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Discharged on Statin Medication

Last updated: May 3, 2018

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:
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

The Non-elective Inpatient Encounter 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.

Notes: Value Set content updated, Jan 2017 and Sept 2017

Specifications

Release Notes

Header

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

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

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated initial populationinfo-icon header to harmonize across all stroke measures.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Update references to align with chart-abstracted measures.

    Measure Section: Reference

    Source of Change: Chart Abstracted Measures

Logic

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

    Measure Section: Denominatorinfo-icon

    Source of Change: QDM Standards

  • Updated denominator exclusioninfo-icon 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.

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: Measure Lead

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

    Measure Section: Initial Population

    Source of Change: 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.

    Measure Section: Initial Population

    Source of Change: QDM Standards

  • Value Setinfo-icon 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 harmonizationinfo-icon effort across measures, in which the statin medications are modularized into different intensity value setsinfo-icon. For this measure, we need all of the medications, so the modularized value sets have been grouped together in this new value set.

    Measure Section: Numeratorinfo-icon

    Source of Change: 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.

    Measure Section: QDM Data Elements

    Source of Change: QDM Standards

Value Set

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

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

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

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • 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).

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

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

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

  • Value set LDL-c (2.16.840.1.113883.3.117.1.7.1.215): Added 2 LOINC codes (43394-6, 50193-2).

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • Value set Statin Allergen (2.16.840.1.113883.3.117.1.7.1.423): Deleted 28 RXNORM codes.

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

  • 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: 4Q 2017 Addendum

  • 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: 4Q 2017 Addendum

  • 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: 4Q 2017 Addendum

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Deleted 22 RXNORM codes.

    Measure Section: QDM Data Elements

    Source of Change: 4Q 2017 Addendum

External Resources