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Discharged on Statin Medication

Compare Versions of: "Discharged on Statin Medication"

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Measure Information 2022 Reporting Period 2023 Reporting Period
Title Discharged on Statin Medication Discharged on Statin Medication
CMS eCQM ID CMS105v10 CMS105v11
Short Name

STK-6

STK-6

CBE ID Not Applicable Not Applicable
Description

Ischemic stroke patients who are prescribed or continuing to take statin medication at hospital discharge

Ischemic stroke patients who are prescribed or continuing to take statin medication at hospital discharge

Definition *See CMS105v10.html *See CMS105v11.html
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

Numerator

Inpatient hospitalizations for patients prescribed or continuing to take statin medication at hospital discharge

Inpatient hospitalizations for patients prescribed or continuing to take statin medication at hospital discharge

Numerator Exclusions

Not Applicable

Not Applicable

Denominator

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

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

* 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 The Joint Commission
Measure Scoring Proportion measure Proportion measure
Measure Type Process measure Process measure
Improvement Notation

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. 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.

Rationale *See CMS105v10.html *See CMS105v11.html
Stratification *See CMS105v10.html *See CMS105v11.html
Risk Adjustment *See CMS105v10.html *See CMS105v11.html
Clinical Recommendation Statement *See CMS105v10.html *See CMS105v11.html
Next Version No Version Available
Previous Version No Version Available

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.

  • Value set LDL-c (2.16.840.1.113883.3.117.1.7.1.215): Added 2 LOINC codes (96259-7, 96597-0) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Deleted 4 RxNorm codes (757702, 757703, 757704, 757705) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Mar 04, 2024