General eCQM Information
| CMS Measure ID | CMS105v9 |
|---|---|
| Short Name | STK-6 |
| NQF Number | Not Applicable |
| Measure Description |
Ischemic stroke patients who are prescribed or continuing to take statin medication 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 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 statin medication at hospital discharge |
| Numerator Exclusions |
Not Applicable |
| Denominator Exceptions |
Inpatient hospitalizations for patients with a reason for not prescribing statin medication at discharge Inpatient hospitalizations for patients with a maximum LDL-c result of less than 70 mg/dL <= 30 days prior to arrival or any time during the hospital stay Inpatient hospitalizations for patients with a statin allergy |
| 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 Inpatient Encounters 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 |
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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: 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
Logic
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Add '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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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 updates: 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 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 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 Statin Grouper (2.16.840.1.113762.1.4.1110.19): Added 4 RxNorm codes (2167565, 2167569, 2167557, 2167573) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update