eCQM Title | # Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
eCQM Identifier (Measure Authoring Tool) | 347 | eCQM Version Number | 6.1.000
NQF Number | Not Applicable | GUID | 5375d6a9-203b-4fff-b851-afa9b68d2ac2
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | Centers for Medicare & Medicaid Services (CMS)
Measure Developer | Mathematica
Endorsed By | None
Description |
    Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:
    *All patients with an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD) or ever had an ASCVD procedure; OR
    *Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
    *Patients aged 40-75 years with a diagnosis of diabetes
Copyright |
    Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets.

    CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) is copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2021 World Health Organization. All Rights Reserved.
Disclaimer |
    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 "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    This measure is intended to have one reporting rate, which aggregates the following populations into a single performance rate for reporting purposes:

    Population 1: All patients who have an active diagnosis of clinical ASCVD or ever had an ASCVD procedure.

    Population 2: Patients aged >= 20 years at the beginning of the measurement period who have ever had a laboratory result of LDL-C >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia.

    Population 3: Patients aged 40 to 75 years at the beginning of the measurement period with an active diagnosis of Type 1 or Type 2 diabetes at any time during the measurement period.

    For the purposes of this measure, a single performance rate can be calculated as follows:

    Performance Rate = (Numerator 1 + Numerator 2 +Numerator 3)/ [(Denominator 1 - Denominator Exclusions 1- Denominator Exceptions 1) + (Denominator 2 - Denominator Exclusions 2 - Denominator Exceptions 2) +(Denominator 3 - Denominator Exclusions 3 - Denominator Exceptions 3)]
Rationale |
    "Cardiovascular disease (CVD) is the leading cause of death in the United States, causing approximately 1 of every 3 deaths in the United States in 2015. In 2015, stroke caused approximately 1 of every 19 deaths in the United States and the estimated annual costs for CVD and stroke were $329.7 billion, including $199.2 billion in direct costs (hospital services, physicians and other professionals, prescribed medications, home health care, and other medical durables) and $130.5 billion in indirect costs from lost future productivity (cardiovascular and stroke premature deaths). CVD costs more than any other diagnostic group" (Benjamin et al., 2018).

    Data collected between 2011 and 2014 indicates that more than 94.6 million U.S. adults, 20 years or older, had total cholesterol levels equal to 200 mg/dL or more, while almost 28.5 million had levels 240 mg/dL or more (Benjamin et al., 2018). Elevated blood cholesterol is a major risk factor for CVD and statin therapy has been associated with a reduced risk of CVD. Numerous randomized trials have demonstrated that treatment with a statin reduces LDL-C and reduces the risk of major cardiovascular events by approximately 20 percent (Ference, 2015).

    In 2018, updated guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults were published (see Grundy et al., 2019). This guideline was published by an Expert Panel, which synthesized evidence from randomized controlled trials to identify people most likely to benefit from cholesterol-lowering therapy. The American College of Cardiology (ACC)/American Heart Association (AHA)/Multi-society (MS) Guideline recommendations are intended to provide a strong evidence-based foundation for the treatment of blood cholesterol for the primary and secondary prevention and treatment of ASCVD in patients of all ages. The document concludes that the addition of statin therapy reduces the risk of ASCVD among high-risk individuals, defined as follows: individuals with clinical ASCVD, with LDL-C >= 190 mg/dL, or with diabetes (Grundy et al., 2019).

    One study surveying U.S. cardiology, primary care, and endocrinology practices found that 1 in 4 guideline-eligible patients were not on a statin and less than half were on the recommended statin intensity. Untreated and undertreated patients had significantly higher LDL-C levels than those receiving guideline-directed statin treatment (Navar et al., 2017). In a follow-up study authored by Nanna et al., the same clinics were divided into tertiles based on the percentage of patients with guideline-recommended statin use. The researchers found that patients in the high-tertile clinics were more likely to achieve target LDL-C levels than patients at the low- or mid-tertile clinics, and this held true when patients were stratified by primary and secondary prevention (Nanna et al., 2019a).

    Research also indicates that certain populations are far less likely to receive guideline-recommended statin therapy than others. A retrospective study of the National Health and Nutrition Examination Survey found that Black and Hispanic race or ethnicity, low income, lack of health insurance coverage, poor health care access, young age, and female gender are predictors of lower statin utilization (Gu et al., 2018). In particular, there is extensive evidence that women are far less likely than men to be prescribed guideline-recommended statin therapy (Zhang et al., 2016; Nanna et al., 2019b), despite research showing that female patients with cardiovascular disease derive the same or greater benefit from statin therapy as male patients with cardiovascular disease (Puri et al., 2014).

    The Statin Safety Expert Panel that participated in a National Lipid Association (NLA) Statin Safety Task Force meeting in October 2013 reaffirms the general safety of statin therapy. The panel members concluded that for most patients requiring statin therapy, the potential benefits of statin therapy outweigh the potential risks. In general terms, the benefits of statins to prevent non-fatal myocardial infarction, revascularization, stroke, and CVD mortality, far outweigh any potential harm related to the drug (Jacobson, 2014).
Clinical Recommendation Statement |
    This electronic clinical quality measure is intended to align with the 2018 ACC/AHA/MS Guideline on the Management of Blood Cholesterol (Grundy et al., 2019), which indicates the use of statins as the first line of cholesterol-lowering medication therapy to lower the risk of ASCVD among at-risk populations.

    Recommendations for Management of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults - Statin Treatment:
    Secondary Prevention:
    1. In patients who are 75 years of age or younger with clinical ASCVD, high-intensity statin therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in LDL-C levels (Class I Recommendation), (Grundy et al., 2019).

    2. In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, moderate-intensity statin therapy should be initiated or continued with the aim of achieving a 30% to 49% reduction in LDL-C levels (Class I Recommendation), (Grundy et al., 2019).

    3. In patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate- or high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug–drug interactions, as well as patient frailty and patient preferences (Class IIa Recommendation), (Grundy et al., 2019).

    Primary Prevention
    1. In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL or higher (>= 4.9 mmol/L), maximally tolerated statin therapy is recommended. (Class I Recommendation), (Grundy et al., 2019).

    2. In adults 40 to 75 years of age with diabetes mellitus, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated (Class I Recommendation), (Grundy et al., 2019).

    Statin Safety and Statin-Associated Side Effects
    A clinician–patient risk discussion is recommended before initiation of statin therapy to review net clinical benefit, weighing the potential for ASCVD risk reduction against the potential for statin-associated side effects, statin–drug interactions, and safety, while emphasizing that side effects can be addressed successfully (Class I Recommendation), (Grundy et al., 2019).
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., Cheng, S., …Munter, P. (2018). Heart disease and stroke statistics—2018 update: A report from the American Heart Association. Circulation, 137(12), e67-e492. doi.10.1161/CIR.0000000000000558'
Reference |
    Reference Type: CITATION
    Reference Text: 'Ference, B.A. (2015, March 10). Statins and the risk of developing new-onset Type 2 diabetes: Expert analysis. Retrieved from https://www.acc.org/latest-in-cardiology/articles/2015/03/10/08/10/statins-and-the-risk-of-developing-new-onset-type-2-diabetes'
Reference |
    Reference Type: CITATION
    Reference Text: 'Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., …Yeboah, J. (2019) 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Journal of the American College of Cardiology, 73 (24), e286-e343. doi.10.1016/j.jacc.2018.11.003'
Reference |
    Reference Type: CITATION
    Reference Text: 'Gu, A., Kamat, S., Argulian, E. (2018). Trends and disparities in statin use and low-density lipoprotein cholesterol levels among US patients with diabetes, 1999–2014. Diabetes Research and Clinical Practice, 139, 1-10. doi:10.1016/j.diabres.2018.02.019'
Reference |
    Reference Type: CITATION
    Reference Text: 'Jacobson, T. A. (2014). Executive summary: NLA Task Force on Statin Safety—2014 update. Journal of Clinical Lipidology, 8(3 Suppl.), S1-S4. doi:10.1016/jacl.2014.03.002'
Reference |
    Reference Type: CITATION
    Reference Text: 'Nanna, M. G., Navar, A. M., Wang, Y. T., Li, S., Virani, S. S., Li, Z., … Peterson, E. D. (2019a). Practice-Level Variation in Statin use and Low-Density Lipoprotein Cholesterol Control in the United States: Results from the Patient and Provider Assessment of Lipid Management (PALM) Registry. American Heart Journal, 214, 113–124. doi:10.1016/j.ahj.2019.05.009'
Reference |
    Reference Type: CITATION
    Reference Text: 'Nanna, M. G., Wang, T. Y., Xiang, Q., Goldberg, A. C., Robinson, J. G., Roger, V. L., … Navar, A. M. (2019b). Sex Differences in the use of Statins in Community Practice. Circulation. Cardiovascular Quality & Outcomes, 12(8), e005562. doi:10.1161/CIRCOUTCOMES.118.005562'
Reference |
    Reference Type: CITATION
    Reference Text: 'Navar, M., Wang, T. Y., Li, S.,Robinson, J. G., Goldberg, A. C., Virani, S., …Peterson, E. D. (2017). Lipid management in contemporary community practice: Results from the Provider Assessment of Lipid Management (PALM) Registry. American Heart Journal, 193, 84-92. doi.10.1016/j.ahj.2017.08.005'
Reference |
    Reference Type: CITATION
    Reference Text: 'Puri, R., Nissen, S. E., Shao, M., Ballantyne, C. M., Barter, P. J., Chapman, M. J., … Nicholls, S. J. (2014). Sex-related differences of coronary atherosclerosis regression following maximally intensive statin therapy: insights from SATURN. JACC. Cardiovascular imaging, 7(10), 1013–1022. doi:10.1016/j.jcmg.2014.04.019'
Reference |
    Reference Type: CITATION
    Reference Text: 'Whelton, P.K., Carey, R.M., Aronow, W.S., Casey, Jr., D.E., Collins, K.J., Dennison Himmelfarb, C., Wright, Jr., J.T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), 1269-1324. doi: 10.1161/HYP.0000000000000066'
Reference |
    Reference Type: CITATION
    Reference Text: ''Zhang, H., Plutzky, J., Shubina, M., & Turchin, A. (2016). Drivers of the Sex Disparity in Statin Therapy in Patients with Coronary Artery Disease: A Cohort Study. PloS one, 11(5), e0155228. doi:10.1371/journal.pone.0155228'
Definition |
    Clinical atherosclerotic cardiovascular disease (ASCVD) includes:
    *Acute coronary syndromes
    *History of myocardial infarction
    *Stable or unstable angina
    *Coronary or other arterial revascularization
    *Stroke or transient ischemic attack (TIA)
    *Peripheral arterial disease of atherosclerotic origin

