Antithrombotic Therapy By End of Hospital Day 2

Last updated: May 3, 2018

CMS Measure ID: CMS72v6
Version: 6
NQF Number: None
Measure Description:

Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2

Initial Patient Population:

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 Statement:

Patients with a principal diagnosis of Ischemic stroke

Denominator Exclusions:

Patients who have a duration of stay less than 2 days

Patients with comfort measures documented on day or the day after arrival

Patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization

Numerator Statement:

Patients who had antithrombotic therapy administered the day of or day after hospital arrival

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival

Measure Steward: The Joint Commission
Short Name: Stroke5
Next Version:
Previous Version:
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

The Non-elective admissions value setinfo-icon 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.

NPO 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 denominatorinfo-icon 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 eCQMinfo-icon we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits:

AND: Intersection of:

Occurrence A of $EncounterInpatientNonElective

Encounter, Performed: Non-Elective Inpatient Encounter (length of stay < 2 day(s))

AND NOT: Encounter, Performed: Emergency Department Visit <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatientNonElective

The following statement addresses patients who were admitted via the ED:

OR: Encounter, Performed: Emergency Department Visit satisfies all

<= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatientNonElective

< 2 day(s) starts before end of Occurrence A of $EncounterInpatientNonElective.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Replaced NQFinfo-icon Number '0438' with 'Not Applicable' as the measure is no longer endorsed.

    Measure Section: NQF Number

    Source of Change: Measure Lead

  • Replaced 'National Quality Forum' with 'None' as the measure is no longer endorsed.

    Measure Section: Endorsed By

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Added Guidance to better align with measure intent.

    Measure Section: Guidance

    Source of Change: JIRA (CQMinfo-icon-2481)

  • Added 'that ends during the measurement period' to the Initial Populationinfo-icon narrative statement to better align with measure logic.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-2520)

Logic

  • Added 'Occurrence A of' to $EncounterInpatientNonElective to correct error of omission.

    Measure Section: Denominatorinfo-icon Exclusions

    Source of Change: JIRA (CQM-2266)

  • Replaced 'Antithrombotic ingredient specific' value setinfo-icon with 'Antithrombotic Therapy' semantic clinical drug value set to ease implementation burden.

    Measure Section: Denominator Exceptions

    Source of Change: JIRA (CQM-1835)

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201): Added 23 RXNORM codes and deleted 34 RXNORM codes.

    Measure Section: QDMinfo-icon Data Elements

    Source of Change: Chart-Abstracted Measures

  • Value set Thrombolytic (t-PA) Therapy (2.16.840.1.113883.3.117.1.7.1.226): Added 2 RXNORM codes (1804799, 1804804) and deleted 1 RXNORM code (308056).

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 3 SNOMEDCT codes (183946001, 183956002, 609589008).

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Deleted 2 ICD9CM codes (430, 431).

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Deleted 12 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Replaced Antithrombotic ingredient specific value set (2.16.840.1.113762.1.4.1021.8) with Antithrombotic Therapy value set (2.16.840.1.113883.3.117.1.7.1.201).

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Value set Intravenous or Intra arterial Thrombolytic (tPA) Therapy (2.16.840.1.113762.1.4.1045.21): Added 1 ICD10CM code (Z92.82).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Antithrombotic Therapy (2.16.840.1.113883.3.117.1.7.1.201): Added 1 RXNORM code (1658717) and deleted 3 RXNORM codes (205251, 308287, 646434).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources