who receive a toxicologic consult

Exclusions: Women who have had a hysterectomy or oophorectomy; minor dermal caustic exposure; Woman who are post-menopausal

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Measure Rationale: Epidemiology of non-natural deaths in pregnancy suggest that 12% may be suicide or accidental overdose (Violence Against Women. 2016 Sep 1. pii: 1077801216663658). Prospective poison center data has shown that up to 12% of women who attempt suicide may be pregnant and 10% of the substances they ingest are known abortifacients (Acad Emerg Med 1997;4:206-9). Management of poisoning can change dramatically if the patient is pregnant. Pregnancy itself is associated with significant factors (e.g. psychosocial stress, mood alteration, economic stress, interpersonal violence) that may increase the chance of suicidal behavior. It is estimated that 5% of birth defects are linked to pharmaceuticals, occupational, or environmental exposures (Tetrology 1991;43:543-546). Yet, toxicologic exposures in pregnancy that result in adverse outcomes have the potential to create a lifetime of medical issues and a heavy socioeconomic burden. Early identification of maternal fetal risk and management thereof can greatly improve outcomes.

Measure Type: Process 

Specialities measures applies to: Medical Toxicology

 

ACMT3: EKG assessment in acute overdoses

Description: Percentage of drug overdose patients with EKG QRS and QTC duration assessment within 60 minutes of arrival to the emergency department.

Numerator: Patients who have an EKG QRS and QTC duration assessment within 60 minutes of arrival to the emergency department.

Denominator: All intentional pharmaceutical overdoses of any age.

Exclusions: Patients who present to the emergency department in cardiac arrest; exploratory pediatric ingestions with non-cardiotoxic ingestions

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Measure Rationale: Cardiotoxicity from xenobiotics involved in overdose is a major cause of poisoning morbidity and mortality. Screening and clinical vigilance can identify early warning signs of cardiovascular decompensation. A review of electrocardiography use states “Including ECG interpretation in the initial approach can provide key information to guide management” (Curr Cardiol Rev. 2012 May; 8(2): 137–151). A prospective validation cohort study found an increased risk of adverse cardiovascular events in adults with suspected acute drug overdose who had either QTc prolongation, non sinus rhythm, ectopy, evidence of myocardial ischemia, increased QT dispersion, or evidence of sodium channel blockade on EKG obtained within one hour of arrival to the emergency department (J Am Heart Assoc. 2017 Feb 3;6(2). pii: e004320. doi: 10.1161/JAHA.116.004320). A leading textbook in medical toxicology recommends that a 12 lead electrocardiogram be obtained on any patient with altered mental status (Goldfrank’s Toxicologic Emergencies, 10th Ed. Hoffman RS, Howland MA, Lewin NA, et al, Eds. New York: McGraw-Hill Education, 2015). Furthermore, a commentary by a respected medical toxicologist recommends obtaining an EKG on a poisoned patient upon hospital arrival (Clin Tox 37(1): 113-5; 1999). Therefore, prompt EKG interpretation is important in managment of toxicologic patients.

Measure Type: Process

Specialities measures applies to: Medical Toxicology; Emergency Medicine

 

ACMT4: Appropriate treatment for acetaminophen ingestions

Description: % of patients of any age with an acetaminophen ingestion for which n-acetylcysteine (NAC) was initiated and discontinued appropriately

Numerator: Patients for whom n-acetylcysteine (NAC) was received within 2 hours of presentation, and patients for whom NAC treatment was discontinued appropriately.

   Appropriate initiation of NAC for an acetaminophen ingestion includes any of the following:
  • Patients with an acute single acetaminophen ingestion with a Rumack-Matthew Nomogram result above the treatment line (150 mcg/mL), or;
  • ALT concentration above the normal hospital reference range in the absence of a known alternative explanation for the AST elevation, or;
  • An acetaminophen concentration > 10 mcg/mL when the time of ingestion is unknown or time of ingestion is > 24 hours.
   Appropriate discontinuation of NAC is defined as:
  • ALT concentration is normal or decreasing (as defined as >25% reduction in ALT) and no signs of hepatic failure, and;
  • A repeat acetaminophen concentration should also be <10 mcg/mL prior to discontinuation of n-acetylcysteine.

Denominator: Patients of any age with an acetaminophen ingestion requiring n-acetylcysteine treatment.

Exclusions: 
  • Hepatic failure as defined by hepatic encephalopathy and INR > 1.5
  • Patients with an acute single acetaminophen ingestion occurring less than 4 hours prior to presentation
  • Patients taking therapeutic doses of acetaminophen
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Measure Rationale: Acetaminophen toxicity is the leading cause of acute hepatic failure in the United States (Hepatology 2005;42:1364-1372). Acetaminophen containing substances account for over 15% of all fatalities from pharmaceuticals, over 100,000 patient exposures and over 30,000 hospitalizations reported to the National Poison Center Database in 2015 (Clin Toxicol 2016;54:924-1109). As Poison Center data collection is passive, it can be expected that the true numbers of acute acetaminophen ingestion are higher than reported. Regardless, acetaminophen exposures are one of the most common poisoning presentations to the emergency department and there is clear evidence that timely treatment for at-risk patients can reduce patient mortality and complications such as hepatic injury. The Rumack-Matthew nomogram is one of the most sensitive screening tools used in medicine with an estimated sensitivity of >97% in determining hepatic injury after acetaminophen poisoning (Clin Toxicol 2002;40:3-20). Treatment at the 150-line was used in the US National Multi-center Open Study of Oral N-Acetylcysteine (NAC) for the Treatment of APAP Overdose and ensures that patients who are at risk will have improved outcomes and reduced mortality (Clin Toxicol 2012;50:91-98; BMJ 1979;2:1097-1100, NEJM 1988;319:1557-1562; Lancet 1990;335:1572-1573; BMJ 1991;303:1026-1029). It also minimizes overuse of NAC in those patients with levels less than 150 mcg/mL for whom there is less risk of damage to the liver (Clin Toxicol 2012;50:91-98).

Measure Type: Process; High Priority; Patient Safety

Specialities measures applies to: Medical Toxicology; Emergency Medicine

 

ACMT5: Assessment of suspected ethylene glycol or methanol exposures

Description: Percentage of patients of any age with suspected exposure to ethylene glycol or methanol for whom appropriate laboratory testing was performed within 4 hours of presentation.

Numerator: Patients for whom the appropriate laboratory testing was completed within 4 hours of presentation

     Appropriate laboratory testing includes at least one of the following tests:

  • Measurement of the serum concentration of the involved substance
  • Calculated osmol gap

Denominator: Patients of any age with suspected exposure to ethylene glycol or methanol

Exclusions: Serum osmolality and quantitative ethylene glycol/methanol testing not available; unintentional accidental ingestions of ethylene glycol or methanol

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Measure Rationale: Approximately 8,500 cases of methanol (MeOH) and ethylene glycol (EG) exposures are reported to American Association of Poison Control Centers (AAPCC) on a yearly basis; about 1,600 per year are evaluated in the hospital setting (Sem in Dial. 2014; 27(4):395). Based on AAPCC data, of these cases that present to a healthcare facility ‘major effect’ is reported in 9.5% and 20.5% of MeOH and EG cases, respectively, while mortality is 2.9% and 2.4%, respectively (Sem in Dial. 2014; 27(4):395, Clin Tox. 2016; 54:924-1109). The prevalence of toxic alcohol poisoning is likely underestimated as reporting to Poison Control Centers is voluntary. An efficacious antidote for toxic alcohol poisoning, 4-methylpyrazole (fomepizole, Antizol©), is widely available, and when administered early after ingestion, prevents mortality and significant morbidity (NEJM. 1999; 340:832, NEJM. 2001; 344:424, NEJM. 2009; 360:2216, Clin Tox. 1999; 37(5):537, Clin Tox. 2002; 40(4):415). Initial, early symptoms of toxic alcohol poisoning mimic ethanol intoxication. Intervention during this early phase of intoxication is associated with positive outcomes (J Intensive Care Med. 2015; 30(5):270, Hum Exp Toxicol. 2007; 26:583, Clin Tox. 1998; 36(3):175, Ther Clin Risk Manag. 2014; 10:61, J Pak Med Assoc. 2017; 67(11):1751). However, patients who present to healthcare and already exhibit symptoms, signs, and laboratory derangement consistent with delayed toxic alcohol toxicity or in whom the diagnosis is delayed have poorer outcomes than those presenting early after ingestion (J Intensive Care Med. 2015; 30(5):270, Hum Exp Toxicol. 2007; 26:583, Clin Tox. 1998; 36(3):175, Ther Clin Risk Manag. 2014; 10:61, J Pak Med Assoc. 2017; 67(11):1751). Mortality from toxic alcohol exposure is prevented by early antidotal therapy. As mortality and morbidity from MeOH and EG are due to metabolites (formic acid and glycolic/oxalic acid, respectively) early antidotal therapy which prevents toxic alcohol metabolism logically prevents or mitigates organ damage. Thus, the National Poisons Information Service and the Association of Clinical Biochemists strongly recommend rapid definitive testing for MeOH or EG exposure (Ann Clin Biochem. 2002; 39:328).