    Lipoprotein density cholesterol (LDL-C) result:
    *A fasting or non-fasting LDL-C laboratory test performed and direct or calculated test result documented in the medical record. When both direct and calculated test results are available on the same day, the direct LDL-C test result should be used.

    Statin therapy:
    *Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.

    Statin Medication Therapy List (NOTE: List does NOT include dosage):

    [Generic name] (Brand or trade name) and (-) Medication type, if applicable:
    [Atorvastatin] (Lipitor) - Statin
    [Fluvastatin] (Lescol XL or Lescol) - Statin
    [Lovastatin (Mevinolin)](Mevacor or Altoprev) -Statin
    [Pitavastatin] (Livalo or Zypitamag or Nikita) - Statin
    [Pravastatin Sodium] (Pravachol) - Statin
    [Rosuvastatin Calcium] (Crestor) - Statin
    [Simvastatin] (Zocor) - Statin
    [Amlodipine Besylate/Atorvastatin Calcium] (Caduet) – Fixed Dose Combination
    [Ezetimibe / Rosuvastatin] (Roszet) – Fixed Dose Combination
    [Ezetimibe/Simvastatin] (Vytorin) – Fixed Dose Combination

    Statin-Associated Muscle Symptoms (SAMS) – The 2018 ACC/AHA/MS Guideline (Grundy et al., 2019) includes the following SAMS: myalgias, myositis, myopathy, or statin-associated autoimmune myopathy. Patients who experience significant or repeated statin-associated muscle symptoms may prefer not to take or continue statin therapy and therefore may be removed from the denominator.
Guidance |
    Initial Population Guidance:
    The initial population covers three distinct populations. Use the following process to prevent counting patients more than once.

    Initial Population 1:
    All patients who have an active diagnosis of clinical ASCVD anytime during the measurement period or ever had an ASCVD procedure.
    -If YES, meets Initial Population 1 risk category
    -If NO, screen for next risk category

    Initial Population 2:
    Patients aged >= 20 years at the beginning of the measurement period who have ever had a laboratory test result of LDL-C >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia

    -If YES, meets Initial Population 2 risk category
    -If NO, screen for next risk category

    Initial Population 3:
    Patients aged 40 to 75 years at the beginning of the measurement period with an active diagnosis of Type 1 or Type 2 diabetes at any time during the measurement period

    -If YES, meets Initial Population 3 risk category
    -If NO, patient does NOT meet Initial Population criteria and is NOT eligible for measure inclusion

    Initial Population Guidance for Encounter:
    In order for the patient to be included in the Initial Population, the patient must have ONE initial population-eligible visit, defined as follows: outpatient visit, initial or established office visit, face-to-face interaction, preventive care services, or annual wellness visit

    LDL-C Laboratory test result options:
    The measure can be reported for all patients with a documented LDL-C level recorded as follows:

    To meet Initial Population 1:
    There is no LDL-C result required.

    To meet Initial Population 2:
    If a patient has ANY previous laboratory result of LDL-C >= 190 mg/dL, report the highest value >= 190 mg/dL.

    To meet Initial Population 3:
    There is no LDL-C result required.

    Numerator instructions and guidance:
    -Current statin therapy use must be documented in the patient's current medication list or ordered during the measurement period.
    -ONLY statin therapy meets the measure Numerator criteria (NOT other cholesterol lowering medications).
    -Prescription or order does NOT need to be linked to an encounter or visit; it may be called to the pharmacy.
    -Statin medication "samples" provided to patients can be documented as "current statin therapy" if documented in the medication list in health/medical record.
    -Patients who meet the denominator criteria for inclusion, but are not prescribed or using statin therapy, will NOT meet performance for this measure unless they have an allowable denominator exception. Patients with an allowable denominator exception should be removed from the denominator of the measure and reported as a valid exception.
    -There is only one performance rate calculated for this measure: the weighted average of the three populations.
    -Adherence to statin therapy is not calculated in this measure.
    -It may not be appropriate to prescribe statin therapy for some patients (see exceptions and exclusions for the complete list).

    Intensity of statin therapy in primary and secondary prevention:
    The expert panel of the 2018 ACC/AHA/MS Guidelines (Grundy et al., 2019) defines recommended intensity of statin therapy on the basis of the average expected LDL-C response to specific statin and dose. Although intensity of statin therapy is important in managing cholesterol, this measure assesses prescription of ANY statin therapy, irrespective of intensity. Assessment of appropriate intensity and dosage documentation added too much complexity to allow inclusion of statin therapy intensity in the measure at this time.

    Lifestyle modification coaching:
    A healthy lifestyle is important for the prevention of cardiovascular disease. However, lifestyle modification monitoring and documentation added too much complexity to allow its inclusion in the measure at this time.

    Millimoles per liter (mmol/L) should be converted to milligrams per deciliter (mg/dL) for reporting this measure.

    This eCQM is a patient-based measure.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    Population 1:
    All patients who have an active diagnosis of clinical ASCVD or ever had an ASCVD procedure.

    Population 2:
    Patients aged >= 20 years at the beginning of the measurement period who have ever had a laboratory result of LDL-C >=190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia.

    Population 3:
    Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes.
Denominator |
    Equals Initial Population
Denominator Exclusions |
    Patients who are breastfeeding at any time during the measurement period.
    Patients who have a diagnosis of rhabdomyolysis at any time during the measurement period.
Numerator |
    Patients who are actively using or who receive an order (prescription) for statin therapy at any time during the measurement period
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    Patients with statin-associated muscle symptoms or an allergy to statin medication.
    Patients who are receiving palliative or hospice care.
    Patients with active liver disease or hepatic disease or insufficiency.
    Patients with end-stage renal disease (ESRD).
    Patients with documentation of a medical reason for not being prescribed statin therapy.
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- Population Criteria 1
  - - Initial Population

      - -     exists "Active ASVCD Diagnosis or Any Prior ASCVD Procedure"
                and exists "Qualifying Encounter during Measurement Period"

  - - Denominator

      - -     "Initial Population 1"

  - - Denominator Exclusions

      - -     exists ( ( ["Diagnosis": "Breastfeeding"]
                  union ["Diagnosis": "Rhabdomyolysis"] ) ExclusionDiagnosis
                  where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
              )

  - - Numerator

      - -     exists "Statin Therapy Ordered during Measurement Period"
                or exists "Prescribed Statin Therapy Any Time during Measurement Period"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     "Has Allergy to Statin"
                or Hospice."Has Hospice Services"
                or PalliativeCare."Palliative Care in the Measurement Period"
                or "Has Hepatitis or Liver Disease Diagnosis"
                or "Has Statin Associated Muscle Symptoms"
                or "Has ESRD Diagnosis"
                or "Has Adverse Reaction to Statin"
                or "Has Medical Reason for Not Ordering Statin Therapy"

  - - Stratification

      - -     None

- Population Criteria 2
  - - Initial Population

      - -     "Patients Age 20 Years and Older with LDL Cholesterol Result Greater than or Equal to 190 or Hypercholesterolemia without ASCVD"
                and exists "Qualifying Encounter during Measurement Period"

  - - Denominator

      - -     "Initial Population 2"

  - - Denominator Exclusions

      - -     exists ( ( ["Diagnosis": "Breastfeeding"]
                  union ["Diagnosis": "Rhabdomyolysis"] ) ExclusionDiagnosis
                  where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
              )

  - - Numerator

      - -     exists "Statin Therapy Ordered during Measurement Period"
                or exists "Prescribed Statin Therapy Any Time during Measurement Period"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     "Has Allergy to Statin"
                or Hospice."Has Hospice Services"
                or PalliativeCare."Palliative Care in the Measurement Period"
                or "Has Hepatitis or Liver Disease Diagnosis"
                or "Has Statin Associated Muscle Symptoms"
                or "Has ESRD Diagnosis"
                or "Has Adverse Reaction to Statin"
                or "Has Medical Reason for Not Ordering Statin Therapy"

  - - Stratification

      - -     None

- Population Criteria 3
  - - Initial Population

      - -     "Patients Age 40 to 75 Years with Diabetes without ASCVD or LDL Greater than 190 or Hypercholesterolemia"
                and exists "Qualifying Encounter during Measurement Period"

  - - Denominator

      - -     "Initial Population 3"

  - - Denominator Exclusions

      - -     exists ( ( ["Diagnosis": "Breastfeeding"]
                  union ["Diagnosis": "Rhabdomyolysis"] ) ExclusionDiagnosis
                  where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
              )

  - - Numerator

      - -     exists "Statin Therapy Ordered during Measurement Period"
                or exists "Prescribed Statin Therapy Any Time during Measurement Period"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     "Has Allergy to Statin"
                or Hospice."Has Hospice Services"
                or PalliativeCare."Palliative Care in the Measurement Period"
                or "Has Hepatitis or Liver Disease Diagnosis"
                or "Has Statin Associated Muscle Symptoms"
                or "Has ESRD Diagnosis"
                or "Has Adverse Reaction to Statin"
                or "Has Medical Reason for Not Ordering Statin Therapy"

  - - Stratification

      - -     None

### Definitions

- - Active ASVCD Diagnosis or Any Prior ASCVD Procedure

    - -     ( ( ["Diagnosis": "Myocardial Infarction"]
                union ["Diagnosis": "Cerebrovascular Disease Stroke or TIA"]
                union ["Diagnosis": "Atherosclerosis and Peripheral Arterial Disease"]
                union ["Diagnosis": "Ischemic Heart Disease or Other Related Diagnoses"]
                union ["Diagnosis": "Stable and Unstable Angina"] ) ASCVDDiagnosis
                where ASCVDDiagnosis.prevalencePeriod overlaps "Measurement Period"
            )
              union ( ( ["Procedure, Performed": "PCI"]
                  union ["Procedure, Performed": "CABG Surgeries"]
                  union ["Procedure, Performed": "Carotid Intervention"]
                  union ["Procedure, Performed": "CABG, PCI Procedure"] ) ASCVDProcedure
                  where Global."NormalizeInterval" ( ASCVDProcedure.relevantDatetime, ASCVDProcedure.relevantPeriod ) starts before
                  end of "Measurement Period"
              )

  - Denominator 1

    - -     "Initial Population 1"

  - Denominator 2

    - -     "Initial Population 2"

  - Denominator 3

    - -     "Initial Population 3"

  - Denominator Exceptions

    - -     "Has Allergy to Statin"
              or Hospice."Has Hospice Services"
              or PalliativeCare."Palliative Care in the Measurement Period"
              or "Has Hepatitis or Liver Disease Diagnosis"
              or "Has Statin Associated Muscle Symptoms"
              or "Has ESRD Diagnosis"
              or "Has Adverse Reaction to Statin"
              or "Has Medical Reason for Not Ordering Statin Therapy"

  - Denominator Exclusions

    - -     exists ( ( ["Diagnosis": "Breastfeeding"]
                union ["Diagnosis": "Rhabdomyolysis"] ) ExclusionDiagnosis
                where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
            )

  - Has Adverse Reaction to Statin

    - -     exists ["Adverse Event": "Statin Allergen"] StatinReaction
              where StatinReaction.relevantDatetime during "Measurement Period"

  - Has Allergy to Statin

    - -     exists ["Allergy/Intolerance": "Statin Allergen"] StatinAllergy
              where StatinAllergy.prevalencePeriod overlaps "Measurement Period"

  - Has Diabetes Diagnosis

    - -     exists ( ["Diagnosis": "Diabetes"] Diabetes
                where Diabetes.prevalencePeriod overlaps "Measurement Period"
            )

  - Has ESRD Diagnosis

    - -     exists ( ["Diagnosis": "End Stage Renal Disease"] ESRD
                where ESRD.prevalencePeriod overlaps "Measurement Period"
            )

