| Measure Information | 2021 Reporting Period |
|---|---|
| CMS eCQM ID | CMS72v9 |
| Short Name | STK-5 |
| NQF Number | Not Applicable |
| Description |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
| Initial Population |
Inpatient hospitalization 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 |
| Numerator |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke |
| Denominator Exclusions |
Inpatient hospitalizations for patients who have a duration of stay less than 2 days. Inpatient hospitalization for patients with comfort measures documented day of or the day after arrival. Inpatient hospitalization for patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization. |
| Denominator Exceptions |
Inpatient hospitalization for patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival. Inpatient hospitalization for patients who receive Ticagrelor or Prasugrel as an antithrombotic therapy the day of or day after hospital arrival. Inpatient hospitalization for patients with an INR greater than 3.5. |
| Steward | The Joint Commission |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| 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 Inpatient Encounters include emergency, urgent, and unplanned admissions. NPO (Nothing by mouth) is not a valid reason for not administering antithrombotic therapy by end of hospital day 2 as another route of administration can be used (i.e. rectal or intravenous). 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. Enoxaparin 40mg once a day is not a therapeutic dose for antithrombotic therapy. This eCQM is an episode-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
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Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2021 Reporting Period | 2022 Reporting Period | 2023 Reporting Period | 2024 Reporting Period |
|---|---|---|---|---|
| Title | Antithrombotic Therapy By End of Hospital Day 2 | Antithrombotic Therapy By End of Hospital Day 2 | Antithrombotic Therapy By End of Hospital Day 2 | Antithrombotic Therapy By End of Hospital Day 2 |
| CMS eCQM ID | CMS72v9 | CMS72v10 | CMS72v11 | CMS72v12 |
| Short Name | STK-5 | STK-5 | STK-5 | STK-5 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Description |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
| Initial Population |
Inpatient hospitalization 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 hospitalization 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 hospitalization 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 hospitalization 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 |
| Denominator |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke |
| Denominator Exclusions | Inpatient hospitalizations for patients who have a duration of stay less than 2 days. Inpatient hospitalization for patients with comfort measures documented day of or the day after arrival. Inpatient hospitalization for patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization. | Inpatient hospitalizations for patients who have a duration of stay less than 2 days. Inpatient hospitalization for patients with comfort measures documented day of or the day after arrival. Inpatient hospitalization for patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization. | * Inpatient hospitalizations for patients who have a duration of stay less than 2 days * Inpatient hospitalization for patients with comfort measures documented day of or the day after arrival * Inpatient hospitalization for patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization | - Inpatient hospitalizations for patients who have a duration of stay less than 2 days - Inpatient hospitalization for patients with comfort measures documented day of or the day after arrival - Inpatient hospitalization for patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization |
| Numerator |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
Inpatient hospitalization for patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival. Inpatient hospitalization for patients who receive Ticagrelor or Prasugrel as an antithrombotic therapy the day of or day after hospital arrival. Inpatient hospitalization for patients with an INR greater than 3.5. |
Inpatient hospitalization for patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival. Inpatient hospitalization for patients who receive Ticagrelor or Prasugrel as an antithrombotic therapy the day of or day after hospital arrival. Inpatient hospitalization for patients with an INR greater than 3.5. |
* Inpatient hospitalization for patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival * Inpatient hospitalization for patients who receive Prasugrel as an antithrombotic therapy the day of or day after hospital arrival * Inpatient hospitalization for patients with an INR greater than 3.5 |
- Inpatient hospitalization for patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival - Inpatient hospitalization for patients who receive Prasugrel as an antithrombotic therapy the day of or day after hospital arrival - Inpatient hospitalization for patients with an INR greater than 3.5 |
| Measure Steward | The Joint Commission | The Joint Commission | The Joint Commission | The Joint Commission |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure | Process measure |
| Improvement Notation |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
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 Inpatient Encounters include emergency, urgent, and unplanned admissions. NPO (Nothing by mouth) is not a valid reason for not administering antithrombotic therapy by end of hospital day 2 as another route of administration can be used (i.e. rectal or intravenous). 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. Enoxaparin 40mg once a day is not a therapeutic dose for antithrombotic therapy. This eCQM is an episode-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
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. NPO (Nothing by mouth) is not a valid reason for not administering antithrombotic therapy by end of hospital day 2 as another route of administration can be used (i.e. rectal or intravenous). 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. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
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. NPO (Nothing by mouth) is not a valid reason for not administering antithrombotic therapy by end of hospital day 2 as another route of administration can be used (i.e. rectal or intravenous). 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. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
The "Nonelective 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. NPO (Nothing by mouth) is not a valid reason for not administering antithrombotic therapy by end of hospital day 2 as another route of administration can be used (i.e., rectal or intravenous). 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. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Next Version | CMS72v10 | CMS72v11 | CMS72v12 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
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Updated eCQM Version Number.
Measure Section: eCQM Version Number
Source of Change: Standards Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Added the following text: 'Enoxaparin/Lovenox 40 mg once a day is not a therapeutic dose for antithrombotic therapy'.
Measure Section: Guidance
Source of Change: ONC Project Tracking System (Jira): CQM-3548
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Added text to identify the Quality Data Model (QDM) version used in the measure specification.
Measure Section: Guidance
Source of Change: Standards Update
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Added text to indicate whether the measure is patient-based or episode-based.
Measure Section: Guidance
Source of Change: Standards Update
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Removed from denominator exclusions 'Inpatient hospitalization for patients with an INR greater than 3.5' to better harmonize with the chart abstracted version of measure and for better alignment with measure intent.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Added to denominator exceptions 'Inpatient hospitalization for patients with an INR greater than 3.5' to better harmonize with the chart abstracted version of measure and for better alignment with measure intent.
Measure Section: Denominator Exceptions
Source of Change: Measure Lead
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Updated denominator exceptions statement to 'Inpatient hospitalization for patients who receive Ticagrelor or Prasugrel as an antithrombotic therapy the day of or day after hospital arrival'.
Measure Section: Denominator Exceptions
Source of Change: Expert Work Group Review
Logic
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Removed from denominator exclusions 'Inpatient hospitalization for patients with an INR greater than 3.5' to better harmonize with the chart abstracted version of measure and for better alignment with measure intent.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Consolidated 'Encounter with Thrombolytic Therapy Medication or Procedures', 'Encounter with Thrombolytic Medication', 'Encounter With Thrombolytic Therapy Prior to Arrival', and 'Encounter With Thrombolytic Therapy Documented As Already Given' into one definition called: 'Encounter with Thrombolytic Therapy Given Prior To Arrival Or During Hospitalization'.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Added 'Encounter with' to TJC.Comfort Measures during Hospitalization definition name for clarification.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Added to denominator exceptions 'Inpatient hospitalization for patients with an INR greater than 3.5' to better harmonize with the chart abstracted version of measure and for better alignment with measure intent.
Measure Section: Denominator Exceptions
Source of Change: Measure Lead
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Replaced 'Ticagrelor Therapy' with 'Pharmacological Contraindications for Antithrombotic Therapy' to improve alignment with chart abstracted measure.
Measure Section: Denominator Exceptions
Source of Change: Expert Work Group Review
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QDM v5.5 standards update: Added 'rank' attribute to 'Encounter, Performed' datatype. Rank with a value of 1 indicates the principal diagnosis.
Measure Section: Multiple Sections
Source of Change: Standards Update
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QDM v5.5 standards update: Removed the 'ordinality' and 'principal diagnosis' attributes, added 'rank' as an attribute.
Measure Section: Multiple Sections
Source of Change: Standards Update
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QDM v5.5 standards update: Modified 'Encounter, Performed' diagnosis attribute to reference diagnosis codes in value sets specified in the logic.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Clinical Quality Language (CQL) Library version update: Updated version number of the TJC_Overall Library (TJC_Overall-4.4.000).
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000).
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Replaced the 'TJC.HospitalizationWithObservationLengthofStay' function with the 'Global.HospitalizationWithObservationLengthofStay' function for harmonization with other measures.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value set Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201): Added 1 RxNorm code (2059015) and deleted 10 RxNorm codes (103863, 1291868, 198466, 199274, 243685, 605252, 797050, 863184, 863186, 896884) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 1 SNOMED CT code (422504002) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Deleted 2 SNOMED CT codes (448851000124103, 76464004) based on clinical/coding expert feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Pharmacological Contraindications for Antithrombotic Therapy (2.16.840.1.113762.1.4.1110.52): Added Pharmacological Contraindications for Antithrombotic Therapy grouping value set that includes value set Ticagrelor Therapy (2.16.840.1.113762.1.4.1110.39) and value set Prasugrel (2.16.840.1.113762.1.4.1110.51) based on the inclusion of Prasugrel; due to pharmacological contraindication when used with certain antithrombotic medications.
Measure Section: Terminology
Source of Change: Expert Work Group Review
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Value set Ticagrelor Therapy value Set (2.16.840.1.113762.1.4.1110.39): Replaced Ticagrelor Therapy with the Pharmacological Contraindications For Antithrombotic Therapy grouping value set (2.16.840.1.113762.1.4.1110.52) which includes both ticagrelor and prasugrel.
Measure Section: Terminology
Source of Change: Measure Lead