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Discharged on Statin Medication

Specifications
Attachment Size
CMS105v9.html 68.47 KB
CMS105v9.zip 71.64 KB
CMS105v9-TRN.xlsx 21.59 KB
CMS Measure ID
CMS105v9
Version
9
NQF Number
Not Applicable
Measure Description

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

Initial Population

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

Inpatient hospitalizations for patients discharged to another hospital

Inpatient hospitalizations for patients who left against medical advice

Inpatient hospitalizations for patients who expired

Inpatient hospitalizations for patients discharged to home for hospice care

Inpatient hospitalizations for patients discharged to a health care facility for hospice care

Inpatient hospitalizations for patients with comfort measures documented

Numerator Statement

Inpatient hospitalizations for patients prescribed or continuing to take statin medication at hospital discharge

Numerator Exclusions

Not Applicable

Denominator Exceptions

Inpatient hospitalizations for patients with a reason for not prescribing statin medication at discharge

Inpatient hospitalizations for patients with a maximum LDL-c result of less than 70 mg/dL

Inpatient hospitalizations for patients with a statin allergy

Measure Steward
Short Name
STK-6
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.

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

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Meaningful Measure
Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

Logic

  • Add 'Encounter with' to TJC.Comfort Measures during Hospitalization definition name​ for clarification.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Clinical Quality Language (CQL) Library version update: Updated version number of the TJC_Overall Library (TJC_Overall-4.4.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards updates: Modified 'Encounter, Performed' diagnosis attribute to reference diagnosis codes in value sets specified in the logic.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • QDM v5.5 standards update: Added 'rank' attribute to 'Encounter, Performed' datatype. Rank with a value of 1 indicates the principal diagnosis.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • QDM v5.5 standards update: Removed the 'ordinality' and 'principal diagnosis' attributes, added 'rank' as an attribute.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

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

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    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 Observation Services (2.16.840.1.113762.1.4.1111.143): Deleted 2 SNOMED CT codes (448851000124103, 76464004) based on clinical/coding expert feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 1 SNOMED CT code (422504002) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Added 4 RxNorm codes (2167565, 2167569, 2167557, 2167573) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: May 18, 2020