  - Has Hepatitis or Liver Disease Diagnosis

    - -     exists ( ( ["Diagnosis": "Hepatitis A"]
                union ["Diagnosis": "Hepatitis B"]
                union ["Diagnosis": "Liver Disease"] ) HepatitisLiverDisease
                where HepatitisLiverDisease.prevalencePeriod overlaps "Measurement Period"
            )

  - Has Medical Reason for Not Ordering Statin Therapy

    - -     exists ( ( ["Medication, Not Ordered": "Low Intensity Statin Therapy"]
                union ["Medication, Not Ordered": "Moderate Intensity Statin Therapy"]
                union ["Medication, Not Ordered": "High Intensity Statin Therapy"] ) NoStatinTherapyOrdered
                with "Qualifying Encounter during Measurement Period" QualifyingEncounter
                  such that NoStatinTherapyOrdered.authorDatetime during QualifyingEncounter.relevantPeriod
                where NoStatinTherapyOrdered.negationRationale in "Medical Reason"
            )

  - Has Statin Associated Muscle Symptoms

    - -     exists ( ["Diagnosis": "Statin Associated Muscle Symptoms"] StatinMuscleSymptom
                where StatinMuscleSymptom.prevalencePeriod overlaps "Measurement Period"
            )

  - Hospice.Has Hospice Services

    - -     exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
                where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
                    or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
                )
                  and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
            )
              or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
                  where HospiceEncounter.relevantPeriod overlaps "Measurement Period"
              )
              or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
                  where HospiceAssessment.result ~ "Yes (qualifier value)"
                    and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps "Measurement Period"
              )
              or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
                  where HospiceOrder.authorDatetime during day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
                  where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period"
              )

  - Hypercholesterolemia Diagnosis

    - -     ( ["Diagnosis": "Familial Hypercholesterolemia"] Hypercholesterolemia
                where Hypercholesterolemia.prevalencePeriod starts before
                end of "Measurement Period"
            )

  - Initial Population 1

    - -     exists "Active ASVCD Diagnosis or Any Prior ASCVD Procedure"
              and exists "Qualifying Encounter during Measurement Period"

  - Initial Population 2

    - -     "Patients Age 20 Years and Older with LDL Cholesterol Result Greater than or Equal to 190 or Hypercholesterolemia without ASCVD"
              and exists "Qualifying Encounter during Measurement Period"

  - Initial Population 3

    - -     "Patients Age 40 to 75 Years with Diabetes without ASCVD or LDL Greater than 190 or Hypercholesterolemia"
              and exists "Qualifying Encounter during Measurement Period"

  - LDL Result Greater Than or Equal To 190

    - -     ["Laboratory Test, Performed": "LDL Cholesterol"] LDL190
              where LDL190.result >= 190 'mg/dL'
                and Global."NormalizeInterval" ( LDL190.relevantDatetime, LDL190.relevantPeriod ) starts before
                end of "Measurement Period"

  - Numerator

    - -     exists "Statin Therapy Ordered during Measurement Period"
              or exists "Prescribed Statin Therapy Any Time during Measurement Period"

  - PalliativeCare.Palliative Care in the Measurement Period

    - -     exists ( ["Assessment, Performed": "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment
                where Global."NormalizeInterval"(PalliativeAssessment.relevantDatetime, PalliativeAssessment.relevantPeriod) overlaps "Measurement Period"
            )
            or exists (["Diagnosis": "Encounter for palliative care"] PalliativeDiagnosis
            where PalliativeDiagnosis.prevalencePeriod overlaps "Measurement Period")
              or exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter
                  where PalliativeEncounter.relevantPeriod overlaps "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Palliative Care Intervention"] PalliativeIntervention
                  where Global."NormalizeInterval"(PalliativeIntervention.relevantDatetime, PalliativeIntervention.relevantPeriod) overlaps "Measurement Period"
              )

  - Patients Age 20 or Older at Start of Measurement Period

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 20

  - Patients Age 20 Years and Older with LDL Cholesterol Result Greater than or Equal to 190 or Hypercholesterolemia without ASCVD

    - -     "Patients Age 20 or Older at Start of Measurement Period"
              and exists ( "LDL Result Greater Than or Equal To 190"
                  union "Hypercholesterolemia Diagnosis"
              )
              and not exists "Active ASVCD Diagnosis or Any Prior ASCVD Procedure"

  - Patients Age 40 to 75 Years with Diabetes without ASCVD or LDL Greater than 190 or Hypercholesterolemia

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 40
              and AgeInYearsAt(date from start of "Measurement Period")<= 75
              and "Has Diabetes Diagnosis"
              and ( not exists "Active ASVCD Diagnosis or Any Prior ASCVD Procedure"
                  and not exists "LDL Result Greater Than or Equal To 190"
                  and not exists "Hypercholesterolemia Diagnosis"
              )

