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Measure: CMS117

Childhood Immunization Status

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS117v12 2024 12.0.000 Childhood Immunization Status
CMS117v11 2023 11 Childhood Immunization Status
CMS117v10 2022 10.0.000 Childhood Immunization Status
CMS117v9 2021 9.2.000 Childhood Immunization Status
CMS117v8 2020 8.3.000 Childhood Immunization Status
CMS117v7 2019 7.2.000 Childhood Immunization Status
CMS117v6 2018 6.2.000 Childhood Immunization Status
CMS117v5 2017 5.1.000 Childhood Immunization Status

Description

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

Guidance

For the MMR, hepatitis B, VZV and hepatitis A vaccines, numerator inclusion criteria include: evidence of receipt of the recommended vaccine; documented history of the illness; or, a seropositive test result for the antigen. For the DTaP, IPV, HiB, pneumococcal conjugate, rotavirus, and influenza vaccines, numerator inclusion criteria include only evidence of receipt of the recommended vaccine. Patients may be included in the numerator for a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be included in the numerator for the DTaP vaccine if they have encephalopathy. Patients may be included in the numerator for the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin. Patients may be included in the numerator for the influenza, MMR, or VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have Immunodefiency, or have HIV. Patients may be included in the numerator for the hepatitis B vaccine if they have had an anaphylactic reaction to common baker's yeast. The measure allows a grace period by measuring compliance with these recommendations between birth and age two.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationChildren who turn 2 years of age during the measurement period and who have a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsExclude patients whose hospice care overlaps the measurement periodWebchart Instructions
NumeratorChildren who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthdayWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS117v8 117 2020 8.3.000 Not Applicable b2802b7a-3580-4be8-9458-921aea62b78c
Steward Developer Endorsed By
National Committee for Quality Assurance National Committee for Quality Assurance
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation

None

Improvement Notation

Higher score equals better quality

Rationale

Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (Centers for Disease Control and Prevention 2017a). Most childhood vaccines are between 90 and 99 percent effective in preventing diseases (HealthyChildren 2015). Vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease and saves nearly $14 billion in direct costs and $69 billion in societal costs each year (Zhou 2014). Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (Centers for Disease Control and Prevention 2017b). When the majority of the community is immunized against a disease, other members of the community are also protected because herd immunity shields them. (National Institute of Allergy and Infectious Diseases 2014).

Clinical Recommendation Statement

Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2018 (Centers for Disease Control and Prevention 2018)

Hepatitis B (HepB)
"Minimum age: birth"
"Birth Dose (Monovalent HepB vaccine only):
-- Mother is HBsAg-Negative: 1 dose within 24 hours of birth for medically stable infants >2,000 grams. Infants <2,000 grams administer 1 dose at
chronological age 1 month or hospital discharge.
-- Mother is HBsAg-Positive: Give HepB vaccine and 0.5 mL of HBIG (at separate anatomic sites) within 12 hours of birth, regardless of birth weight. Test for HBsAg and anti-HBs at age 9–12 months. If HepB series is delayed, test 1–2 months after final dose.
-- Mother’s HBsAg status is unknown: Give HepB vaccine within 12 hours of birth, regardless of birth weight. For infants <2,000 grams, give 0.5 mL of HBIG in addition to HepB vaccine within 12 hours of birth. Determine mother’s HBsAg status as soon as possible. If mother is HBsAg-positive, give 0.5 mL of HBIG to infants >2,000 grams as soon as possible, but no later than 7 days of age.
Routine Series:
-- A complete series is 3 doses at 0, 1–2, and 6–18 months. (Monovalent HepB vaccine should be used for doses given before age 6 weeks.)
-- Infants who did not receive a birth dose should begin the series as soon as feasible.
-- Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
-- Minimum age for the final (3rd or 4th) dose: 24 weeks.
-- Minimum Intervals: Dose 1 to Dose 2: 4 weeks / Dose 2 to Dose 3: 8 weeks / Dose 1 to Dose 3: 16 weeks. (When 4 doses are given, substitute "Dose 4" for "Dose 3" in these calculations.) "

