preview of “stroke list - measuredesc strokecm.pdf” stroke measures... · s p e c ific a tio n...

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13) through 12-31-13 (4Q13) STK-1

Last Updated: Version 4.2a

STROKE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES

Set Measure

ID # Measure Short Name

STK-1 Venous Thromboembolism (VTE) Prophylaxis

STK-2 Discharged on Antithrombotic Therapy

STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK-4 Thrombolytic Therapy

STK-5 Antithrombotic Therapy By End of Hospital Day 2

STK-6 Discharged on Statin Medication

STK-8 Stroke Education

STK-10 Assessed for Rehabilitation


STROKE DATA ELEMENT LIST

General Data Element Name Collected For: Admission Date All Records Birthdate All Records Discharge Date All Records First Name All Records1 Hispanic Ethnicity All Records ICD-9-CM Other Diagnosis Codes All Records ICD-9-CM Other Procedure Codes All Records ICD-9-CM Other Procedure Dates All Records ICD-9-CM Principal Diagnosis Code All Records (Used in Algorithm for STK-2,

STK-3, STK-4, STK-5, STK-6) ICD-9-CM Principal Procedure Code All Records ICD-9-CM Principal Procedure Date All Records Last Name All Records1 Patient HIC# Collected by CMS for patients with a

standard HIC # Patient Identifier All Records1 Payment Source All Records Physician 1 Optional for All Records1

Physician 2 Optional for All Records1

Postal Code All Records1 Race All Records Sample Used in transmission of the Joint

Commissionʼs aggregate data file and the Hospital Clinical Data file2

Sex All Records

1 CMS ONLY 2 Transmission Data Element 3 Joint Commission Only

Algorithm Output Data Element Name Collected For: Measure Category Assignment Used in the calculation of the Joint

Commissionʼs aggregate data and in the transmission of the Hospital Clinical Data file2,3


STROKE DATA ELEMENT LIST

STK Data Element Name Collected For: Anticoagulation Therapy Prescribed At Discharge

STK-3

Antithrombotic Therapy Administered by End of Hospital Day 2

STK-5

Antithrombotic Therapy Prescribed At Discharge

STK-2

Arrival Date STK-4, STK-5 Arrival Time STK-4 Assessed for Rehabilitation Services STK-10 Atrial Fibrillation/Flutter STK-3 Clinical Trial All STK Measures Comfort Measures Only STK-1, STK-2, STK-3, STK-5, STK-6, STK-

8, STK-10 Date Last Known Well STK-4 Discharge Disposition STK-2, STK-3, STK-6, STK-8, STK-10 ED Patient STK-4 Education Addresses Activation of Emergency Medical System

STK-8

Education Addresses Follow-up After Discharge

STK-8

Education Addresses Medications Prescribed at Discharge

STK-8

Education Addresses Risk Factors For Stroke

STK-8

Education Addresses Warning Signs and Symptoms of Stroke

STK-8

Elective Carotid Intervention All STK Measures IV OR IA Thrombolytic (t-PA) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival

STK-5

IV Thrombolytic Initiation STK-4 IV Thrombolytic Initiation Date STK-4 IV Thrombolytic Initiation Time STK-4 Last Known Well STK-4 LDL-c Greater Than or Equal to 100 mg/dL STK-6 LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival

STK-6

Pre-Arrival Lipid-Lowering Agent STK-6 Reason for No VTE Prophylaxis – Hospital Admission

STK-1

Reason For Not Administering Antithrombotic Therapy By End of Hospital Day 2

STK-5


STK Data Element Name Collected For: Reason For Not Initiating IV Thrombolytic STK-4 Reason For Not Prescribing Anticoagulation Therapy at Discharge

STK-3

Reason For Not Prescribing Antithrombotic Therapy at Discharge

STK-2

Reason For Not Prescribing Statin Medication At Discharge

STK-6

Reason for Oral Factor Xa Inhibitor STK-1 Statin Medication Prescribed At Discharge STK-6 Time Last Known Well STK-4 VTE Prophylaxis STK-1 VTE Prophylaxis Date STK-1


Stroke (STK) Initial Patient Population The population of the STK measure set is identified using 4 data elements:

• ICD-9-CM Principal Diagnosis Code • Admission Date • Birthdate • Discharge Date

Patients admitted to the hospital for inpatient acute care with an ICD-9-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2, a Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days are included in the STK Initial Patient Population and are eligible to be sampled.


Return to Transmission Data Processing

Flow: Clinical(Data Transmission section)

ICD-9-CMPrincipal Diagnosis

Code

On Table 8.1 or 8.2

Patient is in the STK Initial Patient Population

PatientAge

>= 18 years

< 18years

Patient Age (in years) = Admission Date minus Birthdate

Use the month and day portion of admission date and birthdate to yield the most accurate age

Patient not in the STK Initial Patient

Population

Patient is not eligible to be sampled for the

STK measure setPatient is eligible to be sampled for the

STK measure set

STK Initial Patient Population Algorithm

Process all cases that have successfully reached the point in the Transmission Data Processing Flow: Clinical which calls this Initial Patient Population Algorithm. Do not process cases that have been rejected before this point in the Transmission Data Processing Flow: Clinical.

Variable Key:Patient Age

Initial Patient Population Reject Case FlagLength of Stay

Set Initial Patient Population Reject Case Flag = “No”

Set Initial Patient Population Reject Case Flag = “Yes”

Start STK Initial Patient Populationlogic sub-routine

ICDStart

ICDEnd

Not on Table 8.1 and 8.2

Length of Stay (in days) = Discharge Date minus Admission Date

Length of Stay

<= 120 days

> 120 days


Stroke (STK) Initial Patient Population Algorithm

Variable Key: Patient Age, Initial Patient Population Reject Case Flag, and Length of Stay.

1. Start STK Initial Patient Population logic sub-routine. Process all cases that have successfully reached the point in the Transmission Data Processing Flow: Clinical which calls this Initial Patient Population Algorithm. Do not process cases that have been rejected before this point in the Transmission Data Processing Flow: Clinical.

2. Check ICD-9-CM Principal Diagnosis Code a. If the ICD-9-CM Principal Diagnosis Code is not on Table 8.1 and 8.2, the

patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. Set the Initial Patient Population Reject Case Flag to equal Yes. Return to Transmission Data Processing Flow: Clinical in the Data Transmission section.

b. If the ICD-9-CM Principal Diagnosis Code is on Table 8.1 or 8.2, continue processing and proceed to the Patient Age calculation.

3. Calculate Patient Age. Patient Age, in years, is equal to the Admission Date minus the Birthdate. Use the month and day portion of admission date and birthdate to yield the most accurate age.

4. Check Patient Age a. If the Patient Age is less than 18 years, the patient is not in the STK Initial

Patient Population and is not eligible to be sampled for the STK measure set. Set the Initial Patient Population Reject Case Flag to equal Yes. Return to TransmissionData Processing Flow: Clinical in the Data Transmission section.

b. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation.

5. Calculate the Length of Stay. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date.

6. Check Length of Stay a. If the Length of Stay is greater than 120 days, the patient is not in the STK

Initial Patient Population and is not eligible to be sampled for the STK measure set. Set the Initial Patient Population Reject Case Flag to equal Yes. Return to Transmission Data Processing Flow: Clinical in the Data Transmission section.


b. If the Length of Stay is less than or equal to 120 days, the patient is in the STK Initial Patient Population and is eligible to be sampled for the STK measure set. Set Initial Patient Population Reject Case Flag to equal No. Return to Transmission Data Processing Flow: Clinical in the Data Transmission section.


STK Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Hospitals that have five or fewer STK discharges (both Medicare and non-Medicare combined) in a quarter are not required to submit STK patient level data to the QIO Clinical Warehouse or the Joint Commissionʼs Data Warehouse.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Quarterly Sampling Hospitals performing quarterly sampling for STK must ensure that its Initial Patient Population and sample size meet the following conditions:

Quarterly Sample Size Based on Initial Patient Population Size for the STK Measure Set

Hospitalʼs Measure

Average Quarterly Initial Patient Population

Size “N”

Minimum Required Sample Size

“n” ≥ 900 180

226-899 20% of Initial Patient Population size 45-225 45

6-44 No sampling; 100% Initial Patient Population required

0-5 Submission of patient level data is encouraged but not required: • CMS: if submission occurs, 1-5 cases

of the initial Patient Population may be submitted

• The Joint Commission: if submission occurs, 100% initial Patient Population required


Monthly Sampling Hospitals performing monthly sampling for STK must ensure that its Initial Patient Population and sample size meet the following conditions:

Monthly Sample Size

Based on Initial Patient Population Size for the STK Measure Set

Hospitalʼs Measure Average Monthly

Initial Patient Population Size “N”

Minimum Required Sample Size

“n” ≥ 300 60

76-299 20% of Initial Patient Population size 15-75 15 < 15 No sampling; 100% Initial Patient

Population required Sample Size Examples • Quarterly sampling:

o A hospitalʼs STK Initial Patient Population size is 100 patients during the fourth quarter. The required sample size is seen to be a minimum of 45 STK patients for this quarter.

o A hospitalʼs STK Initial Patient Population size is 392 patients during the third quarter. The required sample size is 20% of the patient population or 79 cases for the quarter (twenty percent of 392 equals 78.4 rounded to the next highest whole number equals 79).

o A hospitalʼs STK Initial Patient Population is 4 patients during the first quarter. Submission of patient level data is not required. If the hospital chooses to submit patient level data: CMS: the quarterly sample size would be 1 – 4 cases for the

quarter The Joint Commission: the required quarterly sample size would be

100% of the patient population or 4 cases for the quarter.

• Monthly sampling o A hospitalʼs STK Initial Patient Population size is 316 patients during

March. The required sample size is 60 cases from the patient population. o A hospitalʼs STK Initial Patient Population size is 228 patients during July.

The required sample size is 20% of the patient population or 46 cases for the month (twenty percent of 228 equals 45.6 rounded to the next highest whole number equals 46).

Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13) through 12-31-13 (4Q13) STK-1-1

Last Updated: Version 4.2a NQF ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE

Measure Information Form

Measure Set: Stroke (STK) Set Measure ID #: STK-1 Performance Measure Name: Venous Thromboembolism (VTE) Prophylaxis Description: Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. Rationale: Stroke patients are at increased risk of developing venous thromboembolism (VTE). One study noted proximal deep vein thrombosis in more than a third of patients with moderately severe stroke. Reported rates of occurrence vary depending on the type of screening used. Prevention of VTE, through the use of prophylactic therapies, in at risk patients is a noted recommendation in numerous clinical practice guidelines. For acutely ill stroke patients who are confined to bed, thromboprophylaxis with low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux is recommended if there are no contraindications. Aspirin alone is not recommended as an agent to prevent VTE. Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.

Included Populations: Not applicable Excluded Populations: None Data Elements: • Reason for No VTE Prophylaxis – Hospital Admission • Reason for Oral Factor Xa Inhibitor • VTE Prophylaxis • VTE Prophylaxis Date

Denominator Statement: Ischemic or hemorrhagic stroke patients

Included Populations: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2.


Excluded Populations: • Patients less than 18 years of age • Patients who have a Length of Stay less than 2 days • Patients who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented on day of or day after

hospital arrival • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention

Data Elements: • Admission Date • Birthdate • Clinical Trial • Comfort Measures Only • Discharge Date • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code

Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion Selected References: • Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL,

Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. 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. 2007;38:1655-1711.

• Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and Thrombolytic Therapy for Ischemic Stroke. Chest Vol. 119, 2001: 300-320.

• Caprini JA, Arcelus JI. State-of the art venous thromboembolism prophylaxis. SCOPE on Phlebology & Lymphology 1:2005, 228-240.


• Coull BM, Williams LS, Goldstein LB, et al. 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. 2002;33:1934 -1942.

• Desmukh M., Bisignami M, Landau P, Orchard TJ. Deep vein thrombosis in rehabilitating stroke patients: incidence, risk factors and prophylaxis. American Journal Physical Medicine Rehabilitation. 1991; 70:313-316.

• Duncan et al, Stroke Rehabilitation Clinical Practice Guidelines (Stroke. 2005;36:e100-e143.)

• Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.

• Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. Sep 2004;126(3 Suppl):338S-400S.

• Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schu nemann HJ, and for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141: 33S.

• Kucher N, Koo S, Quiroz R, Cooper JM, et al. (2005). Electronic alerts to prevent venous thromboembolism among hospitalized patients. New England Journal of Medicine, 352(10), 969-1036.

• Michota FA. Venous thromboembolism prophylaxis in medical patients. Curr Opin Cardiol. 2004 Nov;19(6):570-4.

• Post-Stroke Rehabilitation Guideline No.16, Agency for Healthcare Policy and Research (Now known as Agency for Healthcare Research and Quality), 1995.

• Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention. Stroke. Vol. 37, 2006:577.


STK-1: Venous Thromboembolism ProphylaxisNumerator: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why

no VTE prophylaxis was given on the day of or the day after hospital admission.Denominator: Ischemic or hemorrhagic stroke patients

Variable Key:LOS

VTE Prophylaxis Day

START

Run cases that are included in the Stroke Initial Patient Population and pass the edits defined in the Transmission Data Processing Flow: Clinical through this

measure.

Length of Stay (LOS) (in days) =Discharge date – Admission date

LOS

≥ 2

Missing

≥ 0 and < 2

Comfort Measures Only

=2, 3, 4

=1

Clinical Trial = YMissing

= N

Elective Carotid Intervention =YMissing

=N

STK-1X

STK-1X

STK-1X

STK-1H

BNot In Measure Population

STK-1Z

STK-1 B

STK-1 B

STK-1 B

STK-1 B


Missing

Only = A

Stop

XCase WillBe Rejected

DIn MeasurePopulation

STK-1D

EIn Numerator Population

STK-1H

STK-1X

STK-1Z

STK-1X

VTE Prophylaxis

DateSTK-1

DMissing

Non-UTD value

UTD

VTE Prophylaxis Day (in days) = VTE Prophylaxis Date - Admission Date

= 0 or 1

≥ 2

STK-1E

< 0

VTE Prophylaxis

Any = 1, 2, 3, 4, 5, 6, 7 or 8

= Y

=N

Missing

STK-1X

STK-1E

STK-1D

= N

=Y

Reason for Oral

Factor XaInhibitor

MissingSTK-1X

= Y STK-1E Only = 4

Reason for No VTE Prophylaxis - Hospital

Admission

Any =1 ,2, 3, 5, 6 or 7

Missing

All = 4 or/and 8 VTE Prophylaxis

VTE Prophylaxis

Any = 8

Reason for NoVTE Prophylaxis - Hospital

Admission

STK-1X

=N

STK-1D

VTE Prophylaxis

Day


STK-1: Venous Thromboembolism (VTE) Prophylaxis

Numerator: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.

Denominator: Ischemic or hemorrhagic stroke patients.

Variable Key: Length of Stay (LOS), VTE Prophylaxis Day

1. Start processing. Run cases that are included in the Stroke (STK) Initial Patient Population and pass the edits defined in the Transmission Data Processing Flow: Clinical through this measure.

2. Check Comfort Measures Only a. If Comfort Measures Only is missing, the case will proceed to a Measure

Category Assignment of X and will be rejected. Stop processing. b. If Comfort Measures Only equals 1, the case will proceed to a Measure

Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Comfort Measures Only equals 2, 3, or 4, continue processing and proceed to Clinical Trial.

3. Check Clinical Trial a. If Clinical Trial is missing, the case will proceed to a Measure Category

Assignment of X and will be rejected. Stop processing. b. If Clinical Trial equals Yes, the case will proceed to a Measure Category

Assignment of B and will not be in the Measure Population. Stop processing.

c. If Clinical Trial equals No, continue processing and proceed to Elective Carotid Intervention.

4. Check admitted for Elective Carotid Intervention a. If Elective Carotid Intervention is missing, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing. b. If Elective Carotid Intervention equals Yes, the case will proceed to a

Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Elective Carotid Intervention equals No, continue processing and proceed to Length of Stay calculation.

5. Calculate the Length of Stay (LOS). Length of Stay, in days, is equal to the Discharge Date minus the Admission Date.


6. Check Length of Stay (LOS) a. If the Length of Stay is greater than or equal to zero and less than 2, the

case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

b. If the Length of Stay is greater than or equal to 2, continue processing and proceed to VTE Prophylaxis.

7. Check VTE Prophylaxis a. If VTE Prophylaxis is missing, the case will proceed to a Measure

Category Assignment of X and will be rejected. Stop processing. b. If VTE Prophylaxis equals A only, continue processing and proceed to

Reason for No VTE Prophylaxis-Hospital Admission. c. If VTE Prophylaxis equals 1, 2, 3, 4, 5, 6, 7 or 8, continue processing and

proceed to step 9 and recheck VTE Prophylaxis.

8. Check Reason for No VTE Prophylaxis-Hospital Admission a. If Reason for No VTE Prophylaxis-Hospital Admission is missing, the case

will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Reason for No VTE Prophylaxis-Hospital Admission equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.

c. If Reason for No VTE Prophylaxis-Hospital Admission equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

9. Recheck VTE Prophylaxis a. If all the VTE Prophylaxis equals 4 or/and 8, continue processing and

recheck VTE Prophylaxis. b. If any VTE Prophylaxis equals 1, 2, 3, 5, 6 or 7, continue processing and

proceed to step 13 and check VTE Prophylaxis Date.

10. Recheck VTE Prophylaxis a. If VTE Prophylaxis equals 4 only, continue processing and proceed to

Reasons for No VTE Prophylaxis-Hospital Admission. b. If any of VTE Prophylaxis equals 8, continue processing and proceed to

step 12 and check Reason for Oral Factor Xa Inhibitor.

11. Check Reason for No VTE Prophylaxis-Hospital Admission a. If Reason for No VTE Prophylaxis-Hospital Admission is missing, the case



b. If Reason for No VTE Prophylaxis-Hospital Admission equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.

c. If Reason for No VTE Prophylaxis-Hospital Admission equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

12. Check Reason for Oral Factor Xa Inhibitor a. If Reason for Oral Factor Xa Inhibitor is missing, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing. b. If Reason for Oral Factor Xa Inhibitor equals Yes, continue processing and

proceed to VTE Prophylaxis Date. c. If Reason for Oral Factor Xa Inhibitor equals No, the case will proceed to a

Measure Category Assignment of D and will be in the Measure Population. Stop processing.

13. Check VTE Prophylaxis Date a. If VTE Prophylaxis Date is missing, the case will proceed to a Measure

Category Assignment of X and will be rejected. Stop processing. b. If VTE Prophylaxis Date equals Unable to Determine (UTD), the case will

proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If the VTE Prophylaxis Date equals a Non-Unable To Determine (non-UTD) Value, continue processing and proceed to VTE Prophylaxis Day calculation.

14. Calculate VTE Prophylaxis Day. The VTE Prophylaxis Day, in days, is equal to the VTE Prophylaxis Date minus the Admission Date.

15. Check VTE Prophylaxis Day a. If the VTE Prophylaxis Day is equal to zero or 1, the case will proceed to a

Measure Category Assignment of E and will be in the Numerator Population. Stop processing.

b. If the VTE Prophylaxis Day is greater than or equal to 2, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If the VTE Prophylaxis Day is less than 0, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.


Last Updated: Version 4.2 NQF ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE


Measure Set: Stroke (STK) Set Measure ID #: STK-2 Performance Measure Name: Discharged on Antithrombotic Therapy Description: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge 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 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. Warfarin 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. Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Included Populations: Not applicable Excluded Populations: None Data Elements: Antithrombotic Therapy Prescribed at Discharge

Denominator Statement: Ischemic stroke patients.

Included Populations: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1.


Excluded Populations: • Patients less than 18 years of age • Patients who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention • 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 • Patients with a documented Reason For Not Prescribing Antithrombotic

Therapy at Discharge

Data Elements: • Admission Date • Birthdate • Clinical Trial • Comfort Measures Only • Discharge Date • Discharge Disposition • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code • Reason For Not Prescribing Antithrombotic Therapy at Discharge

Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion Selected References: • Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL,

Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. 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. 2007;38:1655-1711.

• Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the Early Management of Patients With Ischemic Stroke: Guidelines Update A Scientific Statement From the Stroke Council of the American Heart Association/American Stroke Association. Stroke Vol. 36, 2005: 916:923.


• Brott TG, Clark WM, Grotta JC, et al. Stroke the first hours. Guidelines for acute treatment. Consensus Statement. National Stroke Association. 2000.

• Chen ZM, Sandercock P, Pan HC, et al. 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 2000;31:1240-1249.


• Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in Primary Care, Centre for Health Services Research University of Newcastle upon Tyne, & Centre for Health Economics of York, 1998.



STK-2: Discharged on Antithrombotic TherapyNumerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital dischargeDenominator: Ischemic stroke patients.

ICD-9-CM Principal Diagnosis Code

START

Comfort Measures Only = 1, 2, 3

= 4

Run cases that are included in the Stroke Initial Patient Population and pass the edits defined in the Transmission Data Processing Flow: Clinical

through this measure.

On Table 8.1

Discharge Disposition

=1, 5, 8

Antithrombotic Therapy Prescribed At Discharge = YMissing

=N

= Y

=N

Stop


DIn Measure Population

= 2, 3, 4, 6, 7 Missing

Reason for Not Prescribing Antithrombotic


Not on Table 8.1

Missing Clinical Trial

Elective Carotid Intervention =Y

=N

=Y

=N

Missing


BNot In Measure PopulationMissing

STK-2Z

STK-2Z

Missing


STK-2: Discharged on Antithrombotic Therapy

Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Denominator: Ischemic stroke patients.


2. Check ICD-9-CM Principal Diagnosis Code a. If the ICD-9-CM Principal Diagnosis Code is not on Table 8.1, the case will

proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

b. If the ICD-9-CM Principal Diagnosis Code is on Table 8.1, continue processing and proceed to Discharge Disposition.

3. Check Discharge Disposition a. If Discharge Disposition equals 2, 3, 4, 6 or 7, the case will proceed to a


b. If Discharge Disposition equals 1, 5 or 8 continue processing and proceed to Comfort Measures Only.


Category Assignment of X and will be rejected. Stop processing. b. If Comfort Measures Only equals 1, 2, or 3, the case will proceed to a


c. If Comfort Measures Only equals 4, continue processing and proceed to Clinical Trial.






6. Check admitted for Elective Carotid Intervention

a. If Elective Carotid Intervention is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Elective Carotid Intervention equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Elective Carotid Intervention equals No, continue processing and proceed to Antithrombotic Therapy Prescribed at Discharge.

7. Check Antithrombotic Therapy Prescribed at Discharge a. If Antithrombotic Therapy Prescribed at Discharge is missing, the case will

proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Antithrombotic Therapy Prescribed at Discharge equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.

c. If Antithrombotic Therapy Prescribed at Discharge equals No, continue processing and check Reason for Not Prescribing Antithrombotic Therapy at Discharge.

8. Check Reason for Not Prescribing Antithrombotic Therapy at Discharge a. If Reason for Not Prescribing Antithrombotic Therapy at Discharge is

missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Reason for Not Prescribing Antithrombotic Therapy at Discharge equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Reason for Not Prescribing Antithrombotic Therapy at Discharge equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.




Measure Set: Stroke (STK) Set Measure ID #: STK-3 Performance Measure Name: Anticoagulation Therapy for Atrial Fibrillation/Flutter Description: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. 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 1.5% 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. Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Ischemic stroke patients prescribed anticoagulation therapy at hospital discharge.

Included Populations: Not applicable Excluded Populations: None Data Elements: Anticoagulation Therapy Prescribed at Discharge


Denominator Statement: Ischemic stroke patients with documented atrial fibrillation/flutter.

Included Populations: • Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic

stroke as defined in Appendix A, Table 8.1 • Patients with documented Atrial Fibrillation/Flutter

Excluded Populations: • Patients less than 18 years of age • Patients who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention • 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 • Patients with a documented Reason For Not Prescribing Anticoagulation

Therapy Data Elements: • Admission Date • Atrial Fibrillation/Flutter • Birthdate • Clinical Trial • Comfort Measures Only • Discharge Date • Discharge Disposition • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code • Reason For Not Prescribing Anticoagulation Therapy at Discharge

Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.


Data Reported As: Aggregate rate generated from count data reported as a proportion Selected References: • Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, et.al., the RE-LY Steering

Committee and Investigators. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. NEJM. 2009;361:1139-1151.

• Fuster et al., ACC/AHA/ESC Guidelines for the Management of Patients with Atrial Fibrillation, JACC Vol.38, August 2001:1231-6.

• Goldstein LB, Chair; Adams R; Albert MJ, Appel LJ, Brass LM, Bushnell CD, Culebras A, DeGraba TJ, Gorelick PB, Guyton JR, Hart RG, Howard G, Kelly-Hayes M, Nixon JV, Sacco RL. 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. 2006; 37:1583.

• Prevention of a First Stroke: A Review of Guidelines and a Multidisciplinary Consensus Statement from the National Stroke Association. National Stroke Association. JAMA. 1999; 281:1112-1120.


• Wann SL, Curtis AB, Ellenbogen KA, Estes M, Ezekowitz MD, Jackman WM, January CT, Lowe JE, Page RL, Slotwiner DJ, Stevenson WG, Tracy CM: Amercian College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines. 2011 ACCF/AHA/HRS Focused Update on the Management of Patients with Atrial Fibrillation (Update on Dabigatran). J. Am. Coll. Cardiol. 2011; Vol. 57(11).


STK-3: Anticoagulation Therapy for Atrial Fibrillation/FlutterNumerator: Ischemic stroke patients prescribed anticoagulation therapy at hospital discharge.Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter.


START


= 4

Run cases that are included in the Stroke Initial Patient Population and pass the edits defined in the Transmission Data Processing Flow: Clinical through this measure.

On Table 8.1


= 1, 5, 8

= YMissing

= N

= Y

=N

Stop


= 2, 3, 4, 6, 7 Missing

Atrial Fibrillation/Flutter

Anticoagulation Therapy Prescribed at Discharge

Missing

= Y

= N

Reason For Not Prescribing Anticoagulation


Missing Clinical Trial = Y

Elective Carotid Intervention

=N

=Y

=N

Missing


Missing



STK-3Z

STK-3Z

Not on Table 8.1

Missing


STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter

Numerator: Ischemic stroke patients prescribed anticoagulation therapy at hospital discharge.

Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter.







b. If Discharge Disposition equals 1, 5 or 8, continue processing and proceed to Comfort Measures Only.










6. Check Elective Carotid Intervention

a. If Elective Carotid Intervention is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Elective Carotid Intervention equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Elective Carotid Intervention equals No, continue processing and proceed to Atrial Fibrillation/Flutter.

7. Check Atrial Fibrillation/Flutter. a. If Atrial Fibrillation/Flutter is missing, the case will proceed to a Measure

Category Assignment of X and will be rejected. Stop processing. b. If Atrial Fibrillation/Flutter equals No, the case will proceed to a Measure


c. If Atrial Fibrillation/Flutter equals Yes, continue processing and check Anticoagulation Therapy Prescribed at Discharge.

