Discharged on Statin Medication

Last updated: August 7, 2017

CMS Measure ID: CMS105v5
Version: 5
NQF Number: 0439
Measure Description:

Ischemic stroke patients who are prescribed statin medication at hospital discharge

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

Denominator Statement:

Patients with a principal diagnosis of ischemic stroke

Denominator Exclusions:
  • Patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations.
  • Patients with comfort measures documented
  • Patients discharged to another hospital
  • Patients who left against medical advice
  • Patients who expired
  • Patients discharged to home for hospice care
  • Patients discharged to a health care facility for hospice care
  • Patients with an LDL-c of less than 70 mg/dL <30 days prior to arrival or any time during the hospital stay
Numerator Statement:

Patients prescribed statin medication at hospital discharge

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patients with a reason for not prescribing statin medication at discharge

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: Stroke6
Next Version: Discharged on Statin Medication
Previous Version: Discharged on Statin Medication
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 admissions include emergency, urgent and unplanned admissions.

Addendum Notes: Value Set content updated

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Removed unit of measurement language from Guidance. HQMF now has a header field, 'measure item count', where the unit of measurement can be identified in a computable fashion.

    Section: Guidance

    Source: Measure Lead

  • Updated initial population header to harmonize across all stroke measures.

    Section: Initial Population

    Source: Measure Lead

  • Update references to align with chart-abstracted measures.

    Section: Reference

    Source: Chart Abstracted Measures

Logic

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Denominator

    Source: QDM Standards

  • Updated denominator exclusion logic by removing occurrence of Laboratory Test, Performed because it is not needed since this lab is not referenced elsewhere in the logic. Added occurrence of $EncounterInpatientNonElective since it was missing to ensure the same instance of the encounter is referenced.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Section: Initial Population

    Source: Measure Lead

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Initial Population

    Source: QDM Standards

  • Value Set Statin (2.16.840.1.113883.3.117.1.7.1.225) is replaced by Statin Grouper (2.16.840.1.113762.1.4.1110.19). This is a harmonization effort across measures, in which the statin medications are modularized into different intensity value sets. For this measure, we need all of the medications, so the modularized value sets have been grouped together in this new value set.

    Section: Numerator

    Source: Measure Lead

  • Added new attribute 'principal diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic. Removed QDM data element Attribute: 'Ordinality: Principal' using 'Principal SNOMEDCT Value Set (2.16.840.1.113883.3.1.7.1.14.)’ to conform to QDM 4.2. changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

Value Set

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 3 SNOMEDCT codes (230701008, 307363008, 426107000) and deleted 5 SNOMEDCT codes (233964008, 288723005, 300920004, 64586002, 71444005). Deleted 18 ICD10CM codes.

    Section: None

    Source: None

  • Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMEDCT code (161590003).

    Section: None

    Source: None

  • Value Set Statin (2.16.840.1.113883.3.117.1.7.1.225) is replaced by Statin Grouper (2.16.840.1.113762.1.4.1110.19). This is a harmonization effort across measures, in which the statin medications are modularized into different intensity value sets. For this measure, we need all of the medications, so the modularized value sets have been grouped together in this new value set.

    Section: None

    Source: None

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Added 1 ICD10CM code (I60.2) and deleted 3 ICD10CM codes (I60.20, I60.21, I60.22).

    Section: None

    Source: ICD-10 Addendum

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 18 ICD10CM codes.

    Section: None

    Source: ICD-10 Addendum

External Resources