| Measure Information | 2021 Reporting Period |
|---|---|
| CMS eCQM ID | CMS104v9 |
| Short Name | STK-2 |
| NQF Number | Not Applicable |
| 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 |
| Numerator |
Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
| Numerator Exclusions |
Not Applicable |
| Denominator |
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 |
| 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. |
| 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. |
| Next Version | |
| Previous Version | No Version Available |
Compare eCQM Versions
The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.
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 | Discharged on Antithrombotic Therapy | Discharged on Antithrombotic Therapy | Discharged on Antithrombotic Therapy | Discharged on Antithrombotic Therapy |
| CMS eCQM ID | CMS104v9 | CMS104v10 | CMS104v11 | CMS104v12 |
| Short Name | STK-2 | STK-2 | STK-2 | STK-2 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Description |
Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
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 |
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 |
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 |
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 |
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 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 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 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 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 |
Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
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. |
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. |
* Inpatient hospitalizations for patients with a documented reason for not prescribing antithrombotic therapy at discharge * Inpatient hospitalizations for patients who receive Prasugrel as an antithrombotic therapy at discharge |
- Inpatient hospitalizations for patients with a documented reason for not prescribing antithrombotic therapy at discharge - Inpatient hospitalizations for patients who receive Prasugrel as an antithrombotic therapy at discharge |
| 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 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. |
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. 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 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. 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 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. 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 | CMS104v10 | CMS104v11 | CMS104v12 | 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 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
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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
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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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Replaced 'Medication, Administered' with 'Medication, Discharge' to better align 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 further improve alignment with chart abstracted measure.
Measure Section: Denominator Exceptions
Source of Change: Expert Work Group Review
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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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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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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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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
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 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 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 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
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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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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