Discharged on Statin Medication 9.1.000

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

Measure specifications are in the Public Domain

LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. 
This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty.

There is an extensive and consistent body of evidence supporting the use of statins for secondary prevention in patients with clinically evident atherosclerotic cardiovascular disease (ASCVD), which includes individuals with ischemic stroke due to large artery atherosclerosis, individuals with ischemic stroke due to intrinsic small vessel disease, and individuals with ischemic stroke not directly due to atherosclerosis but with clinically evident atherosclerotic disease in an uninvolved cerebral or noncerebral bed.  Both women and men with clinical ASCVD are at increased risk for recurrent ASCVD and ASCVD death.  High-intensity statin therapy should be initiated or continued as first-line therapy in women and men less than or equal to 75 years of age who have clinical ASCVD, unless contraindicated. In patients with clinical ASCVD and a contraindication to high-intensity statin therapy, moderate-intensity therapy should be considered as an alternative if it can be tolerated.  In individuals greater than 75 years of age, the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and patient preferences should be considered, and statin therapy individualized based on these considerations (Stone, 2013).

For patients with stroke of atherosclerotic origin, intensive lipid lowering therapy with statins should be initiated

Improvement noted as an increase in rate

Amarenco, P., Bogousslavsky, J., Callahan, A., III, et al. (2006, August 10). High-dose atorvastatin after stroke or transient ischemic attack. New England Journal of Medicine, 355(6), 549-559.

Biffi, A., Devan, W. J., Anderson, C. D., et al. (2011, May). Statin treatment and functional outcome after ischemic stroke: Case-control and meta-analysis. Stroke, 42(5), 1314-1319.

Centers for Disease Control and Prevention. (2009, May 1). Prevalence and most common causes of disability among adults—United States, 2005. Morbidity and Mortality Weekly Report, 58(16), 421-426.

Chan, P. S., Nallamothu, B. K., Gurm, H. S., et al. (2007, May 8). Incremental benefit and cost-effectiveness of high-dose statin therapy in high-risk patients with coronary artery disease. Circulation, 115(18), 2398-2409.

Culver, A. L., Ockene, I. S., Balasubramanian, R., et al. (2012, January 23). Statin use and risk of diabetes mellitus in postmenopausal women in the Women's Health Initiative. Archives of Internal Medicine, 172(2),  144-152.

Feher, A., Pusch, G., Koltai, K., et al. (2011, April 14). Statin therapy in the primary and the secondary prevention of ischaemic cerebrovascular diseases. International Journal of Cardiology, 148(2), 131-138.

Grundy, S. M., Cleeman, J. I., Merz, C. N., et al. (2004, July 13). Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation, 110(2), 227-239.

Kernan, W. N., Ovbiagele, B., Black, H. R., et al. (2014, May). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 45(7), 2160-2223.

Kostis, W. J., Cheng, J. Q., Dobrzynski, J. M., et al. (2012, February 7). Meta-analysis of statin effects in women versus men. Journal of the American College of Cardiology, 59(6), 572-582.

Lazar, L. D., Pletcher, M. J., Coxson, P. G., et al. (2011, July 12). Cost-effectiveness of statin therapy for primary prevention in a low-cost statin era. Circulation, 124(2), 146-153.

Mitka, M. (2012, March 7). Some question use of statins to reduce cardiovascular risks in healthy women. JAMA, 307(9), 893-894.

National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Adults Treatment of High Blood Cholesterol in Adults. (2002, December 17). Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)—Final report. Circulation, 106(25), 3143-3421.

Powers, W. J., Rabinstein, A. A., Ackerson, T., et al. (2018, January). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 49, e44-e47.

Rodriguez-Yanez, M., Agulla, J., Rodriguez-Gonzalez, R., et al. (2008, June). Statins and stroke. Therapeutic Advances in Cardiovascular Disease, 2(3), 157-166.

Roger, V. L., Go, A. S., Lloyd-Jones, D. M., et al. (2012, January 3). Heart disease and stroke statistics—2012 update: A report from the American Heart Association. Circulation, 125(1), e2-e220.

Schellinger, P. D., Bryan, R. N., Caplan, L. R., et al. (2010, July 13). Evidence-based guideline: The role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.  Neurology, 75(2), 177-185.

Squizzato, A., Romualdi, E., Dentali, F., et al. (2011). Statins for acute ischemic stroke. Cochrane Database of Systematic Reviews, 8, CD007551.

Stone, N. J., Robinson, J., Lichtenstein, A. H., et al. (2013, November). Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 11, 1-84.

Van Dis, F. J., Keilson, L. M., Rundell, C. A., et al. (1996, June). Direct measurement of serum low-density lipoprotein cholesterol in patients with acute myocardial infarction on admission to the emergency room. American Journal of Cardiology, 77(14), 1232-1234.

Weiss, R., Harder, M., & Rowe, J. (2003, May). The relationship between nonfasting and fasting lipid measurements in patients with or without type 2 diabetes mellitus receiving treatment with 3-hydroxy-3-methylglutaryl-coenzyme a reductase inhibitors. Clinical Therapeutics, 25(5), 1490-1497.

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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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 with a principal diagnosis of ischemic stroke

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 prescribed or continuing to take statin medication at hospital discharge

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 <= 30 days prior to arrival or any time during the hospital stay
Inpatient hospitalizations for patients with a statin allergy

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Initial Population

TJC."Encounter with Principal Diagnosis and Age"

Denominator
- - TJC."Ischemic Stroke Encounter"

Denominator Exclusions

TJC."Ischemic Stroke Encounters with Discharge Disposition"
  union TJC."Encounter with Comfort Measures during Hospitalization"

Numerator

TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
  with "Statin at Discharge" DischargeStatin
    such that DischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod

Numerator Exclusions
- - None

Denominator Exceptions

( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
    with "Statin Not Given at Discharge" NoDischargeStatin
      such that NoDischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod
)
  union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
      with "Statin Allergy" StatinAllergy
        such that StatinAllergy.prevalencePeriod starts on or before 
        end of IschemicStrokeEncounter.relevantPeriod
  )
  union "Encounter with Max LDL less than 70 mg per dL"

Stratification
- - None

Denominator
- - TJC."Ischemic Stroke Encounter"

Denominator Exceptions

( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
    with "Statin Not Given at Discharge" NoDischargeStatin
      such that NoDischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod
)
  union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
      with "Statin Allergy" StatinAllergy
        such that StatinAllergy.prevalencePeriod starts on or before 
        end of IschemicStrokeEncounter.relevantPeriod
  )
  union "Encounter with Max LDL less than 70 mg per dL"

Denominator Exclusions

TJC."Ischemic Stroke Encounters with Discharge Disposition"
  union TJC."Encounter with Comfort Measures during Hospitalization"

Encounter with Max LDL less than 70 mg per dL

TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
  where Max(["Laboratory Test, Performed": "LDL-c"] Ldl
      where Ldl.resultDatetime during Interval[Global."ToDate"(start of IschemicStrokeEncounter.relevantPeriod - 30 days), 
      end of IschemicStrokeEncounter.relevantPeriod]
      return Ldl.result as Quantity
  )< 70 'mg/dL'

Initial Population

TJC."Encounter with Principal Diagnosis and Age"

Numerator

TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
  with "Statin at Discharge" DischargeStatin
    such that DischargeStatin.authorDatetime during IschemicStrokeEncounter.relevantPeriod

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Statin Allergy

["Allergy/Intolerance": "Statin Allergen"]

Statin at Discharge

["Medication, Discharge": "Statin Grouper"]

Statin Not Given at Discharge

["Medication, Not Discharged": "Statin Grouper"] NoStatinDischarge
  where NoStatinDischarge.negationRationale in "Medical Reason"
    or NoStatinDischarge.negationRationale in "Patient Refusal"

TJC.All Stroke Encounter

"Non Elective Inpatient Encounter" NonElectiveEncounter
  where exists ( NonElectiveEncounter.diagnoses Diagnosis
      where Diagnosis.rank = 1
        and ( Diagnosis.code in "Hemorrhagic Stroke"
            or Diagnosis.code in "Ischemic Stroke"
        )
  )

TJC.Encounter with Comfort Measures during Hospitalization

"Ischemic Stroke Encounter" IschemicStrokeEncounter
  with "Intervention Comfort Measures" ComfortMeasure
    such that Coalesce(start of ComfortMeasure.relevantPeriod, ComfortMeasure.authorDatetime)during Global."HospitalizationWithObservation" ( IschemicStrokeEncounter )

TJC.Encounter with Principal Diagnosis and Age

"All Stroke Encounter" AllStrokeEncounter
  with ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    such that Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of AllStrokeEncounter.relevantPeriod ) >= 18

TJC.Intervention Comfort Measures

["Intervention, Order": "Comfort Measures"]
  union ["Intervention, Performed": "Comfort Measures"]

TJC.Ischemic Stroke Encounter

"Encounter with Principal Diagnosis and Age" EncounterWithAge
  where exists ( EncounterWithAge.diagnoses Diagnosis
      where Diagnosis.code in "Ischemic Stroke"
        and Diagnosis.rank = 1
  )

TJC.Ischemic Stroke Encounters with Discharge Disposition

( ( "Ischemic Stroke Encounter" IschemicStrokeEncounter
      where IschemicStrokeEncounter.dischargeDisposition in "Discharge To Acute Care Facility"
        or IschemicStrokeEncounter.dischargeDisposition in "Left Against Medical Advice"
        or IschemicStrokeEncounter.dischargeDisposition in "Patient Expired"
        or IschemicStrokeEncounter.dischargeDisposition in "Discharged to Home for Hospice Care"
        or IschemicStrokeEncounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care"
  )
)

TJC.Non Elective Inpatient Encounter

["Encounter, Performed": "Non-Elective Inpatient Encounter"] NonElectiveEncounter
  where Global."LengthInDays" ( NonElectiveEncounter.relevantPeriod ) <= 120
    and NonElectiveEncounter.relevantPeriod ends during "Measurement Period"

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)
- - years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.HospitalizationWithObservation(Encounter "Encounter, Performed")

Encounter Visit
	let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs
			where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod
			sort by 
			end of relevantPeriod
	),
	VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),
	EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED
			where LastED.relevantPeriod ends 1 hour or less on or before VisitStart
			sort by 
			end of relevantPeriod
	)
	return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), 
	end of Visit.relevantPeriod]

Global.LengthInDays(Value Interval<DateTime>)

difference in days between start of Value and end of Value

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

code "Birth date" ("LOINC Code (21112-8)")
valueset "Comfort Measures" (1.3.6.1.4.1.33895.1.3.0.45)
valueset "Discharge To Acute Care Facility" (2.16.840.1.113883.3.117.1.7.1.87)
valueset "Discharged to Health Care Facility for Hospice Care" (2.16.840.1.113883.3.117.1.7.1.207)
valueset "Discharged to Home for Hospice Care" (2.16.840.1.113883.3.117.1.7.1.209)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Hemorrhagic Stroke" (2.16.840.1.113883.3.117.1.7.1.212)
valueset "Ischemic Stroke" (2.16.840.1.113883.3.117.1.7.1.247)
valueset "LDL-c" (2.16.840.1.113883.3.117.1.7.1.215)
valueset "Left Against Medical Advice" (2.16.840.1.113883.3.117.1.7.1.308)
valueset "Medical Reason" (2.16.840.1.113883.3.117.1.7.1.473)
valueset "Non-Elective Inpatient Encounter" (2.16.840.1.113883.3.117.1.7.1.424)
valueset "Observation Services" (2.16.840.1.113762.1.4.1111.143)
valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
valueset "Patient Expired" (2.16.840.1.113883.3.117.1.7.1.309)
valueset "Patient Refusal" (2.16.840.1.113883.3.117.1.7.1.93)
valueset "Payer" (2.16.840.1.114222.4.11.3591)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Statin Allergen" (2.16.840.1.113762.1.4.1110.42)
valueset "Statin Grouper" (2.16.840.1.113762.1.4.1110.19)

Data Criteria (QDM Data Elements)

"Allergy/Intolerance: Statin Allergen" using "Statin Allergen (2.16.840.1.113762.1.4.1110.42)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
"Encounter, Performed: Non-Elective Inpatient Encounter" using "Non-Elective Inpatient Encounter (2.16.840.1.113883.3.117.1.7.1.424)"
"Encounter, Performed: Observation Services" using "Observation Services (2.16.840.1.113762.1.4.1111.143)"
"Intervention, Order: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Intervention, Performed: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Laboratory Test, Performed: LDL-c" using "LDL-c (2.16.840.1.113883.3.117.1.7.1.215)"
"Medication, Discharge: Statin Grouper" using "Statin Grouper (2.16.840.1.113762.1.4.1110.19)"
"Medication, Not Discharged: Statin Grouper" using "Statin Grouper (2.16.840.1.113762.1.4.1110.19)"
"Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

eMeasure Stroke (eSTK)

Discharged on Statin Medication

Table of Contents

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables