Primary PCI Received Within 90 Minutes of Hospital Arrival

Last updated: June 9, 2017

CMS Measure ID: CMS53v5
Version: 5
NQF Number: 0163
Measure Description:

Acute myocardial infarction (AMI) patients with ST-segment elevation on the ECG closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.

Initial Patient Population:

Patients age 18 and older at the time of hospital admission with a principal diagnosis of Acute Myocardial Infarction (AMI) with hospital stays <= 120 days during the measurement year

Denominator Statement:

Initial population with an ECG (result: Acute or Evolving MI) and a primary PCI procedure closest to the inpatient admission that does not start after fibrinolytic therapy

Denominator Exclusions:

Patients who transferred from another hospital's inpatient, outpatient, or emergency department and ambulatory surgery center facilities are excluded

Numerator Statement:

AMI patients whose time from hospital arrival to primary PCI is 90 minutes or less

Numerator Exclusions:

Not applicable

Denominator Exceptions:

Patients who did not receive PCI within 90 minutes and has a documented reason. Documented reasons include:

Diagnosis: Cardiopulmonary arrest

Procedure, Performed: Endotracheal Intubation

Procedure, Performed: Aortic balloon pump insertion

Procedure, Performed: Ventricular Assist Device placement

Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Domain: Effective Clinical Care
Short Name: AMI8a
Next Version: Primary PCI Received Within 90 Minutes of Hospital Arrival
Previous Version: Primary PCI Received Within 90 Minutes of Hospital Arrival
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

To identify the ECG closest to hospital arrival, the denominator will identify the most recent ECG performed that starts less than 1 hour prior to the emergency department (ED) or inpatient encounter OR the first ECG performed starts after the ED or inpatient encounter started.

PCI procedures analyzed in this measure must be primary procedures. Primary includes emergent or urgent PCI procedures and not those described by the physician/APN/PA anywhere in the record as elective, not emergent, not immediate, not primary, not urgent, or secondary.

From a clinical standpoint, Primary PCI is loosely defined as percutaneous coronary intervention performed in the acute setting in patients with ST segment elevation MI which is intended to restore perfusion in the infarct-related artery. There is currently no way to explicitly express this in QDM, however, using 'FIRST' will likely capture the intent the majority of cases.

Addendum Notes: ICD-10 Value Set addition

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Updated denominator header guidance to include patients in the initial population with an ECG result of acute or evolving MI and a primary PCI procedure that does not start after fibrinolytic therapy.

    Section: Denominator

    Source: Measure Lead

  • Updated Denominator Exception criteria to include documented reasons and for consistency across AMI measures.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Corrected 'PCI within 30 minutes' to 'PCI within 90 minutes' to align with the logic and intent of the measure.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Added a clarifying statement to the current guidance regarding using first to meet the intent of the measure in capturing the primary PCI procedure performed during the inpatient encounter.

    Section: Guidance

    Source: Measure Lead

  • Updated the header language to add clarity and conciseness by removing duplicated population explanations from the guidance, and only listing these explanations in the denominator exclusions and denominator exception sections.

    Section: Guidance

    Source: Measure Lead

  • Removed ED visit information from the Initial Population section of the header to align with the logic.

    Section: Initial Population

    Source: Measure Lead

Logic

  • Added 'FIRST' to replace 'Ordinality: Primary Procedure' to capture the first (primary) PCI procedure performed during an inpatient encounter.

    Section: Denominator

    Source: JIRA (CQM-1692)

  • Removed Occurrence A of from Medication Administered: Fibrinolytic Therapy because it is not referenced elsewhere.

    Section: Denominator

    Source: Measure Lead

  • Updated the timing constraint for 'Occurrence A of Encounter, Performed: Emergency Department Visit'  by changing 'starts after start' to 'starts during' to capture an ECG during the ED visit.

    Section: Denominator

    Source: Measure Lead

  • Replaced variable name '$ReasonForNoFibrinolyticTherapy' with '$ReasonForNoPCI' to align with the measure content.

    Section: Denominator Exceptions

    Source: JIRA (CQM-1557)

  • Extended the temporal operators to 'starts before or concurrent with start of' and 'ends before or concurrent with start of' to provide greater flexibility to hospitals in fulfilling the 'Transfer From' statements.

    Section: Denominator Exclusions

    Source: JIRA (CQM-1656)

  • Removed the ‘Union of’ operator from the Initial Population logic as it is no longer needed to meet the measure intent.

    Section: Initial Population

    Source: Measure Lead

  • Removed the Emergency Department (ED) section of logic from the Initial Population as it is not needed to capture the principal diagnosis.

    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

  • 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

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

  • Value set Primary Procedure (2.16.840.1.113762.1.4.1111.12): Removed Primary Procedure.

    Section: QDM Data Elements

    Source: None

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Variables

    Source: QDM Standards

  • Replaced variable name '$ReasonForNoFibrinolyticTherapy' with '$ReasonForNoPCI' to align with the measure content.

    Section: QDM Variables

    Source: JIRA (CQM-1557)

Value Set

  • Value set Acute Myocardial Infarction (AMI) (2.16.840.1.113883.3.666.5.3011): Added 9 SNOMEDCT codes (15712841000119100, 15712881000119105, 15712921000119103, 15712961000119108, 15713041000119103, 15713081000119108, 15713121000119105, 15713161000119100, 15713201000119105) and deleted 1 SNOMEDCT code (194798004).

    Section: None

    Source: None

  • Value set Acute or Evolving MI (2.16.840.1.113883.3.666.5.3022): Added 9 SNOMEDCT codes (15712841000119100, 15712881000119105, 15712921000119103, 15712961000119108, 15713041000119103, 15713081000119108, 15713121000119105, 15713161000119100, 15713201000119105) and deleted 1 SNOMEDCT code (194798004).

    Section: None

    Source: None

  • Value set Ambulatory surgical center (2.16.840.1.113883.3.666.5.687): Added 2 SNOMEDCT codes (10531005, 69362002).

    Section: None

    Source: None

  • Value set Cardiopulmonary arrest (2.16.840.1.113883.3.666.5.748): Added 1 SNOMEDCT code (699748007).

    Section: None

    Source: None

  • Value set Fibrinolytic Therapy (2.16.840.1.113883.3.666.5.736): Deleted 4 RXNORM codes (238721, 346773, 351449, 562122).

    Section: None

    Source: None

  • Value set STEMI Exclusions (2.16.840.1.113762.1.4.1045.36): Added 3 SNOMEDCT codes (233835003, 30277009, 57054005).

    Section: None

    Source: None

  • Value set Ventricular Assist Device placement (2.16.840.1.113883.3.666.5.3015): Deleted 2 SNOMEDCT codes (16965008, 175113001).

    Section: None

    Source: None

  • Value set PCI (2.16.840.1.113762.1.4.1045.67): Added 96 ICD10PCS codes.

    Section: None

    Source: ICD-10 Addendum

External Resources