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Discharged on Statin Medication

Specifications

Value Set content updated Sept 2017

General eCQM Information

CMS Measure ID CMS105v6
Short Name Stroke6
NQF Number None
Measure Description

Ischemic stroke patients who are prescribed or continuing to take statin medication at hospital discharge

Initial Population Patients age 18 and older discharged from inpatient care (non-elective admissions) with a principal diagnosis of ischemic or hemorrhagic stroke and a length of stay less than or equal to 120 days that ends during measurement period
Denominator Statement

Patients with a principal diagnosis of ischemic stroke

Denominator Exclusions

*Patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations.

*Patients with comfort measures documented

*Patients discharged to another hospital

*Patients who left against medical advice

*Patients who expired

*Patients discharged to home for hospice care

*Patients discharged to a health care facility for hospice care

*Patients with an LDL-c of less than 70 mg/dL <30 days prior to arrival or any time during the hospital stay

Numerator Statement

Patients prescribed or continuing to take statin medication at hospital discharge

Numerator Exclusions

Not Applicable

Denominator Exceptions

Patients with a reason for not prescribing statin medication at discharge

Measure Steward The Joint Commission
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Improvement noted as an increase in rate

Guidance

The "Non-elective Inpatient Encounter" value set intends to capture all non-scheduled hospitalizations. This value set is a subset of the "Inpatient encounter" value set, excluding concepts that specifically refer to elective hospital admissions. Non-elective admissions include emergency, urgent and unplanned admissions.

The "Medication, Discharge" datatype refers to the discharge medication list and is intended to express medications ordered for post-discharge use.

Next Version
Release Notes

Header

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Replaced NQF Number '0439' with 'Not Applicable' as the measure is no longer endorsed.

    Measure Section: NQF Number

    Source of Change: Measure Lead

  • Replaced 'National Quality Forum' with 'None' as the measure is no longer endorsed.

    Measure Section: Endorsed By

    Source of Change: Measure Lead

  • ​Updated the Description narrative statement to better align with measure logic.

    Measure Section: Description

    Source of Change: JIRA (CQM-2457)

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated the Guidance narrative statement to better align with measure logic.

    Measure Section: Guidance

    Source of Change: JIRA (CQM-2457)

  • Added 'that ends during the measurement period' to the Initial Population narrative statement to better align with measure logic.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-2520)

  • ​Updated the Numerator narrative statement to better align with measure logic.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2457)

Logic

  • Replaced 'Statin ingredient specific' value set with 'Statin Grouper' semantic clinical drug value set to ease implementation burden.

    Measure Section: Denominator Exceptions

    Source of Change: JIRA (CQM-1835)

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set LDL-c (2.16.840.1.113883.3.117.1.7.1.215): Added 2 LOINC codes (43394-6, 50193-2).

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Statin Allergen (2.16.840.1.113883.3.117.1.7.1.423): Deleted 28 RXNORM codes.

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 3 SNOMEDCT codes (183946001, 183956002, 609589008).

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Deleted 2 ICD9CM codes (430, 431).

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Deleted 12 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Deleted 17 RXNORM codes.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Replaced Statin ingredient specific value set (2.16.840.1.113762.1.4.1021.7) with Statin Grouper value set (2.16.840.1.113762.1.4.1110.19).

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Deleted 5 RXNORM codes (433848, 1422096, 1422099, 1422086, 1422093).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

Last Updated: May 06, 2020