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Discharged on Antithrombotic Therapy

CMS Measure ID
CMS104v8
Version
8
NQF Number
Not Applicable
Measure Description

Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge

Initial Population

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 the measurement period

Denominator Statement

Inpatient hospitalizations for patients with a principal diagnosis of Ischemic stroke

Denominator Exclusions

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

Numerator Statement

Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge

Numerator Exclusions

Not Applicable

Denominator Exceptions

Inpatient hospitalizations for patients with a documented reason for not prescribing antithrombotic therapy at discharge.

Inpatient hospitalizations for patients who receive Ticagrelor as an antithrombotic therapy during the hospitalization.

Measure Steward
Short Name
STK-2
Previous Version
Measure Scoring
Measure Type
Improvement Notation

Improvement noted as an increase in rate

Guidance

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.

The "Medication, Discharge" datatype refers to the discharge medication list and is intended to express medications ordered for post-discharge use.

Meaningful Measure

Specifications

Attachment Size
CMS104v8.html 71.3 KB
CMS104v8.zip 67.62 KB
CMS104v8-TRN.xlsx 22.86 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated guidance statement to correct grammatical errors.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated initial population statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated denominator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Revised denominator statement to correct grammatical errors.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Updated denominator exclusions statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusion statement to align with logic.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated numerator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated denominator exceptions statement to include patients who receive Ticagrelor during the hospitalization, to align with the chart-abstracted measure.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Logic

  • Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2835

  • Added a union operator and logic to capture denominator exceptions for patients receiving Ticagrelor to improve alignment with the chart-abstracted measure.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Added definition title of 'Encounter With No Antithrombotic At Discharge' to pre-existing logic to align with CQL style guide.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.

    Measure Section: Denominator Exceptions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2835

  • Added 'Encounter With Ticagrelor During Hospitalization' to improve alignment with the chart-abstracted measure.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated definition name from TJC.'Ischemic Stroke Encounters with Discharge Status' to TJC.'Ischemic Stroke Encounters with Discharge Disposition' to align with measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Update to TJC_Overall Library version number (TJC_Overall-3.6.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

 

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201): Added 3 RxNorm codes (1549682, 1730187, 1992427) and deleted 4 RxNorm codes (1536670, 806446, 853499, 978738).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Added Observation Services.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Ticagrelor Therapy (2.16.840.1.113762.1.4.1110.39): New value set with 2 RxNorm codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45): Changed Exclusion Criteria description from ‘None’ to ‘Palliative Care’ for clarity and to align with chart-abstracted measures.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-3396

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Oct 10, 2019