National Quality Forum #: 0028 / 0028e
Description: Percentage of patients1 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 user2,3
Numerator: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user
Denominator: All patients aged 18 years and older
Patient Exclusions: Documentation of medical reason(s) for not screening for tobacco use (e.g. limited life expectancy, other medical reasons)
Data Elements:
- Is patient 18 years or older? (Y/N)
- If yes, did the patient have 2 or more psychiatric, behavioral, or occupational therapy encounters OR 1 or more medical, wellness, or preventative encounters in the measurement period? (Y/N)
- If yes, did the patient receive a tobacco use screening? (Y/N)
- If tobacco user, did patient receive an intervention (counseling and/or pharmacotherapy? (Y/N)
- If yes, did the patient receive a tobacco use screening? (Y/N)
- If yes, did the patient have 2 or more psychiatric, behavioral, or occupational therapy encounters OR 1 or more medical, wellness, or preventative encounters in the measurement period? (Y/N)
***Greater measure specification detail, including data elements for each value set, is available at eCQI Resource Center (funded by the Centers for Medicare and Medicaid Services or CMS) eCQM Resources website. See also Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Measure: CMS138v10).
National goals, target, or benchmarks for comparison
The HIV Quality Measures (HIVQM) Module is a tool within the Ryan White HIV/AIDS Services Report portal. It allows recipients to enter aggregate data specific to HRSA HAB Performance Measures. The HIVQM Module allows recipients to conduct point-in-time benchmarking across Ryan White HIV/AIDS Programs that use the module.
Department of Health and Human Services Clinical Practice Guidelines
"The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco. (A recommendation) The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco. (A recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant persons. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of e-cigarettes for tobacco cessation in adults, including pregnant persons. The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety. (I statement)."4
Use in other federal programs
- CMS, Medicare and Medicaid EHR Incentive Program for Eligible Professionals, eCQM Library, Measure CMS138v10.
- This measure is linked to an exact or similar indicator(s) within the National HIV/AIDS Strategy (2022-2025).
References/notes
1 If tobacco use status of a patient is unknown, the patient cannot be counted in the numerator and should be considered a measure failure. Instances where tobacco use status of "unknown" is recorded include: 1) the patient was not screened; or 2) the patient was screened, and the patient (or caregiver) was unable to provide a definitive answer. If tobacco use status of "unknown" is recorded but the patient has an allowable medical exception, then the patient should be removed from the denominator of the measure and reported as a valid exception.
2 If a patient uses any type of tobacco (i.e., smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation: either counseling and/or pharmacotherapy.
3 The HIV/AIDS Bureau did not develop this measure. The American Medical Association-convened Physician Consortium for Performance Improvement (AMA- PCPI) developed this measure. More details are available on the eCQM Library and eCQM Resources websites.
4 Krist, Alex H., et al. "Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement." JAMA3 (2021): 265-279. Available online. Accessed January 2022.