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Discharged on Antithrombotic Therapy

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eCQMs for 2021 Reporting Period

CMS9v9 - PC-05
CMS71v10 - STK-3
CMS72v9 - STK-5
CMS104v9 - STK-2
CMS105v9 - STK-6
CMS108v9 - VTE-1
CMS111v9 - ED-2
CMS190v9 - VTE-2
CMS506v3

General eCQM Information

CMS Measure ID CMS104v9
Short Name STK-2
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 or Prasugrel as an antithrombotic therapy at discharge.
Measure 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 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.

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.
Meaningful Measure Preventive Care
Next Version
CMS104v10
Previous Version
CMS104v8
Specifications
Attachment Size
CMS104v9.html 75.04 KB
CMS104v9.zip 70.64 KB
CMS104v9-TRN.xlsx 22.23 KB

Data Element Repository

Release Notes

CMS104v9-TRN.xlsx

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated the denominator exceptions statement to 'Inpatient hospitalizations for patients who receive Ticagrelor or Prasugrel as an antithrombotic therapy at discharge.'.

    Measure Section: Denominator Exceptions

    Source of Change: Expert Work Group Review

Logic

  • Added 'Encounter with' to TJC.Comfort Measures during Hospitalization definition name​ for clarification.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Replaced 'Medication, Administered' with 'Medication, Discharge' to better align with measure intent.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Replaced 'Ticagrelor Therapy' with 'Pharmacological Contraindications for Antithrombotic Therapy' to further improve alignment with chart abstracted measure.

    Measure Section: Denominator Exceptions

    Source of Change: Expert Work Group Review

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

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 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

  • 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

  • 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: Measure Lead

  • 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

  • Replaced the Ticagrelor Therapy value Set (2.16.840.1.113762.1.4.1110.39) 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

Last Updated: May 05, 2021