  - Prescribed Statin Therapy Any Time during Measurement Period

    - -     ( ["Medication, Active": "Low Intensity Statin Therapy"]
              union ["Medication, Active": "Moderate Intensity Statin Therapy"]
              union ["Medication, Active": "High Intensity Statin Therapy"] ) ActiveStatin
              where Global."NormalizeInterval" ( ActiveStatin.relevantDatetime, ActiveStatin.relevantPeriod ) overlaps "Measurement Period"

  - Qualifying Encounter during Measurement Period

    - -     ( ["Encounter, Performed": "Annual Wellness Visit"]
              union ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Outpatient Consultation"]
              union ["Encounter, Performed": "Outpatient Encounters for Preventive Care"]
              union ["Encounter, Performed": "Preventive Care Services Established Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Unlisted preventive medicine service"]
              union ["Encounter, Performed": "Preventive Care Services Individual Counseling"]
              union ["Encounter, Performed": "Preventive Care Services Initial Office Visit, 18 and Up"] ) ValidEncounter
              where ValidEncounter.relevantPeriod during "Measurement Period"

  - 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 Therapy Ordered during Measurement Period

    - -     ( ["Medication, Order": "Low Intensity Statin Therapy"]
              union ["Medication, Order": "Moderate Intensity Statin Therapy"]
              union ["Medication, Order": "High Intensity Statin Therapy"] ) StatinOrdered
              where StatinOrdered.authorDatetime during "Measurement Period"

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
- code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
- code "Encounter for palliative care" ("ICD10CM Code (Z51.5)")
- code "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" ("LOINC Code (71007-9)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Unlisted preventive medicine service" ("CPT Code (99429)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
- valueset "Atherosclerosis and Peripheral Arterial Disease" (2.16.840.1.113762.1.4.1047.21)
- valueset "Breastfeeding" (2.16.840.1.113762.1.4.1047.73)
- valueset "CABG Surgeries" (2.16.840.1.113883.3.666.5.694)
- valueset "CABG, PCI Procedure" (2.16.840.1.113762.1.4.1138.566)
- valueset "Carotid Intervention" (2.16.840.1.113883.3.117.1.7.1.204)
- valueset "Cerebrovascular Disease Stroke or TIA" (2.16.840.1.113762.1.4.1047.44)
- valueset "Diabetes" (2.16.840.1.113883.3.464.1003.103.12.1001)
- valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
- valueset "End Stage Renal Disease" (2.16.840.1.113883.3.526.3.353)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Familial Hypercholesterolemia" (2.16.840.1.113762.1.4.1047.100)
- valueset "Hepatitis A" (2.16.840.1.113883.3.464.1003.110.12.1024)
- valueset "Hepatitis B" (2.16.840.1.113883.3.67.1.101.1.269)
- valueset "High Intensity Statin Therapy" (2.16.840.1.113883.3.526.3.1572)
- valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "Ischemic Heart Disease or Other Related Diagnoses" (2.16.840.1.113762.1.4.1047.46)
- valueset "LDL Cholesterol" (2.16.840.1.113883.3.526.3.1573)
- valueset "Liver Disease" (2.16.840.1.113762.1.4.1047.42)
- valueset "Low Intensity Statin Therapy" (2.16.840.1.113883.3.526.3.1574)
- valueset "Medical Reason" (2.16.840.1.113883.3.526.3.1007)
- valueset "Moderate Intensity Statin Therapy" (2.16.840.1.113883.3.526.3.1575)
- valueset "Myocardial Infarction" (2.16.840.1.113883.3.526.3.403)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
- valueset "Outpatient Encounters for Preventive Care" (2.16.840.1.113883.3.526.3.1576)
- valueset "Palliative Care Encounter" (2.16.840.1.113883.3.464.1003.101.12.1090)
- valueset "Palliative Care Intervention" (2.16.840.1.113883.3.464.1003.198.12.1135)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "PCI" (2.16.840.1.113762.1.4.1045.67)
- valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
- valueset "Preventive Care Services Individual Counseling" (2.16.840.1.113883.3.464.1003.101.12.1026)
- valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Rhabdomyolysis" (2.16.840.1.113762.1.4.1047.102)
- valueset "Stable and Unstable Angina" (2.16.840.1.113762.1.4.1047.47)
- valueset "Statin Allergen" (2.16.840.1.113762.1.4.1110.42)
- valueset "Statin Associated Muscle Symptoms" (2.16.840.1.113762.1.4.1108.85)