Diptheria, tetanus, acellular pertussis vaccinations (DTap)
"Minimum age: 6 weeks [4 years for Kinrix or Quadracel] "
"Routine vaccination:
-- 5-dose series at 2, 4, 6, and 15–18 months, and 4–6 years.
Prospectively: A 4th dose may be given as early as age 12 months if at least 6 months have elapsed since the 3rd dose.
Retrospectively: A 4th dose that was inadvertently given as early as 12 months may be counted if at least 4 months have elapsed since the 3rd dose. "

Hib (Haemophilus influenzae type b)
"Minimum age: 6 weeks"
"Routine vaccination:
-- ActHIB, Hiberix, or Pentacel: 4-dose series at 2, 4, 6, and 12–15 months.
-- PedvaxHIB: 3-dose series at 2, 4, and 12–15 months."
-- 

Polio (IPV) 
"Minimum age: 6 weeks"
"Routine vaccination:
-- 4-dose series at ages 2, 4, 6–18 months, and 4–6 years. Administer the final dose on or after the 4th birthday and at least 6 months after the previous dose."

Measles, mumps, rubella (MMR)
"Minimum age: 12 months for routine vaccination"
"Routine vaccination:
-- 2-dose series at 12–15 months and 4–6 years.
-- The 2nd dose may be given as early as 4 weeks after the 1st dose. "

Pneumococcal conjugate (PCV13)
"Minimum age: 6 weeks [PCV13]"
"Routine vaccination with PCV13:
-- 4-dose series at 2, 4, 6, and 12–15 months. "

Varicella (Var) 
"Minimum age: 12 months"
"Routine vaccination:
-- 2-dose series: 12–15 months and 4–6 years.
-- The 2nd dose may be given as early as 3 months after the 1st dose (a dose given after a 4-week interval may be counted)."

Hepatitis A (HepA)
"Minimum age: 12 months"
"Routine vaccination:
-- 2 doses, separated by 6-18 months, between the 1st and 2nd birthdays. (A series begun before the 2nd birthday should be completed even if the child turns 2 before the second dose is given.)"

Rotavirus (RV) 
"Minimum age: 6 weeks"
"Routine vaccination:
Rotarix: 2-dose series at 2 and 4 months.
RotaTeq: 3-dose series at 2, 4, and 6 months.
If any dose in the series is either RotaTeq or unknown, default to 3-dose series. "

 
Influenza (inactivated influenza vaccine (IIV) 
"Minimum age: 6 months"
"Routine vaccination:
-- Administer an age-appropriate formulation and dose of influenza vaccine annually. Children 6 months–8 years who did not receive at least 2 doses of influenza vaccine before July 1, 2017 should receive 2 doses separated by at least 4 weeks. "

Definition

Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the Advisory Committee on Immunization Practices (ACIP) for children two years of age. The measure may differ slightly from the ACIP recommendations because the measure focuses on immunizations that are appropriate by age 2. Also, there may be small differences when there are shortages for a particular vaccine.

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Diagnosis Anaphylactic Reaction to Common Baker's Yeast 2.16.840.1.113883.3.464.1003.199.12.1032
Diagnosis Anaphylactic Reaction to DTaP Vaccine 2.16.840.1.113883.3.464.1003.199.12.1031
Diagnosis Anaphylactic Reaction to Hepatitis A Vaccine 2.16.840.1.113883.3.464.1003.199.12.1026
Diagnosis Disorders of the Immune System 2.16.840.1.113883.3.464.1003.120.12.1001
Diagnosis Encephalopathy due to Childhood Vaccination 2.16.840.1.113883.3.464.1003.114.12.1007
Diagnosis Hepatitis A 2.16.840.1.113883.3.464.1003.110.12.1024
Diagnosis Hepatitis B 2.16.840.1.113883.3.464.1003.110.12.1025
Diagnosis HIV 2.16.840.1.113883.3.464.1003.120.12.1003
Diagnosis Intussusception 2.16.840.1.113883.3.464.1003.199.12.1056
Diagnosis Malignant Neoplasm of Lymphatic and Hematopoietic Tissue 2.16.840.1.113883.3.464.1003.108.12.1009
Diagnosis Measles 2.16.840.1.113883.3.464.1003.110.12.1053
Diagnosis Mumps 2.16.840.1.113883.3.464.1003.110.12.1032
Diagnosis Rubella 2.16.840.1.113883.3.464.1003.110.12.1037
Diagnosis Severe Combined Immunodeficiency 2.16.840.1.113883.3.464.1003.120.12.1007
Diagnosis Varicella Zoster 2.16.840.1.113883.3.464.1003.110.12.1039
Encounter, Performed Encounter Inpatient 2.16.840.1.113883.3.666.5.307
Encounter, Performed Home Healthcare Services 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed Office Visit 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed Preventive Care - Established Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1024
Encounter, Performed Preventive Care- Initial Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1022
Intervention, Order Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Laboratory Test, Performed Anti Hepatitis B Virus Surface Ab 2.16.840.1.113883.3.464.1003.198.12.1073
Laboratory Test, Performed Hepatitis A Antigen Test 2.16.840.1.113883.3.464.1003.198.12.1033
Laboratory Test, Performed Measles Antibody Test (IgG Antibody presence) 2.16.840.1.113883.3.464.1003.198.12.1060
Laboratory Test, Performed Measles Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1059
Laboratory Test, Performed Mumps Antibody Test (IgG Antibody presence) 2.16.840.1.113883.3.464.1003.198.12.1062
Laboratory Test, Performed Mumps Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1061
Laboratory Test, Performed Rubella Antibody Test (IgG Antibody presence) 2.16.840.1.113883.3.464.1003.198.12.1064
Laboratory Test, Performed Rubella Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1063
Laboratory Test, Performed Varicella Zoster Antibody Test (IgG Antibody Presence) 2.16.840.1.113883.3.464.1003.198.12.1067
Laboratory Test, Performed Varicella Zoster Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1066
Patient Characteristic Ethnicity Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex ONC Administrative Sex 2.16.840.1.113762.1.4.1
Procedure, Performed DTaP Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1022
Procedure, Performed Hepatitis A Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1041
Procedure, Performed Hepatitis B Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1042
Procedure, Performed HiB Vaccine (3 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1084
Procedure, Performed HiB Vaccine (4 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1086
Procedure, Performed Inactivated Polio Vaccine (IPV) Administered 2.16.840.1.113883.3.464.1003.110.12.1045
Procedure, Performed Influenza Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1044
Procedure, Performed Measles, Mumps and Rubella (MMR) Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1031
Procedure, Performed Pneumococcal Conjugate Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1046
Procedure, Performed Rotavirus Vaccine (2 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1048
Procedure, Performed Rotavirus Vaccine (3 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1047
Procedure, Performed Varicella Zoster Vaccine (VZV) Administered 2.16.840.1.113883.3.464.1003.110.12.1040

References

Centers for Disease Control and Prevention. 2017a. "Infant Immunizations FAQs" https://www.cdc.gov/vaccines/parents/parent-questions.html
HealthyChildren. 2015. "Safety & Prevention: Why Immunize Your Child." https://www.healthychildren.org/english/safety-prevention/immunizations/Pages/Why-Immunize-Your-Child.aspx
Zhou, F., A. Shefer, J. Wenger, et al. 2014. "Economic Evaluation of the Routine Childhood Immunization Program in the United States, 2009." Pediatrics "133(4). doi:10.1542/peds.2013-0698d.
National Institute of Allergy and Infectious Diseases. 2014. " Vaccine Benefits" https://www.niaid.nih.gov/research/vaccine-benefits
Centers for Disease Control and Prevention. 2018. "Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2018." https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
Centers for Disease Control and Prevention. 2017b. "Vaccines & Immunizations: Why Are Childhood Vaccines So Important?" https://www.cdc.gov/vaccines/vac-gen/howvpd.htm

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. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Copyright

This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2019 National Committee for Quality Assurance. All Rights Reserved. 

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Source: https://ecqi.healthit.gov/ecqm/measures/cms117v8