eCQM Title | Antithrombotic Therapy By End of Hospital Day 2 |
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eCQM Identifier (Measure Authoring Tool) | 72 | eCQM Version Number | 11.1.000 |
NQF Number | Not Applicable | GUID | 93f3479f-75d8-4731-9a3f-b7749d8bcd37 |
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 administered antithrombotic therapy by the end of hospital day 2 |
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Copyright |
Measure specifications are in the Public Domain. LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved. |
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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. |
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Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification |
None |
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Risk Adjustment |
None |
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Rate Aggregation |
None |
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Rationale |
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 (TIA) continues to be the subject of study, substantial evidence is available from completed studies. Data at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity as long as no contraindications exist. Aspirin is the recommended antithrombotic medication for early antithrombotic therapy and most frequently administered unless contraindicated. Anticoagulants at doses to prevent venous thromboembolism (VTE) are insufficient. Subcutaneous lovenox (enoxaparin) and unfractionated heparin (UFH) SQ at lower dosages used for VTE prophylaxis (i.e. enoxaparin SQ 40 mg once daily; enoxaparin SQ 30 mg Q12 hours; UFH 5,000 units or less two or three times daily) are not sufficient for early antithrombotic therapy. Anticoagulants at doses to prevent VTE are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA. |
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Clinical Recommendation Statement |
Antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity as long as no contraindications exist |
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Improvement Notation |
Improvement noted as an increase in rate |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: 'Albers, G. W, Amarenco, P., Easton, J. D., et al. (2001). Antithrombotic and thrombolytic therapy for ischemic stroke. Chest, 119, 300-320. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: 'ESPS Group. (1987, December 12). The European Stroke Prevention Study (ESPS): Principal end-points. Lancet, 2(8572), 1351-1354. ' |
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Reference |
Reference Type: CITATION Reference Text: 'Furie, K. L., Kasner, S. E., Adams, R. J., et al. (2011, January). Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 42(1), 227-276. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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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. ' |
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Reference |
Reference Type: CITATION Reference Text: '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. ' |
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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,' |
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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. ' |
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Reference |
Reference Type: CITATION Reference Text: 'Sacco, R. L., Adams, R., Albers, G., et al. (2006, February). Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for health care professionals from the American Heart Association/American Stroke Association Council on Stroke: Co-sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. Stroke, 37(2), 577-617. ' |
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Definition |
None |
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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 Inpatient Encounters include emergency, urgent, and unplanned admissions. NPO (Nothing by mouth) is not a valid reason for not administering antithrombotic therapy by end of hospital day 2 as another route of administration can be used (i.e. rectal or intravenous). In the denominator exclusions, the intent is to only exclude patients with a total length of stay of <2 days, including ED visit (if there is one). For the eCQM we model both of the scenarios of admission via the ED as well as direct admits. This statement addresses direct admits. 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. |
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Transmission Format |
TBD |
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Initial Population |
Inpatient hospitalization 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 |
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Denominator |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke |
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Denominator Exclusions |
* Inpatient hospitalizations for patients who have a duration of stay less than 2 days * Inpatient hospitalization for patients with comfort measures documented day of or the day after arrival * Inpatient hospitalization for patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24 hours prior to arrival or anytime during hospitalization |
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Numerator |
Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival |
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Numerator Exclusions |
Not Applicable |
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Denominator Exceptions |
* Inpatient hospitalization for patients with a documented reason for not administering antithrombotic therapy the day of or day after hospital arrival * Inpatient hospitalization for patients who receive Prasugrel as an antithrombotic therapy the day of or day after hospital arrival * Inpatient hospitalization for patients with an INR greater than 3.5 |
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Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
TJC."Encounter with Principal Diagnosis and Age"
TJC."Ischemic Stroke Encounter"
"Encounter Less Than Two Days" union "Encounter with Comfort Measures during Day of or Day After Arrival" union "Encounter with Thrombolytic Therapy Given Prior To Arrival Or During Hospitalization"
"Encounter with Antithrombotic Therapy"
None
"No Antithrombotic Ordered or Administered Day Of or Day After Hospital Arrival" union "Encounter with Pharmacological Contraindications for Antithrombotic Therapy Given Day Of or Day After Hospital Arrival" union "Encounter with An INR Greater Than 3.5"
None
TJC."Ischemic Stroke Encounter"
"No Antithrombotic Ordered or Administered Day Of or Day After Hospital Arrival" union "Encounter with Pharmacological Contraindications for Antithrombotic Therapy Given Day Of or Day After Hospital Arrival" union "Encounter with An INR Greater Than 3.5"
"Encounter Less Than Two Days" union "Encounter with Comfort Measures during Day of or Day After Arrival" union "Encounter with Thrombolytic Therapy Given Prior To Arrival Or During Hospitalization"
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter where Global."HospitalizationWithObservationLengthofStay" ( IschemicStrokeEncounter ) < 2
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["Laboratory Test, Performed": "INR"] INR such that INR.resultDatetime during day of TJC."CalendarDayOfOrDayAfter" ( start of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) ) and INR.result > 3.5
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["Medication, Administered": "Antithrombotic Therapy"] Antithrombotic such that Global."NormalizeInterval" ( Antithrombotic.relevantDatetime, Antithrombotic.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( start of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) )
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with TJC."Intervention Comfort Measures" ComfortMeasures such that Coalesce(start of Global."NormalizeInterval"(ComfortMeasures.relevantDatetime, ComfortMeasures.relevantPeriod), ComfortMeasures.authorDatetime)during day of TJC."CalendarDayOfOrDayAfter" ( start of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) )
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["Medication, Administered": "Pharmacological Contraindications For Antithrombotic Therapy"] PharmacologicalContraindications such that Global."NormalizeInterval" ( PharmacologicalContraindications.relevantDatetime, PharmacologicalContraindications.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( start of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) )
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with [Diagnosis: "Intravenous or Intra arterial Thrombolytic (tPA) Therapy Prior to Arrival"] PriorTPA such that PriorTPA.authorDatetime during Global."HospitalizationWithObservation" ( IschemicStrokeEncounter )
"Encounter with Thrombolytic Therapy Medication or Procedures" union "Encounter with Thrombolytic Therapy Prior to Arrival" union "Encounter with Thrombolytic Therapy Documented As Already Given"
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with "Thrombolytic Therapy Medication or Procedures" ThrombolyticTherapy such that Global."NormalizeInterval" ( ThrombolyticTherapy.relevantDatetime, ThrombolyticTherapy.relevantPeriod ) starts during Interval[start of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) - 24 hours, end of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) )
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter where exists IschemicStrokeEncounter.diagnoses Diagnosis where Diagnosis.code in "Intravenous or Intra arterial Thrombolytic (tPA) Therapy Prior to Arrival"
TJC."Encounter with Principal Diagnosis and Age"
"Reason for Not Ordering Antithrombotic" union "Reason for Not Administering Antithrombotic"
TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with "No Antithrombotic Ordered or Administered" NoAntithrombotic such that NoAntithrombotic.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( start of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) )
"Encounter with Antithrombotic Therapy"
["Medication, Not Administered": "Antithrombotic Therapy"] NoAntithromboticGiven where NoAntithromboticGiven.negationRationale in "Medical Reason" or NoAntithromboticGiven.negationRationale in "Patient Refusal"
["Medication, Not Ordered": "Antithrombotic Therapy"] NoAntithromboticOrder where NoAntithromboticOrder.negationRationale in "Medical Reason" or NoAntithromboticOrder.negationRationale in "Patient Refusal"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
["Medication, Administered": "Thrombolytic (t-PA) Therapy"] union ["Procedure, Performed": "Intravenous or Intra-arterial Thrombolytic (t-PA) Therapy"]
"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" ) )
"All Stroke Encounter" AllStrokeEncounter where AgeInYearsAt(date from(start of AllStrokeEncounter.relevantPeriod))>= 18
["Intervention, Order": "Comfort Measures"] union ["Intervention, Performed": "Comfort Measures"]
"Encounter with Principal Diagnosis and Age" EncounterWithAge where exists ( EncounterWithAge.diagnoses Diagnosis where Diagnosis.code in "Ischemic Stroke" and Diagnosis.rank = 1 )
["Encounter, Performed": "Non-Elective Inpatient Encounter"] NonElectiveEncounter where Global."LengthInDays" ( NonElectiveEncounter.relevantPeriod ) <= 120 and NonElectiveEncounter.relevantPeriod ends during day of "Measurement Period"
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]
"LengthInDays"("HospitalizationWithObservation"(Encounter))
difference in days between start of Value and end of Value
if pointInTime is not null then Interval[pointInTime, pointInTime] else if period is not null then period else null as Interval<DateTime>
Interval["TruncateTime"(StartValue), "TruncateTime"(StartValue + 2 days))
DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |
eMeasure Stroke (eSTK) |
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