Discharged on Statin Medication | eCQI Resource Center

Measure Information	2023 Reporting Period
CMS eCQM ID	CMS105v11
Short Name	STK-6
NQF Number	Not Applicable
Description	Ischemic stroke patients who are prescribed or continuing to take statin medication 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 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 statin medication at hospital discharge
Numerator Exclusions	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
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 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.
Meaningful Measure	Preventive Care
Next Version	No Version Available
Previous Version	CMS105v10

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Measure Information	2021 Reporting Period	2022 Reporting Period	2023 Reporting Period
Title	Discharged on Statin Medication	Discharged on Statin Medication	Discharged on Statin Medication
CMS eCQM ID	CMS105v9	CMS105v10	CMS105v11
Short Name	STK-6	STK-6	STK-6
NQF Number	Not Applicable	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	Ischemic stroke patients who are prescribed or continuing to take statin medication 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 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	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	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 statin medication at hospital discharge	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	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	* 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	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 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. 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. 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.
Meaningful Measure	Preventive Care	Preventive Care	Preventive Care
Next Version	CMS105v10	CMS105v11	No Version Available
Previous Version	No Version Available	CMS105v9	CMS105v10

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Data Element Repository

Data Elements contained within CMS105v11

Value Sets

Value Sets to be used with CMS105v11

Release Notes

CMS105v11-TRN.xlsx

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