| Measure Information | 2022 Reporting Period |
|---|---|
| CMS eCQM ID | CMS71v11 |
| Short Name |
STK-3 |
| NQF Number | Not Applicable |
| Description |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation 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 measurement period |
| Numerator |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
| 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 anticoagulation 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 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. 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. |
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| Measure Information | 2021 Reporting Period | 2022 Reporting Period | 2023 Reporting Period | 2024 Reporting Period |
|---|---|---|---|---|
| Title | Anticoagulation Therapy for Atrial Fibrillation/Flutter | Anticoagulation Therapy for Atrial Fibrillation/Flutter | Anticoagulation Therapy for Atrial Fibrillation/Flutter | Anticoagulation Therapy for Atrial Fibrillation/Flutter |
| CMS eCQM ID | CMS71v10 | CMS71v11 | CMS71v12 | CMS71v13 |
| Short Name |
STK-3 |
STK-3 |
STK-3 |
STK-3 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Description |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation 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 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 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 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 measurement period |
| Denominator |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter. |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
| 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 anticoagulation therapy at hospital discharge. |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation 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 anticoagulation therapy at discharge |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation 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 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. |
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. 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. 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 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. 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 | CMS71v11 | CMS71v12 | CMS71v13 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
-
Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
-
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
-
Added clarifying language to the guidance section of episode-based measures to define the episode.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
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Updated Global.'Inpatient Encounter' definition by adding 'day of' to ensure all cases within the measurement period are captured and evaluated in the initial population.
Measure Section: Definitions
Source of Change: Measure Lead
-
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated TJC_Overall CQL Library to version 5.2.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead