| Measure Information | 2023 Reporting Period |
|---|---|
| CMS eCQM ID | CMS71v12 |
| Short Name |
STK-3 |
| NQF Number | Not Applicable |
| Description |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy 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 |
| Numerator |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
| 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 |
| Denominator Exceptions |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
| 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 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. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
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Compare eCQM Versions
The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.
Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2021 Reporting Period | 2022 Reporting Period | 2023 Reporting Period | 2024 Reporting Period |
|---|---|---|---|---|
| Title | Anticoagulation Therapy for Atrial Fibrillation/Flutter | Anticoagulation Therapy for Atrial Fibrillation/Flutter | Anticoagulation Therapy for Atrial Fibrillation/Flutter | Anticoagulation Therapy for Atrial Fibrillation/Flutter |
| CMS eCQM ID | CMS71v10 | CMS71v11 | CMS71v12 | CMS71v13 |
| Short Name |
STK-3 |
STK-3 |
STK-3 |
STK-3 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Description |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy 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. |
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 |
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 |
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 |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter. |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
| 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 | 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 | * 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 | - 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 |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge. |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
| Measure Steward | The Joint Commission | The Joint Commission | The Joint Commission | The Joint Commission |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure | Process measure |
| Improvement Notation |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
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. |
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. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
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. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The "Nonelective 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. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Next Version | CMS71v11 | CMS71v12 | CMS71v13 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated references.
Measure Section: Reference
Source of Change: Standards/Technical Update
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Updated guidance to indicate patients in Acute Hospital Care at Home programs are included in the denominator population.
Measure Section: Guidance
Source of Change: Measure Lead
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Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
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Added bullets for readability and consistency with other measures per external review.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Logic
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Updated definition name to distinguish it from library definition and to match its purpose.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Replaced age calculation from BirthDate with CQL function AgeInYearsAt in the TJCOverall library.
Measure Section: Definitions
Source of Change: Measure Lead
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Added function 'TruncateTime' to replace retired Global.'ToDate'. Function 'CalendarDayOfOrDayAfter' now uses TJC.'TruncateTime' rather than the retired Global.'ToDate' in TJCOverall library.
Measure Section: Functions
Source of Change: Measure Lead
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Updated the version number of the TJC Overall Library to v6.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
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Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
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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/Technical Update
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Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical 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.
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Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMED CT code (397745006) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Anticoagulant Therapy (2.16.840.1.113883.3.117.1.7.1.200): Added 1 RxNorm code (2588062) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead