Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)
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| Measure Information | 2023 Reporting Period | 2024 Reporting Period | 2025 Reporting Period |
|---|---|---|---|
| Title | Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) | Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) | Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) |
| CMS eCQM ID | CMS996v3 | CMS996v4 | CMS996v5 |
| Short Name | OP-40 (STEMI) |
OP-40 (STEMI) |
|
| CBE ID* | 3613e | 3613e | 3613e |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| Description |
Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival |
Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival |
Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process |
| Stratification | *See CMS996v3.html |
None |
None |
| Risk Adjustment | *See CMS996v3.html |
None |
None |
| Rationale | *See CMS996v3.html |
Studies have shown that delays in the treatment of acute myocardial infarction (AMI) leads to increased risk of in-hospital mortality and morbidity, with nearly two lives per 1,000 patients lost per hour of delay in treatment (Sohlpour & Yusuf, 2014; Fibrinolytic Therapy Trialists’ Collaborative Group, 1994). For patients receiving fibrinolytic therapy, the American Heart Association (AHA) estimates that 65 lives will be saved per 1,000 patients if treatment is administered within the first hour of symptom onset, and 131 lives will be saved per 1,000 patients treated if fibrinolytic therapy is delivered within the first three hours (O’Connor et al., 2010). The total ischemic time—that is, the time from onset of STEMI symptoms to the initiation of some form of reperfusion therapy—is the principal determinant of health outcomes for patients with an AMI, so timely care is essential to minimize disease morbidity and mortality. Primary PCI is the preferred treatment approach, with guidelines recommending initiation of PCI within 120 minutes from first medical contact (O’Gara et al., 2013). In situations where it is unlikely or impossible for a patient to receive primary PCI within the 120-minute timeframe, fibrinolytic therapy may be used for reperfusion and should be rapidly administered to reduce mortality and minimize morbidity; guidelines recommend that fibrinolytic therapy administration occur within 30 minutes of hospital arrival; this may also require rapid transfer for PCI (O’Gara et al., 2013). Implementation of an eCQM addressing appropriateness and effectiveness of care for STEMI patients in the ED has the potential to improve the delivery of care furthering alignment with current clinical practice guidelines, while reducing adverse health outcomes such as mortality, bleeding events, and reinfarction. Use of the proposed eCQM could also reduce burden on facilities currently measured using the chart-abstracted Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (OP-2) measure and broaden the population for which performance scores could be publicly reported. |
Studies have shown that delays in the treatment of acute myocardial infarction (AMI) leads to increased risk of in-hospital mortality and morbidity, with nearly two lives per 1,000 patients lost per hour of delay in treatment (Sohlpour & Yusuf, 2014; Fibrinolytic Therapy Trialists’ Collaborative Group, 1994). For patients receiving fibrinolytic therapy, the American Heart Association (AHA) estimates that 65 lives will be saved per 1,000 patients if treatment is administered within the first hour of symptom onset, and 131 lives will be saved per 1,000 patients treated if fibrinolytic therapy is delivered within the first three hours (O’Connor et al., 2010). The total ischemic time—that is, the time from onset of STEMI symptoms to the initiation of some form of reperfusion therapy—is the principal determinant of health outcomes for patients with an AMI, so timely care is essential to minimize disease morbidity and mortality. Primary PCI is the preferred treatment approach, with guidelines recommending initiation of PCI within 120 minutes from first medical contact (O’Gara et al., 2013). In situations where it is unlikely or impossible for a patient to receive primary PCI within the 120-minute timeframe, fibrinolytic therapy may be used for reperfusion and should be rapidly administered to reduce mortality and minimize morbidity; guidelines recommend that fibrinolytic therapy administration occur within 30 minutes of hospital arrival; this may also require rapid transfer for PCI (O’Gara et al., 2013). Implementation of an eCQM addressing appropriateness and effectiveness of care for STEMI patients in the ED has the potential to improve the delivery of care furthering alignment with current clinical practice guidelines, while reducing adverse health outcomes such as mortality, bleeding events, and reinfarction. Use of the proposed eCQM could also reduce burden on facilities currently measured using the chart-abstracted Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (OP-2) measure and broaden the population for which performance scores could be publicly reported. |
| Clinical Recommendation Statement | *See CMS996v3.html |
Primary PCI in STEMI: The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that: - "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration." - "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact."
Fibrinolytic Therapy when there is an Anticipated Delay to Performing Primary PCI within 120 Minutes of First Medical Contact: The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that: - "In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.”
Transfer to a PCI-Capable Hospital after Fibrinolytic Therapy: The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that: - Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset. - Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy. - Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. |
Primary PCI in STEMI: The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that: - "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration." - "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact."
Fibrinolytic Therapy when there is an Anticipated Delay to Performing Primary PCI within 120 Minutes of First Medical Contact: The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association(AHA) clinical practice guideline for the management of STEMI recommends that: - "In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.”
Transfer to a PCI-Capable Hospital after Fibrinolytic Therapy: The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that: - Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe heart failure (HF), irrespective of the time delay from MI onset. - Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy. - Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. |
| Improvement Notation |
Improvement noted as an increase in the rate |
Improvement noted as an increase in the rate |
Improvement noted as an increase in the rate |
| Definition | *See CMS996v3.html |
None |
None |
| Guidance |
This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Initial Population |
All emergency department encounters for patients 18 years and older at the start of the encounter with a diagnosis of ST-segment elevation myocardial infarction (STEMI) during the measurement period |
All emergency department encounters for patients 18 years and older at the start of the encounter with a diagnosis of ST-segment elevation myocardial infarction (STEMI) during an Emergency Department encounter that ends during the measurement period |
All emergency department encounters for patients 18 years and older at the start of the encounter with a diagnosis of ST-segment elevation myocardial infarction (STEMI) during an Emergency Department encounter that ends during the measurement period |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions |
Patients with the following conditions are excluded from measure denominator: • Expired in the ED • Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase Within 90 days before start of ED encounter: • Ischemic stroke • Significant facial and/or closed head trauma • Peptic ulcer • Intracranial or intraspinal surgery Within 21 days before end of ED encounter: • Major surgery Within 24 hours before start of ED encounter and during ED encounter: • Suspected aortic dissection • Severe neurologic impairment • Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device • Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation • Cardiopulmonary arrest, including: cardiac arrest, CPR, defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (>10 minutes) CPR At the start of ED encounter: • Bleeding or bleeding diathesis (excluding menses) • Known malignant intracranial neoplasm (primary or metastatic) • Known structural cerebral vascular lesion (e.g., AVM) • Advanced dementia • Pregnancy • Active oral anticoagulant therapy |
Patients with the following conditions are excluded from measure denominator: During ED encounter: - Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase At the start of ED encounter: - Bleeding or bleeding diathesis (excluding menses) - Known malignant intracranial neoplasm (primary or metastatic) - Known structural cerebral vascular lesion (e.g., arteriovenous malformation) - Advanced dementia - Pregnancy - Active oral anticoagulant therapy Within 24 hours before start of ED encounter or during ED encounter: - Aortic dissection or ruptured aortic aneurysm - Severe neurologic impairment - Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device - Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation - Cardiopulmonary arrest, including: cardiac arrest, CPR, defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (>10 minutes) CPR Within 21 days before start of or starts during ED encounter: - Major surgery Within 90 days before start of or at start of ED encounter: - Ischemic stroke - Significant facial and/or closed head trauma - Peptic ulcer Within 90 days before start of ED encounter: - Intracranial or intraspinal surgery Expired in the ED |
Patients with the following conditions are excluded from measure denominator: At some point during ED encounter: - Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase Starts before the start of ED encounter and does not end before ED encounter: - Bleeding or bleeding diathesis (excluding menses) - Known malignant intracranial neoplasm (primary or metastatic) - Known structural cerebral vascular lesion (e.g., arteriovenous malformation) - Advanced dementia - Pregnancy - Diagnosis of allergy to thrombolytics At the start of ED encounter, or most recent dose within 90 days or less of ED encounter: -Active oral anticoagulant therapy Occurs 24 hours or less before start of ED encounter or during ED encounter: - Aortic dissection or ruptured aortic aneurysm - Severe neurologic impairment - Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device - Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation - Cardiopulmonary arrest, including: cardiac arrest, cardiopulmonary resuscitation (CPR), defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (>10 minutes) CPR Occurs 21 days or less before start of or starts during ED encounter: - Major surgery Occurs 90 days before start of or at start of ED encounter: - Ischemic stroke - Significant facial and/or closed head trauma - Peptic ulcer Occurs 90 days or less before start of ED encounter: - Intracranial or intraspinal surgery With a discharge disposition of patient expired in the ED |
| Numerator |
Emergency department encounters with a diagnosis of STEMI: - where time from ED arrival to fibrinolysis is 30 minutes or fewer; OR - where PCI is performed within 90 minutes of arrival for non-transfer patients; OR - where the patient is transferred within 45 minutes of ED arrival. |
Emergency department encounters with a diagnosis of STEMI: - where time from ED arrival to fibrinolysis is 30 minutes or fewer; OR - where PCI is performed within 90 minutes of arrival for non-transfer patients; OR - where the patient is transferred within 45 minutes of ED arrival |
Emergency department encounters with a diagnosis of STEMI: - where time from ED arrival to fibrinolysis is 30 minutes or fewer; OR - where PCI is performed within 90 minutes of arrival; OR - where the patient is transferred within 45 minutes of ED arrival |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
Emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours. |
| Telehealth Eligible | No | No | No |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Additional Resources for CMS996v5
Header
Updated the eCQM version number.
Measure Section:
eCQM Version Number
Source of Change:
Annual Update
Changed all references from NQF to CBE to identify the consensus-based entity role.
Measure Section:
CBE Number
Source of Change:
Annual Update
Updated copyright.
Measure Section:
Copyright
Source of Change:
Annual Update
Updated Denominator Exclusion language to clarify the diagnosis of ischemic stroke, significant facial and/or closed head trauma, peptic ulcer, and oral anticoagulant therapy may start within 90 days before the start of the emergency department encounter or at the start of the emergency department encounter to better align with measure intent.
Measure Section:
Denominator Exclusions
Source of Change:
ONC Project Tracking System (JIRA): CQM-5803
Added denominator exception for emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours, as percutaneous coronary intervention within 24 hours of fibrinolytic administration is against clinical best practice.
Measure Section:
Denominator Exceptions
Source of Change:
ONC Project Tracking System (JIRA): CQM-6595
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Logic
Updated Denominator Exclusion language to clarify the diagnosis of ischemic stroke, significant facial and/or closed head trauma, peptic ulcer, and active oral anticoagulant therapy may start within 90 days before the start of the emergency department encounter or at the start of the emergency department encounter to better align with measure intent.
Measure Section:
Denominator Exclusions
Source of Change:
ONC Project Tracking System (JIRA): CQM-5803
Added denominator exception for emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours, as percutaneous coronary intervention within 24 hours of fibrinolytic administration is against clinical best practice.
Measure Section:
Denominator Exceptions
Source of Change:
ONC Project Tracking System (JIRA): CQM-6595
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.
Measure Section:
Definitions
Source of Change:
Standards/Technical Update
Updated Denominator Exclusion language to clarify the diagnosis of ischemic stroke, significant facial and/or closed head trauma, peptic ulcer, and active oral anticoagulant therapy may start within 90 days before the start of the emergency department encounter or at the start of the emergency department to better align with measure intent.
Measure Section:
Definitions
Source of Change:
ONC Project Tracking System (JIRA): CQM-5803
Restructured approach to identify emergency department encounters for efficiency and to avoid duplicative calls.
Measure Section:
Definitions
Source of Change:
Measure Lead
Added denominator exception for emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours, as percutaneous coronary intervention within 24 hours of fibrinolytic administration is against clinical best practice.
Measure Section:
Definitions
Source of Change:
ONC Project Tracking System (JIRA): CQM-6595
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Functions
Source of Change:
Annual Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Added direct reference code ICD-10-CM code (Z92.82) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Cerebral Vascular Lesion (2.16.840.1.113883.3.3157.4025): Added 1 SNOMED CT code (1259720004) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (285641009, 87101000119106, 96981000119102) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Closed Head and Facial Trauma (2.16.840.1.113883.3.3157.4026): Added 7 SNOMED CT codes (262689001, 262952002, 262955000, 874937002, 874939004, 874940002, 874943000) based on review by technical experts, SMEs, and/or public feedback. Deleted 43 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Intracranial or Intraspinal surgery (2.16.840.1.113762.1.4.1170.2): Deleted 84 ICD-10-PCS codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Malignant Intracranial Neoplasm Group (2.16.840.1.113762.1.4.1170.3): Deleted 1 SNOMED CT code (96981000119102) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Neurologic impairment (2.16.840.1.113883.3.464.1003.114.12.1012): Removed 1 ICD-9-CM code (344.60) based on applicability of value set and/or OID. Replaced 1 SNOMED CT code (24300005) with 1 SNOMED CT code (860614004) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Major Surgical Procedure (2.16.840.1.113883.3.3157.4056): Added 269 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 55 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set (2.16.840.1.113883.3.3157.4055): Renamed to Pregnant State based on recommended value set naming conventions.
Measure Section:
Terminology
Source of Change:
Annual Update
Removed ICD-9 extensional value sets from select grouping value sets, leaving codes from active terminologies (ICD-10 and SNOMED), to reduce implementer burden.
Measure Section:
Terminology
Source of Change:
Standards/Technical Update