measure-evaluate: subject push-down for all 12 measures

Author: Alexandra Pavlyshina

aidbox-custom-operations/measure-evaluate/app/evaluate_measure.py

@@ -144,8 +144,18 @@ def build_evidence_sql(measure_sql: str, evidence_sql_fragment: str,
 def build_patient_sql(measure_sql: str, patient_id: str | None) -> str:
     """Convert aggregate measure SQL to patient-level query.
 
-    Replaces the final SELECT COUNT(*) with a patient-level SELECT,
-    optionally filtered to a single patient.
+    Replaces the final SELECT COUNT(*) with a patient-level SELECT.
+
+    Push-down behavior: when patient_id is provided, this function does two things:
+      1. Substitutes `-- $SUBJ$ <col-expr>` markers in CTEs with
+         `AND <col-expr> = '<pid>'`. The col-expr can be a simple
+         `e.patient_id` or a raw JSONB path (e.g. `o.resource->'subject'->>'id'`).
+      2. Pushes the patient filter into the outer FROM clause as
+         `WHERE id = '<pid>'` instead of a top-level WHERE on the joined result.
+      3. Replaces `/*$SUBJ_PARAM$*/` with `, '<pid>'` to pass the subject
+         to shared exclusion functions.
+
+    Measures without these markers keep old behavior (outer WHERE only).
     """
     # Find where the final SELECT starts
     idx = measure_sql.rfind("\nSELECT\n    COUNT(*)")
@@ -157,10 +167,23 @@ def build_patient_sql(measure_sql: str, patient_id: str | None) -> str:
 
     ctes = measure_sql[:idx]
 
-    patient_filter = ""
     if patient_id:
         pid = _sanitize_patient_id(patient_id)
-        patient_filter = f"\n    WHERE ap.patient_id = '{pid}'"
+        # Marker-based push-down (no-op when markers absent in measure SQL)
+        ctes = re.sub(
+            r"--\s*\$SUBJ\$\s+(.+?)\s*$",
+            lambda m: f"AND {m.group(1)} = '{pid}'",
+            ctes,
+            flags=re.MULTILINE,
+        )
+        ctes = ctes.replace("/*$SUBJ_PARAM$*/", f", '{pid}'")
+        outer_from = (
+            f"FROM (SELECT id AS patient_id FROM patient_flat WHERE id = '{pid}') ap"
+        )
+    else:
+        # Population mode — remove SUBJ_PARAM markers entirely (no-op comment)
+        ctes = ctes.replace("/*$SUBJ_PARAM$*/", "")
+        outer_from = "FROM (SELECT id AS patient_id FROM patient_flat) ap"
 
     # Detect multi-group numerators (numerator_2, numerator_3, ...)
     extra_nums = []
@@ -182,11 +205,10 @@ def build_patient_sql(measure_sql: str, patient_id: str | None) -> str:
     CASE WHEN ip.patient_id IS NOT NULL THEN 1 ELSE 0 END AS den,
     CASE WHEN ip.patient_id IS NOT NULL AND de.patient_id IS NOT NULL THEN 1 ELSE 0 END AS exc,
     CASE WHEN ip.patient_id IS NOT NULL AND de.patient_id IS NULL AND n.patient_id IS NOT NULL THEN 1 ELSE 0 END AS num{extra_select}
-FROM (SELECT id AS patient_id FROM patient_flat) ap
+{outer_from}
 LEFT JOIN initial_population ip ON ip.patient_id = ap.patient_id
 LEFT JOIN denominator_exclusion de ON de.patient_id = ap.patient_id
 LEFT JOIN numerator n ON n.patient_id = ap.patient_id{extra_join}"""
-        + patient_filter
         + "\nORDER BY ap.patient_id;"
     )
     return patient_sql

aidbox-custom-operations/measure-evaluate/sql/02-shared-exclusions.sql

@@ -2,17 +2,43 @@
 -- Reusable SQL functions for exclusion blocks shared across multiple measures.
 -- Eliminates ~100 lines of copy-paste per measure.
 --
+-- Each function accepts an optional p_subject parameter (DEFAULT NULL).
+--   p_subject IS NULL  → population mode (scan whole cohort, used by population reports)
+--   p_subject = '<id>' → subject mode (filter early via ix_*_subject indexes; ~100× faster)
+--
+-- Existing 2-arg callers (shared_hospice(mp.mp_start, mp.mp_end)) continue to work — the
+-- subject parameter defaults to NULL and the filter condition becomes a no-op.
+--
 -- Usage in measure SQL (LATERAL pattern):
 --   hospice AS (SELECT h.* FROM mp, LATERAL shared_hospice(mp.mp_start, mp.mp_end) h),
 --   palliative AS (SELECT h.* FROM mp, LATERAL shared_palliative(mp.mp_start, mp.mp_end) h),
---   ...
+--
+-- With push-down for a specific patient:
+--   hospice AS (SELECT h.* FROM mp, LATERAL shared_hospice(mp.mp_start, mp.mp_end, $subject) h),
 --
 -- Prerequisites: shared/sql/01-views.sql (flat views must exist)
 
+-- ============================================================
+-- Drop existing functions in reverse-dependency order.
+-- shared_advanced_illness_frailty depends on the other three (frailty/illness/dementia),
+-- so it must be dropped first.
+-- ============================================================
+DROP FUNCTION IF EXISTS shared_advanced_illness_frailty(timestamptz, timestamptz);
+DROP FUNCTION IF EXISTS shared_hospice(timestamptz, timestamptz);
+DROP FUNCTION IF EXISTS shared_palliative(timestamptz, timestamptz);
+DROP FUNCTION IF EXISTS shared_has_frailty(timestamptz, timestamptz);
+DROP FUNCTION IF EXISTS shared_advanced_illness(timestamptz, timestamptz);
+DROP FUNCTION IF EXISTS shared_dementia_meds(timestamptz, timestamptz);
+DROP FUNCTION IF EXISTS shared_nursing_home(timestamptz, timestamptz);
+
 -- ============================================================
 -- HOSPICE (6 sub-checks) — used by 9 measures
 -- ============================================================
-CREATE OR REPLACE FUNCTION shared_hospice(p_mp_start timestamptz, p_mp_end timestamptz)
+CREATE OR REPLACE FUNCTION shared_hospice(
+    p_mp_start timestamptz,
+    p_mp_end timestamptz,
+    p_subject text DEFAULT NULL
+)
 RETURNS TABLE(patient_id text) AS $$
   SELECT DISTINCT patient_id FROM (
     -- Inpatient discharge to hospice
@@ -25,6 +51,7 @@ RETURNS TABLE(patient_id text) AS $$
         AND e.period_end <= p_mp_end AND e.period_end >= p_mp_start
         AND (r.resource->'hospitalization'->'dischargeDisposition'->'coding'->0->>'code'
             IN ('428361000124107', '428371000124100'))
+        AND (p_subject IS NULL OR e.patient_id = p_subject)
     UNION ALL
     -- Hospice encounter
     SELECT e.patient_id
@@ -34,6 +61,7 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE e.status = 'finished'
         AND e.period_start <= p_mp_end
         AND (e.period_end IS NULL OR e.period_end >= p_mp_start)
+        AND (p_subject IS NULL OR e.patient_id = p_subject)
     UNION ALL
     -- Hospice observation (LOINC 45755-6 = yes)
     SELECT o.patient_id
@@ -43,6 +71,7 @@ RETURNS TABLE(patient_id text) AS $$
         AND o.status IN ('final', 'amended', 'corrected')
         AND o.effective_start <= p_mp_end
         AND (o.effective_end IS NULL OR o.effective_end >= p_mp_start)
+        AND (p_subject IS NULL OR o.patient_id = p_subject)
     UNION ALL
     -- Hospice order (ServiceRequest)
     SELECT sr.patient_id
@@ -52,6 +81,7 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE sr.status IN ('active', 'completed')
         AND sr.intent IN ('order', 'original-order', 'reflex-order', 'filler-order', 'instance-order')
         AND sr.authored_on >= p_mp_start AND sr.authored_on <= p_mp_end
+        AND (p_subject IS NULL OR sr.patient_id = p_subject)
     UNION ALL
     -- Hospice procedure
     SELECT pr.patient_id
@@ -61,6 +91,7 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE pr.status = 'completed'
         AND pr.performed_start <= p_mp_end
         AND (pr.performed_end IS NULL OR pr.performed_end >= p_mp_start)
+        AND (p_subject IS NULL OR pr.patient_id = p_subject)
     UNION ALL
     -- Hospice diagnosis
     SELECT c.patient_id
@@ -71,13 +102,18 @@ RETURNS TABLE(patient_id text) AS $$
         OR c.verification_status IN ('confirmed', 'unconfirmed', 'provisional', 'differential'))
         AND c.onset_date <= p_mp_end
         AND (c.abatement_date IS NULL OR c.abatement_date >= p_mp_start)
+        AND (p_subject IS NULL OR c.patient_id = p_subject)
   ) sub
 $$ LANGUAGE sql STABLE;
 
 -- ============================================================
 -- PALLIATIVE CARE (4 sub-checks) — used by 5 measures
 -- ============================================================
-CREATE OR REPLACE FUNCTION shared_palliative(p_mp_start timestamptz, p_mp_end timestamptz)
+CREATE OR REPLACE FUNCTION shared_palliative(
+    p_mp_start timestamptz,
+    p_mp_end timestamptz,
+    p_subject text DEFAULT NULL
+)
 RETURNS TABLE(patient_id text) AS $$
   SELECT DISTINCT patient_id FROM (
     -- Palliative observation (LOINC 71007-9)
@@ -87,6 +123,7 @@ RETURNS TABLE(patient_id text) AS $$
         AND o.status IN ('final', 'amended', 'corrected')
         AND o.effective_start <= p_mp_end
         AND (o.effective_end IS NULL OR o.effective_end >= p_mp_start)
+        AND (p_subject IS NULL OR o.patient_id = p_subject)
     UNION ALL
     -- Palliative diagnosis
     SELECT c.patient_id
@@ -97,6 +134,7 @@ RETURNS TABLE(patient_id text) AS $$
         OR c.verification_status IN ('confirmed', 'unconfirmed', 'provisional', 'differential'))
         AND c.onset_date <= p_mp_end
         AND (c.abatement_date IS NULL OR c.abatement_date >= p_mp_start)
+        AND (p_subject IS NULL OR c.patient_id = p_subject)
     UNION ALL
     -- Palliative encounter
     SELECT e.patient_id
@@ -106,6 +144,7 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE e.status = 'finished'
         AND e.period_start <= p_mp_end
         AND (e.period_end IS NULL OR e.period_end >= p_mp_start)
+        AND (p_subject IS NULL OR e.patient_id = p_subject)
     UNION ALL
     -- Palliative procedure
     SELECT pr.patient_id
@@ -115,13 +154,18 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE pr.status = 'completed'
         AND pr.performed_start <= p_mp_end
         AND (pr.performed_end IS NULL OR pr.performed_end >= p_mp_start)
+        AND (p_subject IS NULL OR pr.patient_id = p_subject)
   ) sub
 $$ LANGUAGE sql STABLE;
 
 -- ============================================================
 -- FRAILTY INDICATORS (5 sub-checks) — used by 4 measures
 -- ============================================================
-CREATE OR REPLACE FUNCTION shared_has_frailty(p_mp_start timestamptz, p_mp_end timestamptz)
+CREATE OR REPLACE FUNCTION shared_has_frailty(
+    p_mp_start timestamptz,
+    p_mp_end timestamptz,
+    p_subject text DEFAULT NULL
+)
 RETURNS TABLE(patient_id text) AS $$
   SELECT DISTINCT patient_id FROM (
     -- Frailty Device (DeviceRequest)
@@ -131,6 +175,7 @@ RETURNS TABLE(patient_id text) AS $$
         AND vs.valueset_url = 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.118.12.1300'  -- FrailtyDevice
     WHERE dr.status IN ('active', 'completed')
         AND dr.authored_on >= p_mp_start AND dr.authored_on <= p_mp_end
+        AND (p_subject IS NULL OR dr.patient_id = p_subject)
     UNION ALL
     -- Frailty Diagnosis
     SELECT c.patient_id
@@ -141,6 +186,7 @@ RETURNS TABLE(patient_id text) AS $$
         OR c.verification_status IN ('confirmed', 'unconfirmed', 'provisional', 'differential'))
         AND c.onset_date <= p_mp_end
         AND (c.abatement_date IS NULL OR c.abatement_date >= p_mp_start)
+        AND (p_subject IS NULL OR c.patient_id = p_subject)
     UNION ALL
     -- Frailty Encounter
     SELECT e.patient_id
@@ -150,6 +196,7 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE e.status = 'finished'
         AND e.period_start <= p_mp_end
         AND (e.period_end IS NULL OR e.period_end >= p_mp_start)
+        AND (p_subject IS NULL OR e.patient_id = p_subject)
     UNION ALL
     -- Frailty Symptom
     SELECT o.patient_id
@@ -159,6 +206,7 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE o.status IN ('preliminary', 'final', 'amended', 'corrected')
         AND o.effective_start <= p_mp_end
         AND (o.effective_end IS NULL OR o.effective_end >= p_mp_start)
+        AND (p_subject IS NULL OR o.patient_id = p_subject)
     UNION ALL
     -- Frailty via Medical Equipment (ObservationScreeningAssessment)
     SELECT o.patient_id
@@ -168,13 +216,18 @@ RETURNS TABLE(patient_id text) AS $$
     WHERE o.code = '98181-1' AND o.code_system = 'http://loinc.org'
         AND o.status IN ('final', 'amended', 'corrected')
         AND o.effective_end >= p_mp_start AND o.effective_end <= p_mp_end
+        AND (p_subject IS NULL OR o.patient_id = p_subject)
   ) sub
 $$ LANGUAGE sql STABLE;
 
 -- ============================================================
 -- ADVANCED ILLNESS (condition within MP-1yr to MP end) — used by 4 measures
 -- ============================================================
-CREATE OR REPLACE FUNCTION shared_advanced_illness(p_mp_start timestamptz, p_mp_end timestamptz)
+CREATE OR REPLACE FUNCTION shared_advanced_illness(
+    p_mp_start timestamptz,
+    p_mp_end timestamptz,
+    p_subject text DEFAULT NULL
+)
 RETURNS TABLE(patient_id text) AS $$
     SELECT c.patient_id
     FROM condition_flat c
@@ -184,12 +237,17 @@ RETURNS TABLE(patient_id text) AS $$
         OR c.verification_status IN ('confirmed', 'unconfirmed', 'provisional', 'differential'))
         AND c.onset_date >= (p_mp_start - INTERVAL '1 year')
         AND c.onset_date <= p_mp_end
+        AND (p_subject IS NULL OR c.patient_id = p_subject)
 $$ LANGUAGE sql STABLE;
 
 -- ============================================================
 -- DEMENTIA MEDICATIONS (active, overlapping MP-1yr to MP end) — used by 4 measures
 -- ============================================================
-CREATE OR REPLACE FUNCTION shared_dementia_meds(p_mp_start timestamptz, p_mp_end timestamptz)
+CREATE OR REPLACE FUNCTION shared_dementia_meds(
+    p_mp_start timestamptz,
+    p_mp_end timestamptz,
+    p_subject text DEFAULT NULL
+)
 RETURNS TABLE(patient_id text) AS $$
     SELECT mr.patient_id
     FROM medicationrequest_flat mr
@@ -199,27 +257,37 @@ RETURNS TABLE(patient_id text) AS $$
         AND mr.intent IN ('order', 'original-order', 'reflex-order', 'filler-order', 'instance-order')
         AND COALESCE(mr.validity_start, mr.authored_on) <= p_mp_end
         AND COALESCE(mr.validity_end, mr.authored_on) >= (p_mp_start - INTERVAL '1 year')
+        AND (p_subject IS NULL OR mr.patient_id = p_subject)
 $$ LANGUAGE sql STABLE;
 
 -- ============================================================
 -- ADVANCED ILLNESS + FRAILTY combined (standard: age >= 66) — used by CMS125, 130, 131
 -- CMS165 uses its own variant with age 66-80 / >=81 split
 -- ============================================================
-CREATE OR REPLACE FUNCTION shared_advanced_illness_frailty(p_mp_start timestamptz, p_mp_end timestamptz)
+CREATE OR REPLACE FUNCTION shared_advanced_illness_frailty(
+    p_mp_start timestamptz,
+    p_mp_end timestamptz,
+    p_subject text DEFAULT NULL
+)
 RETURNS TABLE(patient_id text) AS $$
     SELECT p.id AS patient_id
     FROM patient_flat p
-    JOIN shared_has_frailty(p_mp_start, p_mp_end) f ON f.patient_id = p.id
-    LEFT JOIN shared_advanced_illness(p_mp_start, p_mp_end) ai ON ai.patient_id = p.id
-    LEFT JOIN shared_dementia_meds(p_mp_start, p_mp_end) dm ON dm.patient_id = p.id
+    JOIN shared_has_frailty(p_mp_start, p_mp_end, p_subject) f ON f.patient_id = p.id
+    LEFT JOIN shared_advanced_illness(p_mp_start, p_mp_end, p_subject) ai ON ai.patient_id = p.id
+    LEFT JOIN shared_dementia_meds(p_mp_start, p_mp_end, p_subject) dm ON dm.patient_id = p.id
     WHERE EXTRACT(YEAR FROM AGE(p_mp_end, p.birth_date::date)) >= 66
         AND (ai.patient_id IS NOT NULL OR dm.patient_id IS NOT NULL)
+        AND (p_subject IS NULL OR p.id = p_subject)
 $$ LANGUAGE sql STABLE;
 
 -- ============================================================
 -- NURSING HOME (age >= 66, housing status = lives in nursing home) — used by 4 measures
 -- ============================================================
-CREATE OR REPLACE FUNCTION shared_nursing_home(p_mp_start timestamptz, p_mp_end timestamptz)
+CREATE OR REPLACE FUNCTION shared_nursing_home(
+    p_mp_start timestamptz,
+    p_mp_end timestamptz,
+    p_subject text DEFAULT NULL
+)
 RETURNS TABLE(patient_id text) AS $$
     SELECT o.patient_id
     FROM observation_flat o
@@ -229,4 +297,5 @@ RETURNS TABLE(patient_id text) AS $$
         AND o.value_code = '160734000'
         AND o.status IN ('final', 'amended', 'corrected')
         AND o.effective_end <= p_mp_end
+        AND (p_subject IS NULL OR o.patient_id = p_subject)
 $$ LANGUAGE sql STABLE;