Measure Type: Process; High Priority; Patient Safety 

Specialities measures applies to: Medical Toxicology; Emergency Medicine

 

ACMT6: Repeat assessment of salicylate concentrations in overdose patients

Description: Percentage of patients of any age with suspected drug overdose with an initial plasma salicylate concentration >15 mg/dL who had a second plasma salicylate concentration sample collected within 4 hours following the time the initial sample was obtained

Numerator: Patients who received a second plasma salicylate concentration within 4 hours following the initial test

Denominator: Patients of any age with suspected drug overdose with an initial plasma salicylate concentration > 15 mg/dL

Exclusions: Patients who died within 4 hours of the initial test; Patients who did not experience a drug overdose; patients on hemodialysis within 4 hours of initial test.

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Measure Rationale: Individuals with salicylate overdose typically have signs and symptoms of toxicity such as hyperventilation, abdominal discomfort, tinnitus, or muffled hearing. However, in patients with altered mental status following a poly-drug ingestion, these clinical features are often obscured by coingestants. Serum salicylate concentrations may rise late or fluctuate following acute overdose, so clinical decisions should not be based on a single value. Because a number of factors such as coingestants, chronicity, and serum pH, influence the clinical manifestations of salicylate toxicity, interpretation of serum levels is complex. Sedation and endotracheal intubation are high risk procedures that are associated with significant mortality in salicylate toxic patients, particularly if the salicylate toxicity is unrecognized (Clin Toxicol (2009) 47: 739 [Abstract]; Acad Emerg Med (2008) 15: 866). A study of salicylate and acetaminophen screening in 1820 suspected overdose patients found that 6.1% had detectable salicylate without a history of salicylate ingestion (Am J Emerg Med (1996) 14: 443). In acute overdose, systemic salicylate absorption can be delayed and erratic, making reliance on a single serum concentration problematic. Although controlled studies are lacking, multiple case reports have documented late peaks in salicylate concentration with delayed toxicity (Am J Emerg Med (2009) 27: 1173e1; J Med Toxicol (2010) 6: 150; Clin Toxicol (2013) 51: 677, abstract 226). Therefore, prompt identification and serial salicylate measurements are necessary in the appropriate management of poisoned patients.

Measure Type: Process; High Priority; Patient Safety 

Specialities measures applies to: Medical Toxicology; Critical Care Medicine; Emergency Medicine

 

 

PREVIOUS DEVELOPED PQRS MEASURES INCLUDED IN THE ToxIC QCDR

PQRS 130: Documentation of Current Medications in the Medical Record

Description: Percentage of visits for patients aged 18 years and older for which the eligible clinician 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-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration

Numerator: Eligible clinician attests to documenting, updating or reviewing a patient s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route of administration.

Denominator: All visits for Patients aged 18 years and older.

Exclusions: Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician

 

PQRS 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Nominator: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. 

Denominator: All patients aged 18 years and older

Exclusions: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy

  

PQRS 402: Tobacco Use and Help with Quitting Among Adolescents

Description: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

Nominator: Patients who were screened for tobacco use at least once within 18 months (during the measurement period or the six months prior to the measurement period) AND who received tobacco cessation counseling intervention if identified as a tobacco user

Denominator: All patients aged 12-20 years with a visit during the measurement period.

Exclusions: None

  

PQRS 431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user

Numerator: Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.

Denominator: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.

Exclusions: Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectanc