Discharged on Statin Medication
Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.
The Joint Commission
The Joint Commission
National Quality Forum
Finalized Date/Time
Measure specifications are in the Public Domain.
LOINC(R) is a registered trademark of the Regenstrief Institute.
This material contains SNOMED Clinical Terms (R) (SNOMED CT(c) ) copyright 2004-–2010 International Health Terminology Standards Development Organization. All rights reserved.
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None
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An elevated serum lipid level has been a well-documented risk factor for coronary artery disease (CAD) and reflects an organ-specific manifestation of atherosclerosis which is a disease process that can affect the heart and the major and minor branches of the arterial tree. The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of myocardial infarction and other major vascular events for patients with CAD (or coronary risk equivalent conditions) according to the National Cholesterol Education Program’s Adult Treatment Panel III (NCEP ATP III) Guidelines. Recently, there has been an increased focus on the detection of patients with these risk factors when they present with other manifestations of atherosclerosis, and assuring that these patients are treated with lipid lowering medication if they meet NCEP ATPIII guidelines. While symptomatic carotid artery disease is one of the recognized coronary disease risk equivalents that qualify patients for treatment under ATPIII, there was little data until recently about the role of lipid lowering to prevent recurrent stroke or major vascular events in patients who presented with atherosclerotic stroke but did not otherwise qualify for treatment under ATPIII. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study examined the effects of statins to lower LDL cholesterol in patients with stroke or TIA of atherosclerotic origin who had no other reason for taking lipid lowering therapy (i.e., they were without prior CAD or risk equivalent conditions), and had a fasting LDL greater than or equal to 100 mg/dL. The trial convincingly demonstrated that intensive lipid lowering therapy using statin medication was associated with a dramatic reduction in the rate of recurrent ischemic stroke and major coronary events. The treatment was well tolerated and cost effective. As a result, intensive lipid lowering therapy through use of a statin medication is now recommended for all patients with stroke or TIA of atherosclerotic origin who have an LDL greater than or equal to 100 mg/dL (or with LDL less than 100 mg/dL due to being on lipid lowering therapy prior to admission).
Based on these guidelines, all patients with ischemic stroke or TIA should have lipid profile measurement performed within 48 hours of admission unless results are available from within the past 30 days. A large body of evidence suggests that non-fasting lipid levels drawn in the first 48 hours after a major vascular event are reliable predictors of baseline lipid profiles, but after that time they may become unreliable. It is recommended that all patients with ischemic stroke or TIA with coronary heart disease or symptomatic atherosclerotic disease who have an LDL greater than or equal to 100 mg/dL (or with LDL less than 100 mg/dL due to being on lipid lowering therapy prior to admission) should be treated with a statin. The target goal for cholesterol lowering is an LDL-c level of less than 100 mg/dL. An LDL-c less than 70 mg/dL is recommended for very high-risk persons with multiple risk factors. For patients with stroke of atherosclerotic origin, intensive lipid lowering therapy with statins should be initiated in those who have an LDL greater than or equal to 100 mg/dL (or with LDL less than 100 mg/dL due to being on lipid lowering therapy prior to admission).
For patients with stroke of atherosclerotic origin, intensive lipid lowering therapy with statins should be initiated in those who have an LDL greater than or equal to 100 mg/dL (or with LDL less than 100 mg/dL due to being on lipid lowering therapy prior to admission).
An increase in rate
NQF ID Number
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.
eMeasure Identifier
105
measureStartDate
measureEndDate
Adams, R. J., G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, P. Gorelick, et al. "Update to the Aha/Asa Recommendations for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack." [In eng]. Stroke 39, no. 5 (May 2008): 1647-52.
Amarenco, P., J. Bogousslavsky, A. Callahan, 3rd, L. B. Goldstein, M. Hennerici, A. E. Rudolph, H. Sillesen, et al. "High-Dose Atorvastatin after Stroke or Transient Ischemic Attack." [In eng]. N Engl J Med 355, no. 6 (Aug 10 2006): 549-59
Feher, A., G. Pusch, K. Koltai, A. Tibold, B. Gasztonyi, L. Szapary, and G. Feher. "Statintherapy in the Primary and the Secondary Prevention of Ischaemic Cerebrovascular Diseases." [In eng]. Int J Cardiol 148, no. 2 (Apr 14 2011): 131-8.
Furie, K. L., S. E. Kasner, R. J. Adams, G. W. Albers, R. L. Bush, S. C. Fagan, J. L. Halperin, et al. "Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association." [In eng]. Stroke 42, no. 1 (Jan 2011): 227-76.
National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Adults Treatment of High Blood Cholesterol in Adults."Third Report of the National Cholesterol Education Program (Ncep) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel Iii) Final Report." [In eng]. Circulation 106, no. 25 (Dec 17 2002): 3143-421.
Squizzato, A., E. Romualdi, F. Dentali, and W. Ageno. "Statins for Acute Ischemic Stroke." [In eng]. Cochrane Database Syst Rev, no. 8 (2011): CD007551.
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The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.
Lipid-lowering medications are intended as active home meds that the patient may or may not continue to take during hospitalization.
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, including patients admitted for observation.
Transmission Format
None
Initial Patient Population
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 or equal to 120 days.
Denominator
Patients with a principal diagnosis of ischemic stroke and an LDL greater than or equal to 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival.
Denominator Exclusions
Patients with comfort measures documented
Patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations.
Patients discharged to another hospital
Patients who left against medical advice
Patients who expired
Patients discharged to home for hospice care
Patients discharged to a health care facility for hospice care
Numerator
Patients prescribed statin medication at hospital discharge.
Numerator Exclusions
Not Applicable
Denominator Exceptions
Patients with a reason for not prescribing statin medication at discharge.
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.
eMeasure Stroke (eSTK)
Population criteria
-
Initial Patient Population =
- AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (length of stay <= 120 day(s))"
- AND: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter" ends during "Measurement Period"
- AND:
- OR: "Diagnosis, Active: Hemorrhagic Stroke (ordinality: 'Principal')"
- OR: "Diagnosis, Active: Ischemic Stroke (ordinality: 'Principal')"
- starts during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
-
Denominator =
- AND: "Initial Patient Population"
- AND: "Diagnosis, Active: Ischemic Stroke (ordinality: 'Principal')" starts during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND:
- OR:
- AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND:
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 30 day(s) ends before start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 48 hour(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
- AND: "Occurrence A of Laboratory Test, Result: LDL-c (result >= 100 mg/dL)"
- OR:
- AND:
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 30 day(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 48 hour(s) starts after start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND: "Occurrence A of Laboratory Test, Result: LDL-c (result >= 100 mg/dL)"
- AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- OR:
- AND NOT: "Occurrence A of Medication, Active: Lipid-lowering Agent" ends before start of
- OR: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND: "Occurrence A of Medication, Active: Lipid-lowering Agent" starts before or during
- OR: "Occurrence A of Encounter, Performed: Emergency Department Visit"
- OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- OR:
- AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND NOT:
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 30 day(s) ends before start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 48 hour(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
- OR:
- AND NOT:
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 30 day(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- OR: "Occurrence A of Laboratory Test, Performed: LDL-c" <= 48 hour(s) starts after start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
-
Denominator Exclusions =
- AND:
- OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Discharged to Home for Hospice Care')"
- OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Discharge To Another Hospital')"
- OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Discharged to Health Care Facility for Hospice Care')"
- OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Left Against Medical Advice')"
- OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Patient Expired')"
- OR:
- AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- AND:
- OR: "Intervention, Order: Comfort Measures"
- OR: "Intervention, Performed: Comfort Measures"
- starts during "Occurrence A of Encounter, Performed: Emergency Department Visit"
- OR:
- OR: "Intervention, Order: Comfort Measures"
- OR: "Intervention, Performed: Comfort Measures"
- starts during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
-
Numerator =
- AND: "Medication, Discharge: Statin" starts during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
-
Denominator Exceptions =
- AND:
- OR: "Medication, Allergy: Statin Allergen" starts before or during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
- OR:
- OR: "Medication, Discharge not done: Patient Refusal" for "Statin ingredient specific "
- OR: "Medication, Discharge not done: Medical Reason" for "Statin ingredient specific "
- starts during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"
Patient Characteristic Birthdate: birth date
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (length of stay <= 120 day(s))
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Measurement Period
Diagnosis, Active: Hemorrhagic Stroke (ordinality: 'Principal')
Diagnosis, Active: Ischemic Stroke (ordinality: 'Principal')
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Initial Patient Population
Diagnosis, Active: Ischemic Stroke (ordinality: 'Principal')
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Laboratory Test, Result: LDL-c (result >= 100 mg/dL)
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Laboratory Test, Result: LDL-c (result >= 100 mg/dL)
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Medication, Active: Lipid-lowering Agent
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Medication, Active: Lipid-lowering Agent
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Laboratory Test, Performed: LDL-c
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Initial Patient Population
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Discharged to Home for Hospice Care')
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Discharge To Another Hospital')
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Discharged to Health Care Facility for Hospice Care')
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Left Against Medical Advice')
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (discharge status: 'Patient Expired')
Occurrence A of Encounter, Performed: Emergency Department Visit
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Intervention, Order: Comfort Measures
Intervention, Performed: Comfort Measures
Occurrence A of Encounter, Performed: Emergency Department Visit
Intervention, Order: Comfort Measures
Intervention, Performed: Comfort Measures
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Denominator
Medication, Allergy: Statin Allergen
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Medication, Discharge not done: Patient Refusal
Medication, Discharge not done: Medical Reason
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Denominator
Medication, Discharge: Statin
Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter
Data criteria (QDM Data Elements)
-
"Diagnosis, Active: Hemorrhagic Stroke" using "Hemorrhagic Stroke Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.212)"
-
"Diagnosis, Active: Ischemic Stroke" using "Ischemic Stroke Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.247)"
-
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.292)"
-
"Encounter, Performed: Non-Elective Inpatient Encounter" using "Non-Elective Inpatient Encounter SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.424)"
-
"Intervention, Order: Comfort Measures " using "Comfort Measures SNOMEDCT Value Set (1.3.6.1.4.1.33895.1.3.0.45)"
-
"Intervention, Performed: Comfort Measures " using "Comfort Measures SNOMEDCT Value Set (1.3.6.1.4.1.33895.1.3.0.45)"
-
"Laboratory Test, Performed: LDL-c" using "LDL-c LOINC Value Set (2.16.840.1.113883.3.117.1.7.1.215)"
-
"Laboratory Test, Result: LDL-c" using "LDL-c LOINC Value Set (2.16.840.1.113883.3.117.1.7.1.215)"
-
"Medication, Active: Lipid-lowering Agent" using "Lipid-lowering Agent RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.217)"
-
"Medication, Allergy: Statin Allergen" using "Statin Allergen RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.423)"
-
"Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)"
-
"Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.93)"
-
"Medication, Discharge: Statin" using "Statin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.225)"
-
"Medication, Discharge: Statin ingredient specific" using "Statin ingredient specific RXNORM Value Set (2.16.840.1.113762.1.4.1021.7)"
-
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"
-
Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"
-
Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"
-
Attribute: "Discharge status: Left Against Medical Advice" using "Left Against Medical Advice SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.308)"
-
Attribute: "Discharge status: Discharge To Another Hospital" using "Discharge To Another Hospital SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.87)"
-
Attribute: "Discharge status: Patient Expired" using "Patient Expired SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.309)"
-
Attribute: "Ordinality: Principal" using "Principal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.14)"
Patient Characteristic Birthdate: birth date
Diagnosis, Active: Hemorrhagic Stroke
Diagnosis, Active: Ischemic Stroke
Lipid-lowering Agent
LDL-c
Medication, Discharge: Statin
Emergency Department Visit
Medication, Allergy: Statin Allergen
Non-Elective Inpatient Encounter
Intervention, Order: Comfort Measures
Intervention, Performed: Comfort Measures
LDL-c
Medication, Discharge: Statin ingredient specific
Medication, Discharge not done: Patient Refusal
Medication, Discharge not done: Medical Reason
Medication, Active: Lipid-lowering Agent
Laboratory Test, Result: LDL-c
Encounter, Performed: Emergency Department Visit
Encounter, Performed: Non-Elective Inpatient Encounter
Laboratory Test, Performed: LDL-c
Reporting Stratification
- None
Supplemental Data Elements
-
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"
-
"Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"
-
"Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"
-
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeSex Value Set (2.16.840.1.113762.1.4.1)"
Patient Characteristic Ethnicity: Ethnicity
Patient Characteristic Sex: ONC Administrative Sex
Patient Characteristic Payer: Payer
Patient Characteristic Race: Race