Discharged on Antithrombotic Therapy

Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge

Measure specifications are in the Public Domain

LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. 
This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty.

None

None

None

The effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity and recurrence rates has been studied in several large clinical trials. While the use of these agents for patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study, substantial evidence is available from completed studies. Data at this time suggest that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist.

For patients with a stroke due to a cardioembolic source (e.g. atrial fibrillation, mechanical heart valve), warfarin is recommended unless contraindicated. In recent years, novel oral anticoagulant agents (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients. Anticoagulation therapy is not generally recommended for secondary stroke prevention in patients presumed to have a non-cardioembolic stroke.
Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA.

Clinical trial results suggest that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist

Improvement noted as an increase in rate

Adams, H., Adams, R., del Zoppo, G., et al. (2005, April). Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update—A scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke, 36(4): 916-923. 

Adams, H. P., Jr., del Zoppo, G., Alberts, M. J., et al. (2007, May). Guidelines for the early management of adults with ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke, 38(5), 1655-1711. 

Albers, G. W, Amarenco, P., Easton, J. D., et al. (2001). Antithrombotic and thrombolytic therapy for ischemic stroke. Chest, 119, 300-320. 

Albers, G. W., Amarenco, P., Easton, J. D., et al. (2004, September). Antithrombotic and thrombolytic therapy for ischemic stroke: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3), 483S-512S. 

Antiplatelet Trialists’ Collaboration. (1994, January 8). Collaborative overview of randomised trials of antiplatelet therapy—I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ, 308(6921), 81-106. 

Antithrombotic Trialists’ Collaboration. (2002, January 12). Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high-risk patients. BMJ, 324(7329), 71-86. 

Bhatt, D. L., Fox, K. A., Hacke, W., et al. (2006, April 20). Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. New England Journal of Medicine, 354(16), 1706-1717. 

Brott, T. G., Clark, W. M., Fagan, S. C., et al. (2000). Stroke: The first hours. Guidelines for acute treatment. Washington, DC: National Stroke Association. 

Canadian Cooperative Study Group. (1978, July 13). A randomized trial of aspirin and sulfinpyrazone in threatened stroke.  New England Journal of Medicine, 299(2), 53-59. 

CAPRIE Steering Committee. (1996, November 16). A randomised, blinded trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet, 348(9038), 1329-1339.

Centers for Disease Control and Prevention. (2009, May 1). Prevalence and most common causes of disability among adults—United States, 2005. Morbidity and Mortality Weekly Report, 58(16),  421-426. 

Chen, Z. M., Sandercock, P., Pan, H. C., et al. (2000, June). Indications for early aspirin use in acute ischemic stroke: A combined analysis of 40,000 randomized patients from the Chinese Acute Stroke Trial and the International Stroke Trial. Stroke, 31(6), 1240-1249. 

Coull, B. M., Williams, L. S., Goldstein, L. B., et al. (2002, July). Anticoagulants and antiplatelet agents in acute ischemic stroke: Report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a Division of the American Heart Association). Stroke, 33(7), 1934-1942. 

Diener, H. C., Bogousslavsky, J., Brass, L. M., et al. (2004, July). Aspirin and lopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): Randomised, double-blind, placebo-controlled trial. Lancet, 364(9431), 331-337. 

Dutch Tia Trial Study Group. (1991, October 31). A comparison of two doses of aspirin (30 mg vs. 283 mg a day) in patients after a transient ischemic attack or minor ischemic stroke. New England Journal of Medicine, 325(18), 1261-1266. 

Eccles, M., Freemantle, N., & Mason, J. (1998, April 25). North of England Evidence-Based Guideline Development Project: Guideline on the use of aspirin as secondary prophylaxis for vascular disease in primary care. BMJ, 316(7140), 1303-1309. 

ESPRIT Study Group, Halkes, P. H., van Gijn, J., et al. (2006, May 20). Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): Randomised controlled trial. Lancet, 367(9523), 1665-1673. 

ESPS Group. (1987, December 12). The European Stroke Prevention Study (ESPS): Principal end-points. Lancet, 2(8572), 1351-1354. 

Farrell, B., Godwin, J., Richards, S., et al. (1991, December). The United Kingdom Transient Ischaemic Attack (Uk-Tia) Aspirin Trial: Final results. Journal of Neurology, Neurosurgery, and Psychiatry, 54(12), 1044-1054. 

Gaspoz, J. M., Coxson, P. G., Goldman, P. A., et al. (2002, June 6). Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease. New England Journal of Medicine, 346(23), 1800-1806. 

Gent, M., Blakely, J. A., Easton, J. D., et al. (1989, June 3). The Canadian American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet 1(8649), 1215-1220. 

Gorelick, P. B., Richardson, D., Kelly, M., et al. (2003, June 11). Aspirin and ticlopidine for prevention of recurrent stroke in black patients: A randomized trial. JAMA, 289(22), 2947-2957. 

Guyatt, G. H., Akl, E. A., Crowther, M., et al. (2012, February). Executive summary: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2 Suppl.), 7S-47S. 

Guyatt, G., Schunemann, H., Cook, D., et al. (2001, January). Grades of recommendation for antithrombotic agents. Chest, 119(1 Suppl.), 3S-7S. 

Hass, W. K., Easton, J. D., Adams, H. P., Jr., et al. (1989, August 24). Randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients. New England Journal of Medicine, 321(8), 501-507. 

International Stroke Trial Collaborative Group. (1997, May 31). The International Stroke Trial (IST): A randomised trial of aspirin, subcutaneous heparin, both, or neither among 19,435 patients with acute ischaemic stroke. Lancet, 349(9065), 1569-1581. 

Jauch, E. C., Saver, J. L., Adams, H. P., Jr., et al. (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 44(3), 870-947. 

Johnson, E. S., Lanes, S. F., Wentworth, C. E., III, et al. (1999, June 14). A metaregression analysis of the dose-response effect of aspirin on stroke. Archives of Internal Medicine, 159(11), 1248-1253. 

Kennedy, J., Hill, M. D., Ryckborst, K. J., et al. (2007, November). Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): A randomised controlled pilot trial. Lancet Neurology, 6(11): 961-969. 

Kernan, W. N., Ovbiagele, B., Black, H. R., et al. (2014, May). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 45(7), 2160-2223. 

Powers, W. J., Rabinstein, A. A., Ackerson, T., et al. (2018, January). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 49, e45-e46. 

Roger, V. L., Go, A. S., Lloyd-Jones, D. M., et al. (2012, January 3). Heart disease and stroke statistics—2012 update: A report from the American Heart Association. Circulation, 125(1), e2-e220. 

Sacco, R. L., Diener, H. C., Yusuf, S., et al. (2008, September 18). Aspirin and Extended-Release Dipyridamole Versus Clopidogrel for Recurrent Stroke. New England Journal of Medicine, 359(12), 1238-1251. 

SALT Collaborative Group. (1991, November 30). Swedish Aspirin Low-Dose Trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebrovascular ischaemic events. Lancet, 338(8779), 1345-1349. 

UK-Tia Study Group. (1988, January 30). United Kingdom Transient Ischaemic Attack (UK-Tia) Aspirin Trial: Interim results. British Medical Journal (Clinical Research Ed.), 296(6618), 316-320. 

None

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.

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5.  Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Inpatient hospitalizations for 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 the measurement period

Inpatient hospitalizations for patients with a principal diagnosis of Ischemic stroke

Inpatient hospitalizations for patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations.
Inpatient hospitalizations for patients discharged to another hospital
Inpatient hospitalizations for patients who left against medical advice
Inpatient hospitalizations for patients who expired
Inpatient hospitalizations for patients discharged to home for hospice care
Inpatient hospitalizations for patients discharged to a health care facility for hospice care
Inpatient hospitalizations for patients with comfort measures documented

Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge

Not Applicable

Inpatient hospitalizations for patients with a documented reason for not prescribing antithrombotic therapy at discharge.
Inpatient hospitalizations for patients who receive Ticagrelor or Prasugrel as an antithrombotic therapy at discharge.

For every patient evaluated by this measure also identify payer, race, ethnicity and sex