Antithrombotic Therapy by End of Hospital Day 2

Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2

Measure specifications are in the Public Domain.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. 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.

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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 if 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.

Antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity if no contraindications exist

Improvement noted as an increase in rate

Reference Type: CITATION

Reference Text: 'Adams, H., Adams, R., del Zoppo, G., Goldstein, L. B., Stroke Council of the American Heart Association, & American Stroke Association. (2005). 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. https://doi.org/10.1161/01.STR.0000163257.66207.2d'

Reference Type: CITATION

Reference Text: 'Adams, H. P., Jr., del Zoppo, G., Alberts, M. J., et al. (2007). 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.'

Reference Type: CITATION

Reference Text: 'Albers, G. W, Amarenco, P., Easton, J. D., Sacco, R. L., & Teal, P., . . . (2001). Antithrombotic and thrombolytic therapy for ischemic stroke. Chest, 119(1 Supp), 300S-320S. https://doi.org/10.1378/chest.119.1_suppl.300s'

Reference Type: CITATION

Reference Text: 'Antithrombotic Trialists’ Collaboration (2002). Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high-risk patients. BMJ (Clinical research ed.), 324(7329), 71-86. https://doi.org/10.1136/bmj.324.7329.71'

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 Text: 'Centers for Disease Control and Prevention (CDC) (2009). Prevalence and most common causes of disability among adults—United States, 2005. MMWR. Morbidity and mortality weekly report, 58(16), 421-426.'

Reference Type: CITATION

Reference Text: 'Chen, Z. M., Sandercock, P., Pan, H. C., Counsell, C., Collins, R., Liu, L. S., . . . Peto, R. (2000). 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. On behalf of the CAST and IST collaborative groups. Stroke, 31(6), 1240-1249. https://doi.org/10.1161/01.str.31.6.1240'

Reference Type: CITATION

Reference Text: 'Coull, B. M., Williams, L. S., Goldstein, L. B., Meschia, J. F., Heitzman, D., Chaturvedi, S., (2002). 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. https://doi.org/10.1161/01.str.0000028456.18614.93'

Reference Type: CITATION

Reference Text: 'Eccles, M., Freemantle, N., & Mason, J. (1998). North of England Evidence-Based Guideline Development Project: Guideline on the use of aspirin as secondary prophylaxis for vascular disease in primary care. BMJ, (Clinical research ed.), 316(7140), 1303-1309. https://doi.org/10.1136/bmj.316.7140.1303'

Reference Type: CITATION

Reference Text: 'ESPS Group. (1987). The European Stroke Prevention Study (ESPS). Principal end-points. Lancet (London, England), 2(8572), 1351-1354.'

Reference Type: CITATION

Reference Text: 'Furie, K. L., Kasner, S. E., Adams, R. J., Albers, G. W., Bush, R. L., Fagan, S. C., . . . Council on Clinical Cardiology, and Interdisciplinary Council on Quality of Care and Outcomes Research (2011). 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. https://doi.org/10.1161/STR.0b013e3181f7d043'

Reference Type: CITATION

Reference Text: 'Gaspoz, J. M., Coxson, P. G., Goldman, P. A., Williams, L. W., Kuntz, K. M., Hunink, M. G., & Goldman, L (2002). Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease. New England journal of medicine, 346(23), 1800-1806. https://doi.org/10.1056/NEJM200206063462309'

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Reference Text: 'Guyatt, G. H., Akl, E. A., Crowther, M., Gutterman, D. D., Schuünemann, H. J., & American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel (2012). 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. https://doi.org/10.1378/chest.1412S3'

Reference Type: CITATION

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

Reference Type: CITATION

Reference Text: 'Jauch, E. C., Saver, J. L., Adams, H. P., Jr., Bruno, A., Connors, J. J., Demaerschalk, B. M., . . . Council on Clinical Cardiology (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. https://doi.org/10.1161/STR.0b013e318284056a'

Reference Type: CITATION

Reference Text: 'Johnson, E. S., Lanes, S. F., Wentworth, C. E., 3rd, Satterfield, M. H., Abebe, B. L., & Dicker, L. W. (1999). A metaregression analysis of the dose-response effect of aspirin on stroke. Archives of internal medicine, 159(11), 1248-1253. https://doi.org/10.1001/archinte.159.11.1248'

Reference Type: CITATION

Reference Text: 'Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., . . . American Heart Association Stroke Council (2018). 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(3), e46–e110. https://doi.org/10.1161/STR.0000000000000158'

Reference Type: CITATION

Reference Text: 'Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E. J., Berry, J. D., Borden, W. B., . . . American Heart Association Statistics Committee and Stroke Statistics Subcommittee (2012). Heart disease and stroke statistics—2012 update: A report from the American Heart Association. Circulation, 125(1), e2-e220. https://doi.org/10.1161/CIR.0b013e31823ac046'

Reference Type: CITATION

Reference Text: 'Sacco, R. L., Adams, R., Albers, G., Alberts, M. J., Benavente, O., Furie, K., . . . American Academy of Neurology (2006). 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. https://doi.org/10.1161/01.STR.0000199147.30016.74'

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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. 

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 emergency department (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.

TBD

Inpatient hospitalizations (non-elective admissions) for patients age 18 and older, discharged from inpatient care with a principal diagnosis of ischemic stroke, ending during the measurement period

Equals Initial Population

- Inpatient hospitalization 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

Inpatient hospitalization for patients who had antithrombotic therapy administered the day of or day after hospital arrival

Not Applicable

- 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 international normalized ratio (INR) greater than 3.5.

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

eMeasure Stroke (eSTK)