Discharged on Statin Medication

Last updated: May 4, 2017

CMS Measure ID: CMS105v3
Version: 3
NQF Number: 0439
Measure Description:

Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.

Initial Patient 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 or equal to 120 days.

Denominator Statement:

Patients with a principal diagnosis of ischemic stroke and an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival.

Denominator Exclusions:
  • Patients with comfort measures documented
  • Patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations.
  • 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
Numerator Statement:

Patients prescribed 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
Domain: Effective Clinical Care
Short Name: Stroke6
Next Version: Discharged on Statin Medication
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in rate

Guidance:

The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

Lipid-lowering medications are intended as active home meds that the patient may or may not continue to take during hospitalization.

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, including patients admitted for observation.

Specifications

External Resources