### Data Criteria (QDM Data Elements)

- "Adverse Event: Statin Allergen" using "Statin Allergen (2.16.840.1.113762.1.4.1110.42)"
- "Allergy/Intolerance: Statin Allergen" using "Statin Allergen (2.16.840.1.113762.1.4.1110.42)"
- "Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)" using "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) (LOINC Code 71007-9)"
- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Diagnosis: Atherosclerosis and Peripheral Arterial Disease" using "Atherosclerosis and Peripheral Arterial Disease (2.16.840.1.113762.1.4.1047.21)"
- "Diagnosis: Breastfeeding" using "Breastfeeding (2.16.840.1.113762.1.4.1047.73)"
- "Diagnosis: Cerebrovascular Disease Stroke or TIA" using "Cerebrovascular Disease Stroke or TIA (2.16.840.1.113762.1.4.1047.44)"
- "Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
- "Diagnosis: Encounter for palliative care" using "Encounter for palliative care (ICD10CM Code Z51.5)"
- "Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease (2.16.840.1.113883.3.526.3.353)"
- "Diagnosis: Familial Hypercholesterolemia" using "Familial Hypercholesterolemia (2.16.840.1.113762.1.4.1047.100)"
- "Diagnosis: Hepatitis A" using "Hepatitis A (2.16.840.1.113883.3.464.1003.110.12.1024)"
- "Diagnosis: Hepatitis B" using "Hepatitis B (2.16.840.1.113883.3.67.1.101.1.269)"
- "Diagnosis: Ischemic Heart Disease or Other Related Diagnoses" using "Ischemic Heart Disease or Other Related Diagnoses (2.16.840.1.113762.1.4.1047.46)"
- "Diagnosis: Liver Disease" using "Liver Disease (2.16.840.1.113762.1.4.1047.42)"
- "Diagnosis: Myocardial Infarction" using "Myocardial Infarction (2.16.840.1.113883.3.526.3.403)"
- "Diagnosis: Rhabdomyolysis" using "Rhabdomyolysis (2.16.840.1.113762.1.4.1047.102)"
- "Diagnosis: Stable and Unstable Angina" using "Stable and Unstable Angina (2.16.840.1.113762.1.4.1047.47)"
- "Diagnosis: Statin Associated Muscle Symptoms" using "Statin Associated Muscle Symptoms (2.16.840.1.113762.1.4.1108.85)"
- "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
- "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
- "Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
- "Encounter, Performed: Outpatient Encounters for Preventive Care" using "Outpatient Encounters for Preventive Care (2.16.840.1.113883.3.526.3.1576)"
- "Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090)"
- "Encounter, Performed: Preventive Care Services Established Office Visit, 18 and Up" using "Preventive Care Services Established Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1025)"
- "Encounter, Performed: Preventive Care Services Individual Counseling" using "Preventive Care Services Individual Counseling (2.16.840.1.113883.3.464.1003.101.12.1026)"
- "Encounter, Performed: Preventive Care Services Initial Office Visit, 18 and Up" using "Preventive Care Services Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
- "Encounter, Performed: Unlisted preventive medicine service" using "Unlisted preventive medicine service (CPT Code 99429)"
- "Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Palliative Care Intervention" using "Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135)"
- "Laboratory Test, Performed: LDL Cholesterol" using "LDL Cholesterol (2.16.840.1.113883.3.526.3.1573)"
- "Medication, Active: High Intensity Statin Therapy" using "High Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1572)"
- "Medication, Active: Low Intensity Statin Therapy" using "Low Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1574)"
- "Medication, Active: Moderate Intensity Statin Therapy" using "Moderate Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1575)"
- "Medication, Not Ordered: High Intensity Statin Therapy" using "High Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1572)"
- "Medication, Not Ordered: Low Intensity Statin Therapy" using "Low Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1574)"
- "Medication, Not Ordered: Moderate Intensity Statin Therapy" using "Moderate Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1575)"
- "Medication, Order: High Intensity Statin Therapy" using "High Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1572)"
- "Medication, Order: Low Intensity Statin Therapy" using "Low Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1574)"
- "Medication, Order: Moderate Intensity Statin Therapy" using "Moderate Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1575)"
- "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)"
- "Procedure, Performed: CABG Surgeries" using "CABG Surgeries (2.16.840.1.113883.3.666.5.694)"
- "Procedure, Performed: CABG, PCI Procedure" using "CABG, PCI Procedure (2.16.840.1.113762.1.4.1138.566)"
- "Procedure, Performed: Carotid Intervention" using "Carotid Intervention (2.16.840.1.113883.3.117.1.7.1.204)"
- "Procedure, Performed: PCI" using "PCI (2.16.840.1.113762.1.4.1045.67)"

### 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 |
    None