Antithrombotic Therapy By End of Hospital Day 2

Last updated: May 5, 2017

CMS Measure ID: CMS72v5
Version: 5
NQF Number: 0438
Measure Description:

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

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 than or equal to 120 days

Denominator Statement:

Patients with a principal diagnosis of Ischemic stroke

Denominator Exclusions:

Patients who have a duration of stay less than 2 days

Patients with comfort measures documented on day or the day after arrival

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

Numerator Statement:

Patients who had antithrombotic therapy administered the day of or day after hospital arrival

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

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

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: Stroke5
Previous Version: Antithrombotic Therapy By End of Hospital Day 2
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

The Non-elective admissions 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.

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:

AND: Intersection of:

Occurrence A of $EncounterInpatientNonElective

Encounter, Performed: Non-Elective Inpatient Encounter (length of stay < 2 day(s))

AND NOT: Encounter, Performed: Emergency Department Visit <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatientNonElective

The following statement addresses patients who were admitted via the ED:

OR: Encounter, Performed: Emergency Department Visit satisfies all

<= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatientNonElective

< 2 day(s) starts before end of Occurrence A of $EncounterInpatientNonElective.

Addendum Notes: ICD-10 Value Set addition

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Added additional guidance language to clarify intent of the measure.

    Section: Guidance

    Source: JIRA (CQM-1512)

  • Removed unit of measurement language from Guidance. HQMF now has a header field, 'measure item count', where the unit of measurement can be identified in a computable fashion.

    Section: Guidance

    Source: Measure Lead

  • Updated initial population header to harmonize across all stroke measures.

    Section: Initial Population

    Source: Measure Lead

Logic

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Denominator

    Source: QDM Standards

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Section: Initial Population

    Source: Measure Lead

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Initial Population

    Source: QDM Standards

  • Added new attribute 'principal diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic. Removed QDM data element Attribute: 'Ordinality: Principal' using 'Principal SNOMEDCT Value Set (2.16.840.1.113883.3.1.7.1.14.)’ to conform to QDM 4.2. changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

Value Set

  • Value set Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201): Added 6 RXNORM codes (103863, 1659195, 1659197, 198463, 198464, 198473) and deleted 35 RXNORM codes.

    Section: None

    Source: JIRA (CQM-1513)

  • Value set Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201): Added 6 RXNORM codes (103863, 1659195, 1659197, 198463, 198464, 198473) and deleted 35 RXNORM codes.

    Section: None

    Source: JIRA (CQM-1830)

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 3 SNOMEDCT codes (230701008, 307363008, 426107000) and deleted 5 SNOMEDCT codes (233964008, 288723005, 300920004, 64586002, 71444005). Deleted 18 ICD10CM codes.

    Section: None

    Source: None

  • Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMEDCT code (161590003).

    Section: None

    Source: None

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Added 1 ICD10CM code (I60.2) and deleted 3 ICD10CM codes (I60.20, I60.21, I60.22).

    Section: None

    Source: ICD-10 Addendum

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 18 ICD10CM codes.

    Section: None

    Source: ICD-10 Addendum

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