| Measure Information | 2023 Reporting Period |
|---|---|
| CMS eCQM ID | CMS72v11 |
| Short Name | STK-5 |
| NQF Number | Not Applicable |
| 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 |
| Numerator |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
| Numerator Exclusions |
Not Applicable |
| Denominator |
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 |
| 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 Prasugrel as an antithrombotic therapy the day of or day after hospital arrival * Inpatient hospitalization for patients with an INR greater than 3.5 |
| 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. 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 <2 days, including ED visit (if there is one). For the eCQM we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits. 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. |
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| Measure Information | 2021 Reporting Period | 2022 Reporting Period | 2023 Reporting Period | 2024 Reporting Period |
|---|---|---|---|---|
| Title | Antithrombotic Therapy By End of Hospital Day 2 | Antithrombotic Therapy By End of Hospital Day 2 | Antithrombotic Therapy By End of Hospital Day 2 | Antithrombotic Therapy By End of Hospital Day 2 |
| CMS eCQM ID | CMS72v9 | CMS72v10 | CMS72v11 | CMS72v12 |
| Short Name | STK-5 | STK-5 | STK-5 | STK-5 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Description |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 |
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 |
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 |
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 |
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 |
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 |
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. | 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. | * 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 | - 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 |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
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. |
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. |
* 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 Prasugrel as an antithrombotic therapy the day of or day after hospital arrival * Inpatient hospitalization for patients with an INR greater than 3.5 |
- 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 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 | 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. 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 <2 days, including ED visit (if there is one). For the eCQM we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits. Enoxaparin 40mg once a day is not a therapeutic dose for antithrombotic therapy. 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. 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 <2 days, including ED visit (if there is one). For the eCQM we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits. 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. 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 <2 days, including ED visit (if there is one). For the eCQM we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits. 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. 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 <2 days, including ED visit (if there is one). For the eCQM we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits. 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. |
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| Previous Version | No Version Available |
Data Element Repository
Header
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
-
Added clarifying text noting VTE prophylaxis does not suffice as antithrombotic therapy.
Measure Section: Rationale
Source of Change: Measure Lead
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Updated guidance to indicate patients in Acute Hospital Care at Home programs are included in the denominator population.
Measure Section: Guidance
Source of Change: Measure Lead
-
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
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Updated denominator exceptions statement to remove ticagrelor as an applicable exception, per the new FDA-approved indication for its use in ischemic stroke. Ticagrelor is now included in the value sets for numerator compliance.
Measure Section: Denominator Exceptions
Source of Change: Measure Lead
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Added bullets and made minor grammar edits for readability and consistency with other measures per external review.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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Updated definition name to distinguish it from library definition and to match its purpose.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Replaced age calculation from BirthDate with CQL function AgeInYearsAt in the TJCOverall library.
Measure Section: Definitions
Source of Change: Measure Lead
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Replaced Global.ToDate() with TJC.TruncateTime() in the function of TJC.'CalendarDayOfOrDayAfter'.
Measure Section: Functions
Source of Change: Measure Lead
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Updated the version number of the TJC Overall Library to v6.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
-
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/Technical Update
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Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
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Updated the timing precision in definitions using the function TJC.'CalendarDayOfOrDayAfter' from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
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Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical 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 Pharmacological Contraindications For Antithrombotic Therapy (2.16.840.1.113762.1.4.1110.52): Deleted 2 RxNorm codes (1116635, 1666332) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Antithrombotic Therapy (2.16.840.1.113762.1.4.1110.62): Added 2 RxNorm codes (1116635, 1666332) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations. Added 4 RxNorm codes (2588062, 198466, 243670, 252857) based on terminology update.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMED CT code (397745006) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead