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Antithrombotic Therapy By End of Hospital Day 2

eCQMs for 2022 Reporting Period

General eCQM Information

CMS Measure ID CMS72v10
Short Name STK-5
NQF Number Not Applicable
Measure 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
Denominator Statement

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.

Numerator Statement

Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival

Numerator Exclusions

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.

Measure Steward The Joint Commission
Measure Scoring Proportion
Measure Type Process
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

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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Meaningful Measure Preventive Care
Previous Version

Release Notes

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

  • Removed from guidance the phrase 'Enoxaparin 40mg once a day is not a therapeutic dose for antithrombotic therapy.' because it is not consistent with current measure logic.

    Measure Section: Guidance

    Source of Change: ONC Project Tracking System (Jira): CQM-3989

Logic

  • 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

  • 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

  • Updated TJC_Overall CQL Library to version 5.2.000.

    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.

  • Value set Intravenous or Intra-arterial Thrombolytic (t-PA) Therapy (2.16.840.1.113762.1.4.1045.21): Added 8 ICD-10-PCS codes (3E03017, 3E03317, 3E04017, 3E04317, 3E05017, 3E05317, 3E06017, 3E06317) based on terminology update.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CQM-4425

  • Replaced value set Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201) with value set Antithrombotic Therapy (2.16.840.1.113762.1.4.1110.62) based on applicability of value set and/or OID.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Antithrombotic Therapy (2.16.840.1.113762.1.4.1110.62): Added 2 RxNorm codes (854228, 854235) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Thrombolytic (t-PA) Therapy (2.16.840.1.113883.3.117.1.7.1.226): Added 1 RxNorm code (313212) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021