Discharged on Statin Medication

Last updated: October 25, 2017

CMS Measure ID: CMS105v6
Version: 6
NQF Number: None
Measure Description:

Ischemic stroke patients who are prescribed or continuing to take 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 that ends during measurement period

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 or continuing to take 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
Short Name: Stroke6
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.

The Medication, Discharge datatype refers to the discharge medication list and is intended to express medications ordered for post-discharge use.

Addendum 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 NQF Number '0439' 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 the Description narrative statement to better align with measure logic.

    Measure Section: Description

    Source of Change: JIRA (CQM-2457)

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated the Guidance narrative statement to better align with measure logic.

    Measure Section: Guidance

    Source of Change: JIRA (CQM-2457)

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

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-2520)

  • ​Updated the Numerator narrative statement to better align with measure logic.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-2457)

Logic

  • Replaced 'Statin ingredient specific' value set with 'Statin Grouper' 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 sets.

  • 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: Measure Lead

  • 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: JIRA (CQM-1835)

  • 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

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Deleted 17 RXNORM codes.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Replaced Statin ingredient specific value set (2.16.840.1.113762.1.4.1021.7) with Statin Grouper value set (2.16.840.1.113762.1.4.1110.19).

    Measure Section: QDM Data Elements

    Source of Change: JIRA (CQM-1835)

  • Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Deleted 5 RXNORM codes (433848, 1422096, 1422099, 1422086, 1422093).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources