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Antithrombotic Therapy By End of Hospital Day 2

CMS Measure ID
CMS72v8
Version
8
NQF Number
Not Applicable
Measure Description

Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2

Initial Population

Inpatient hospitalization for 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

Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke

Denominator Exclusions

Inpatient hospitalizations for patients who have a duration of stay less than 2 days

Inpatient hospitalization for patients with comfort measures documented day of or the day after arrival

Inpatient hospitalization for patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization

Inpatient hospitalization for patients with an INR greater than 3.5

Numerator Statement

Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival

Numerator Exclusions

Not Applicable

Denominator Exceptions

Inpatient hospitalization for patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival

Inpatient hospitalization for patients who receive Ticagrelor as an antithrombotic therapy the day of or day after hospital arrival

Measure Steward
Short Name
STK-5
Previous Version
Measure Scoring
Measure Type
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 Inpatient Encounters include emergency, urgent, and unplanned admissions.

NPO is not a valid reason for not administering antithrombotic therapy by end of hospital day 2 as another route of administration can be used (i.e. rectal or intravenous).

In the denominator exclusions, the intent is to only exclude patients with a total length of stay of <2 days, including ED visit (if there is one). For the eCQM we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits.

Meaningful Measure

Specifications

Attachment Size
CMS72v8.html 75.68 KB
CMS72v8.zip 75.56 KB
CMS72v8-TRN.xlsx 24.05 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated guidance statement to correct grammatical errors.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated initial population statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated denominator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Updated denominator statement to correct grammatical errors.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Updated denominator exclusions statement with missing text and corrected grammatical errors.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions statement with 'Inpatient hospitalization for patients with an INR greater than 3.5' to better align with chart-abstracted measure.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2961

  • Updated numerator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated denominator exceptions statement to include patients who receive Ticagrelor during the hospitalization, to align with the chart-abstracted measure.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Logic

  • Added a union operator and logic to capture denominator exclusion for patients with an INR greater than 3.5.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2961

  • Added definition title 'Encounter With Thrombolytic Therapy Documented As Already As Given' to improve data flow of the measure.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2981

  • Added 'Encounter With An INR Greater Than 3.5' to better align with chart-abstracted measure.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2961

  • Added logic to capture encounters where t-PA was administered prior to arrival using diagnosis as an attribute of the encounter or as a diagnosis datatype to improve the logic and data flow of the measure.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-3279

  • Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2835

  • Replaced '…1 day or less on or after day of start of Global.'Hospitalization'(IschemicStrokeEncounter) with '... 'during TJC.CalendarDayOfDayAfter' start of Global.'Hospitalization with Observation'. RelevantPeriod)' to improve timing functionality and alignment with measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Replaced the Global 'Hospitalization Length of Stay' function with the TJC 'HospitalizationWithObservationLengthOfStay' function to include observation status within the measure calculation and improve alignment with measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: Expert Work Group Review

  • Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA): CQM-2835

  • Replaced '…1 day or less on or after day of start of Global.'Hospitalization'(IschemicStrokeEncounter) with '... 'during TJC.CalendarDayOfDayAfter' start of Global.'Hospitalization with Observation'. RelevantPeriod)' to improve timing functionality and alignment with measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added a union operator and logic to capture denominator exceptions for patients receiving Ticagrelor to improve alignment with the chart-abstracted measure.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.

    Measure Section: Denominator Exceptions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2835

  • Replaced '…1 day or less on or after day of start of Global.'Hospitalization'(IschemicStrokeEncounter) with '... 'during TJC.CalendarDayOfDayAfter' start of Global.'Hospitalization with Observation'. RelevantPeriod)' to improve timing functionality and alignment with measure intent.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Added 'Encounter With Ticagrelor Therapy' to improve alignment with the chart-abstracted measure.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added TJC.CalendarDayOfDayAfterCalendarDayOfOrDayAfter for consistency across measures.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Update to TJC_Overall Library version number (TJC_Overall-3.6.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

 

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 Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201): Added 3 RxNorm codes (1549682, 1730187, 1992427) and deleted 4 RxNorm codes (1536670, 806446, 853499, 978738).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Added Observation Services.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set INR (2.16.840.1.113883.3.117.1.7.1.213): Added INR.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-2961

  • Value set Intravenous or Intra-arterial Thrombolytic (t-PA) Therapy (2.16.840.1.113762.1.4.1045.21): Removed grouping.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-2981

  • Value set Intravenous or Intra arterial Thrombolytic (tPA) Therapy Prior to Arrival (2.16.840.1.113762.1.4.1110.21): New value set with 1 ICD-10-CM code (Z92.82) to capture administration of intravenous or intra-arterial thrombolytic (t-PA) therapy of within 24 hours prior to admission.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-2981

  • Value set Ticagrelor Therapy (2.16.840.1.113762.1.4.1110.39): New value set with 2 RxNorm codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45): Changed Exclusion Criteria description from ‘None’ to ‘Palliative Care’ for clarity and to align with chart-abstracted measures.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-3396

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 22, 2019