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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
Measure Steward The Joint Commission The Joint Commission
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

Measure Scoring Proportion measure Proportion measure
Measure Type Process Process
Stratification *See CMS105v10.html *See CMS105v11.html
Risk Adjustment *See CMS105v10.html *See CMS105v11.html
Rationale *See CMS105v10.html *See CMS105v11.html
Clinical Recommendation Statement *See CMS105v10.html *See CMS105v11.html
Improvement Notation

Improvement noted as an increase in rate

Improvement noted as an increase in rate

Definition *See CMS105v10.html *See CMS105v11.html
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.

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

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

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 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

Next Version No Version Available
Previous Version No Version Available

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards/Technical Update

  • 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

  • Added bullets for readability and consistency with other measures per external review.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Denominator Exceptions

    Source of Change: Standards/Technical Update

  • Replaced reference to Global.ToDate with identical function named TJC.TruncateTime because Global.ToDate was retired.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Replaced age calculation from BirthDate with CQL function AgeInYearsAt in the TJCOverall library.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added function 'TruncateTime' to replace retired Global.'ToDate'. Function 'CalendarDayOfOrDayAfter' now uses TJC.'TruncateTime' rather than the retired Global.'ToDate' in TJCOverall library.

    Measure Section: Functions

    Source of Change: Measure Lead

  • 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

  • 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

  • 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 version number of the TJC Overall Library to v6.0.000.

    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 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

  • Value set Statin Allergen (2.16.840.1.113762.1.4.1110.42): Added 1 SNOMED CT code (96302009) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Added 4 RxNorm codes (2535745, 2535747, 2535749, 2535750) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • 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

Last Updated: Sep 23, 2024