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Discharged on Antithrombotic Therapy

Measure Information 2022 Reporting Period
CMS eCQM ID CMS104v10
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

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

Numerator

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. 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
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Measure Information 2021 Reporting Period 2022 Reporting Period 2023 Reporting Period
Title Discharged on Antithrombotic Therapy Discharged on Antithrombotic Therapy Discharged on Antithrombotic Therapy
CMS eCQM ID CMS104v9 CMS104v10 CMS104v11
Short Name STK-2 STK-2 STK-2
NQF Number 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

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

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

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
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

Numerator Exclusions

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

Measure Steward The Joint Commission The Joint Commission The Joint Commission
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type 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

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 (https://ecqi.healthit.gov/qdm) 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.

Meaningful Measure Preventive Care Preventive Care Preventive Care
Next Version CMS104v10 CMS104v11 No Version Available
Previous Version No Version Available

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

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.

  • 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

Last Updated: Aug 29, 2022