eCQM Title

Anticoagulation Therapy for Atrial Fibrillation/Flutter

eCQM Identifier (Measure Authoring Tool)

eCQM Version Number

13.1.000

NQF Number

Not Applicable

GUID

03876d69-085b-415c-ae9d-9924171040c2

Measurement Period

January 1, 20XX through December 31, 20XX

Measure Steward

The Joint Commission

Measure Developer

The Joint Commission

Endorsed By

None

Description

Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge

Measure specifications are in the Public Domain.

LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.

Disclaimer

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.

Measure Scoring

Proportion

Measure Type

Process

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

Nonvalvular atrial fibrillation (NVAF) is a common arrhythmia and an important risk factor for stroke. It is one of several conditions and lifestyle factors that have been identified as risk factors for stroke. It has been estimated that over 2 million adults in the United States have NVAF. While the median age of patients with atrial fibrillation is 75 years, the incidence increases with advancing age. For example, The Framingham Heart Study noted a dramatic increase in stroke risk associated with atrial fibrillation with advancing age, from one and a half percent for those 50 to 59 years of age to 23.5% for those 80 to 89 years of age. Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation. Analysis of five placebo-controlled clinical trials investigating the efficacy of warfarin in the primary prevention of thromboembolic stroke, found the relative risk of thromboembolic stroke was reduced by 68% for atrial fibrillation patients treated with warfarin. The administration of anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients with TIA or prior stroke.

Clinical Recommendation Statement

The administration of anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing recurrent stroke in high stroke risk atrial fibrillation patients with TIA or prior stroke

Improvement Notation

Improvement noted as an increase in rate

Reference

Reference Type: CITATION

Reference Text: 'Berge, E., Abdelnoor, M., Nakstad, P. H., et al. (2000, April 8). Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: A double-blind randomised study. Lancet, 355(9211), 1205-1210. '

Reference

Reference Type: CITATION

Reference Text: '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. '

Reference

Reference Type: CITATION

Reference Text: 'Connolly, S. J., Ezekowitz, M. D., Yusuf, S., et al. (2009, September 17). Dabigatran versus warfarin in patients with atrial fibrillation. New England Journal of Medicine, 361(12), 1139-1151. '

Reference

Reference Type: CITATION

Reference Text: 'Fuster, V., Ryden, L. E., Asinger, R. W., et al. (2001, October). ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation). Journal of the American College of Cardiology, 38(4), 1231-1266. '

Reference

Reference Type: CITATION

Reference Text: 'Fuster, V., Ryden, L. E., Cannom, D. S., et al. (2006, August 15). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). Circulation, 114(7), e257-354. '

Reference

Reference Type: CITATION

Reference Text: 'Goldstein, L. B., Adams, R., Alberts, M. J., et al. (2006, June). Primary prevention of ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Stroke, 37(6), 1583-1633. '

Reference

Reference Type: CITATION

Reference Text: 'Gorelick, P. B., Sacco, R. L., Smith, D. B., et al. (1999, March). Prevention of a first stroke: A review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA, 281(12), 1112-1120. '

Reference

Reference Type: CITATION

Reference Text: 'Hart, R. G., Benavente, O., McBride R., et al. (1999, October 5). Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: A meta-analysis. Annals of Internal Medicine, 131(7), 492-501. '

Reference

Reference Type: CITATION

Reference Text: '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. '

Reference

Reference Type: CITATION

Reference Text: '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. '

Reference

Reference Type: CITATION

Reference Text: 'Kleindorfer, D. O., Towfighi, A., Chaturvedi, S., Cockroft, K. M., Gutierrez, J., Lombardi-Hill, D., ... Williams, L. S. (2021). 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association. Stroke, 52(7), e364-e467. https://doi.org/10.1161/STR.0000000000000375'

Reference

Reference Type: CITATION

Reference Text: 'Lin, H. J., Wolf, P. A., Kelly-Hayes, M., et al. (1996, October). Stroke severity in atrial fibrillation: The Framingham Study. Stroke 27(10), 1760-1764'

Reference

Reference Type: CITATION

Reference Text: 'Penado, S., Cano, M., Acha, O., et al. (2003, February 15). Atrial fibrillation as a risk factor for stroke recurrence. American Journal of Medicine, 114 (3), 206-210.'

Reference

Reference Type: CITATION

Reference Text: '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, e31-e32.'

Reference

Reference Type: CITATION

Reference Text: '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.'

Reference

Reference Type: CITATION

Reference Text: 'Saxena, R., & Koudstaal, P. J. (2011). Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack (review). Cochrane Database of Systematic Reviews, (4), CD000185.'

Reference

Reference Type: CITATION

Reference Text: 'Saxena, R., Lewis, S., Berge, E., et al. (2001, October). Risk of early death and recurrent stroke and effect of heparin in 3,169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke, 32(10), 2333-2337.'

Reference

Reference Type: CITATION

Reference Text: 'Van Walraven, C., Hart, R. G., Singer, D. E., et al. (2002, November 20).Oral anticoagulants vs. aspirin in nonvalvular atrial fibrillation: An individual patient meta-analysis. JAMA, 288(19), 2441-2448.'

Reference

Reference Type: CITATION

Reference Text: 'Wann, L. S., Curtis, A. B., Ellenbogen, K. A., et al. (2011, March 15). 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 57(11), 1330-1337.'

Definition

None

Guidance

The "Nonelective 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 Inpatient Encounters 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.

The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission Format

TBD

Initial Population

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 measurement period

Denominator

Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter

Denominator Exclusions

- 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

Numerator

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge

Supplemental Data Elements

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

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

TJC."Encounter with Principal Diagnosis and Age"

Denominator

"Encounter with a History of Atrial Ablation"
  union "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Flutter"

Denominator Exclusions

( "Denominator" Encounter
    where Encounter.dischargeDisposition in "Discharge To Acute Care Facility"
      or Encounter.dischargeDisposition in "Left Against Medical Advice"
      or Encounter.dischargeDisposition in "Patient Expired"
      or Encounter.dischargeDisposition in "Discharged to Home for Hospice Care"
      or Encounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care"
)
  union "Encounter with Comfort Measures during Hospitalization for Patients with Documented Atrial Fibrillation or Flutter"

Numerator

"Denominator" Encounter
  with ["Medication, Discharge": "Anticoagulant Therapy"] DischargeAnticoagulant
    such that DischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod

- Numerator Exclusions
  - None

Denominator Exceptions

"Denominator" Encounter
  with "Documented Reason for Not Giving Anticoagulant at Discharge" NoDischargeAnticoagulant
    such that NoDischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod

- Stratification
  - None

Definitions

Denominator

"Encounter with a History of Atrial Ablation"
  union "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Flutter"

Denominator Exceptions

"Denominator" Encounter
  with "Documented Reason for Not Giving Anticoagulant at Discharge" NoDischargeAnticoagulant
    such that NoDischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod

Denominator Exclusions

( "Denominator" Encounter
    where Encounter.dischargeDisposition in "Discharge To Acute Care Facility"
      or Encounter.dischargeDisposition in "Left Against Medical Advice"
      or Encounter.dischargeDisposition in "Patient Expired"
      or Encounter.dischargeDisposition in "Discharged to Home for Hospice Care"
      or Encounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care"
)
  union "Encounter with Comfort Measures during Hospitalization for Patients with Documented Atrial Fibrillation or Flutter"

Documented Reason for Not Giving Anticoagulant at Discharge

["Medication, Not Discharged": "Anticoagulant Therapy"] NoAnticoagulant
  where NoAnticoagulant.negationRationale in "Medical Reason For Not Providing Treatment"
    or NoAnticoagulant.negationRationale in "Patient Refusal"

Encounter with a History of Atrial Ablation

( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
    with ["Procedure, Performed": "Atrial Ablation"] AtrialAblationProcedure
      such that Global."NormalizeInterval" ( AtrialAblationProcedure.relevantDatetime, AtrialAblationProcedure.relevantPeriod ) starts before start of IschemicStrokeEncounter.relevantPeriod
)
  union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
      with ["Diagnosis": "History of Atrial Ablation"] AtrialAblationDiagnosis
        such that AtrialAblationDiagnosis.prevalencePeriod starts before start of IschemicStrokeEncounter.relevantPeriod
  )
  union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
      with ["Assessment, Performed": "History of Atrial Ablation"] AtrialAblationAssessment
        such that Global."EarliestOf" ( AtrialAblationAssessment.relevantDatetime, AtrialAblationAssessment.relevantPeriod ) on or before 
        end of IschemicStrokeEncounter.relevantPeriod
  )

Encounter with Comfort Measures during Hospitalization for Patients with Documented Atrial Fibrillation or Flutter

"Denominator" Encounter
  with TJC."Intervention Comfort Measures" ComfortMeasure
    such that Coalesce(start of Global."NormalizeInterval"(ComfortMeasure.relevantDatetime, ComfortMeasure.relevantPeriod), ComfortMeasure.authorDatetime)during Global."HospitalizationWithObservation" ( Encounter )

Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Flutter

( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
    with ["Diagnosis": "Atrial Fibrillation or Flutter"] AtrialFibrillationFlutter
      such that AtrialFibrillationFlutter.prevalencePeriod starts on or before 
      end of IschemicStrokeEncounter.relevantPeriod
)
  union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
      where exists ( IschemicStrokeEncounter.diagnoses Diagnosis
          where Diagnosis.code in "Atrial Fibrillation or Flutter"
      )
  )

Initial Population

TJC."Encounter with Principal Diagnosis and Age"

Numerator

"Denominator" Encounter
  with ["Medication, Discharge": "Anticoagulant Therapy"] DischargeAnticoagulant
    such that DischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

TJC.All Stroke Encounter

"Non Elective Inpatient Encounter" NonElectiveEncounter
  where exists ( NonElectiveEncounter.diagnoses Diagnosis
      where Diagnosis.rank = 1
        and ( Diagnosis.code in "Hemorrhagic Stroke"
            or Diagnosis.code in "Ischemic Stroke"
        )
  )

TJC.Encounter with Principal Diagnosis and Age

"All Stroke Encounter" AllStrokeEncounter
  where AgeInYearsAt(date from start of AllStrokeEncounter.relevantPeriod)>= 18

TJC.Intervention Comfort Measures

["Intervention, Order": "Comfort Measures"]
  union ["Intervention, Performed": "Comfort Measures"]

TJC.Ischemic Stroke Encounter

"Encounter with Principal Diagnosis and Age" EncounterWithAge
  where exists ( EncounterWithAge.diagnoses Diagnosis
      where Diagnosis.code in "Ischemic Stroke"
        and Diagnosis.rank = 1
  )

TJC.Non Elective Inpatient Encounter

["Encounter, Performed": "Nonelective Inpatient Encounter"] NonElectiveEncounter
  where Global."LengthInDays" ( NonElectiveEncounter.relevantPeriod ) <= 120
    and NonElectiveEncounter.relevantPeriod ends during day of "Measurement Period"

Functions

Global.Earliest(period Interval<DateTime>)

if ( HasStart(period)) then start of period 
  else 
end of period

Global.EarliestOf(pointInTime DateTime, period Interval<DateTime>)
- - Earliest(NormalizeInterval(pointInTime, period))

Global.HasStart(period Interval<DateTime>)

not ( start of period is null
    or start of period = minimum DateTime
)

Global.HospitalizationWithObservation(Encounter "Encounter, Performed")

Encounter Visit
	let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs
			where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod
			sort by 
			end of relevantPeriod
	),
	VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),
	EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED
			where LastED.relevantPeriod ends 1 hour or less on or before VisitStart
			sort by 
			end of relevantPeriod
	)
	return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), 
	end of Visit.relevantPeriod]

Global.LengthInDays(Value Interval<DateTime>)

difference in days between start of Value and end of Value

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

if pointInTime is not null then Interval[pointInTime, pointInTime]
  else if period is not null then period 
  else null as Interval<DateTime>

Terminology

valueset "Anticoagulant Therapy" (2.16.840.1.113883.3.117.1.7.1.200)
valueset "Atrial Ablation" (2.16.840.1.113883.3.117.1.7.1.203)
valueset "Atrial Fibrillation or Flutter" (2.16.840.1.113883.3.117.1.7.1.202)
valueset "Comfort Measures" (1.3.6.1.4.1.33895.1.3.0.45)
valueset "Discharge To Acute Care Facility" (2.16.840.1.113883.3.117.1.7.1.87)
valueset "Discharged to Health Care Facility for Hospice Care" (2.16.840.1.113883.3.117.1.7.1.207)
valueset "Discharged to Home for Hospice Care" (2.16.840.1.113883.3.117.1.7.1.209)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Hemorrhagic Stroke" (2.16.840.1.113883.3.117.1.7.1.212)
valueset "History of Atrial Ablation" (2.16.840.1.113762.1.4.1110.76)
valueset "Ischemic Stroke" (2.16.840.1.113883.3.117.1.7.1.247)
valueset "Left Against Medical Advice" (2.16.840.1.113883.3.117.1.7.1.308)
valueset "Medical Reason For Not Providing Treatment" (2.16.840.1.113883.3.117.1.7.1.473)
valueset "Nonelective Inpatient Encounter" (2.16.840.1.113883.3.117.1.7.1.424)
valueset "Observation Services" (2.16.840.1.113762.1.4.1111.143)
valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
valueset "Patient Expired" (2.16.840.1.113883.3.117.1.7.1.309)
valueset "Patient Refusal" (2.16.840.1.113883.3.117.1.7.1.93)
valueset "Payer" (2.16.840.1.114222.4.11.3591)
valueset "Race" (2.16.840.1.114222.4.11.836)

Data Criteria (QDM Data Elements)

"Assessment, Performed: History of Atrial Ablation" using "History of Atrial Ablation (2.16.840.1.113762.1.4.1110.76)"
"Diagnosis: Atrial Fibrillation or Flutter" using "Atrial Fibrillation or Flutter (2.16.840.1.113883.3.117.1.7.1.202)"
"Diagnosis: History of Atrial Ablation" using "History of Atrial Ablation (2.16.840.1.113762.1.4.1110.76)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
"Encounter, Performed: Nonelective Inpatient Encounter" using "Nonelective Inpatient Encounter (2.16.840.1.113883.3.117.1.7.1.424)"
"Encounter, Performed: Observation Services" using "Observation Services (2.16.840.1.113762.1.4.1111.143)"
"Intervention, Order: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Intervention, Performed: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Medication, Discharge: Anticoagulant Therapy" using "Anticoagulant Therapy (2.16.840.1.113883.3.117.1.7.1.200)"
"Medication, Not Discharged: Anticoagulant Therapy" using "Anticoagulant Therapy (2.16.840.1.113883.3.117.1.7.1.200)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"Procedure, Performed: Atrial Ablation" using "Atrial Ablation (2.16.840.1.113883.3.117.1.7.1.203)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

eMeasure Stroke (eSTK)