Statin Prescribed at Discharge

Last updated: February 1, 2017

CMS Measure ID: CMS30v6
Version: 6
NQF Number: None
Measure Description:

Acute myocardial infarction (AMI) patients who are prescribed a statin medication at hospital discharge

Initial Patient Population:

Patients age 18 and older at the time of hospital admission with a principal diagnosis of Acute Myocardial Infarction (AMI) with hospital stays <= 120 days during the measurement year

Denominator Statement:

All patients in the Initial Population

Denominator Exclusions:
  • Patients with Comfort Measures documented
  • 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:

AMI patients who are prescribed a statin medication at hospital discharge

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patients with LDL of less than 100 mg/dL within the first 24 hours after hospital arrival or 30 days prior to hospital arrival.

Or patients with a documented Reason for Not Prescribing Statin Medication at Discharge. This includes patients with a statin allergy, the administration of statin medications are on HOLD, or a medical or patient reason for not prescribing a statin.

Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Domain: Effective Clinical Care
Short Name: AMI10
Previous Version: Statin Prescribed at Discharge
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

Exclusion element guidance:

Medical or patient reasons for not performing a test or giving a medication are categories for valid medical or patient reasons that are not specifically listed in the exclusion section of the measure. Each is expected to be captured and made available for measurement or clinical decision support within the EHR workflow but the exact method or location of capture is a local or vendor decision.

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Updated Endorsed by to 'None.'

    Section: Endorsed By

    Source: Measure Lead

  • Updated NQF Number to 'Not Applicable.'

    Section: NQF Number

    Source: Measure Lead

Logic

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Added Statin Grouper.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Removed the ‘Union of’ operator from the Initial Population logic as it is no longer needed to meet the measure intent.

    Section: Initial Population

    Source: Measure Lead

  • Removed the Emergency Department (ED) section of logic from the Initial Population as it is not needed to capture the principal diagnosis.

    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

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Added Statin Grouper.

    Section: Numerator

    Source: Measure Lead

  • 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 Statin (2.16.840.1.113883.3.117.1.7.1.225): Removed Statin.

    Section: QDM Data Elements

    Source: None

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Added Statin Grouper.

    Section: QDM Data Elements

    Source: None

Value Set

  • Value set Acute Myocardial Infarction (AMI) (2.16.840.1.113883.3.666.5.3011): Added 9 SNOMEDCT codes (15712841000119100, 15712881000119105, 15712921000119103, 15712961000119108, 15713041000119103, 15713081000119108, 15713121000119105, 15713161000119100, 15713201000119105) and deleted 1 SNOMEDCT code (194798004).

    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

External Resources