8. Check Anticoagulation Therapy Prescribed at Discharge. a. If Anticoagulation Therapy Prescribed at Discharge is missing, the case


b. If Anticoagulation Therapy Prescribed at Discharge equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.

c. If Anticoagulation Therapy Prescribed at Discharge equals No, continue processing and check Reason for Not Prescribing Anticoagulation Therapy at Discharge.

9. Check Reason for Not Prescribing Anticoagulation Therapy at Discharge. a. If Reason for Not Prescribing Anticoagulation Therapy at Discharge is


b. If Reason for Not Prescribing Anticoagulation Therapy at Discharge equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the measure population. Stop processing.

c. If Reason for Not Prescribing Anticoagulation Therapy at Discharge equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.



Measure Information Form Measure Set: Stroke (STK) Set Measure ID #: STK-4 Performance Measure Name: Thrombolytic Therapy Description: Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. Rationale: The administration of thrombolytic agents to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials. These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration approved the use of intravenous recombinant tissue plasminogen activator (IV r-TPA or t-PA) for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV t-PA in patients treated within 3 hours of symptom onset. While controversy still exists among some specialists, the major society practice guidelines developed in the United States all recommend the use of IV t-PA for eligible patients. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of time last known well.

Included Populations: Not applicable Excluded Populations: None Data Elements: • Date Last Known Well • Time Last Known Well • IV Thrombolytic Initiation • IV Thrombolytic Initiation Date • IV Thrombolytic Initiation Time


Denominator Statement: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well.

Included Populations: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1

Excluded Populations: • Patients less than 18 years of age • Patients who have a Length of Stay greater than 120 days • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention • Time Last Known Well to arrival in the emergency department greater

than 2 hours • Patients with a documented Reason For Not Initiating IV Thrombolytic

Data Elements: • Admission Date • Arrival Date • Arrival Time • Birthdate • Clinical Trial • Date Last Known Well • Discharge Date • ED Patient • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code • Last Known Well • Reason For Not Initiating IV Thrombolytic • Time Last Known Well

Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion


Selected References: • Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL,

Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. 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. 2007;38:1655-1711.

• Adams H, Adams R, Del Zoppo G, Goldstein LB. American Heart Association/American Stroke Association Guidelines Update A Scientific Statement From the Stroke Council of the Guidelines for the Early Management of Patients With Ischemic Stroke: 2005, Stroke.2005;36;916-923.

• Antithrombotic and Thrombolytic Therapy for Ischemic Stroke The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Gregory W. Albers, MD, Chair; Pierre Amarenco, MD; J. Donald Easton, MD; Ralph L. Sacco, MD; and Philip Teal, MD (CHEST 2004; 126:483S–512S).

• del Zoppo GJ, Saver JL, Jauch EC, Adams HP. Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator: A Science Advisory From the American Heart Association/ American Stroke Association. Stroke. 2009;40:2945-2948.

• Diagnosis and Initial Treatment of Ischemic Stroke, Institute for Clinical Systems Improvement (ICSI), 2001.

• Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Gidetti D, et. al. Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. The European Cooperative Acute Stroke Study (ECASS) Investigators. NEJM. 2008;359(13):1317-29.

• Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995;274:1017-1025.

• Management of Patients with Stroke. Assessment, investigation, immediate management and secondary prevention, Scottish Intercollegiate Guidelines Network, 1997.

• Marler JR, Tilley BC, Lu M, Brott TG, Lyden PC, Grotta JC, Broderick JP, Levine SR, Frankel MP, Horowitz SH, Haley EC, Lewandowski CA, Kwiatkowski TP. Early stroke treatment associated with better outcome The NINDS rt-PA Stroke Study. Neurology 2000;55: 1649-1655.


• STROKE the First Hours Guidelines for Acute Treatment, National Stroke Association, 2000.


• The ATLANTIS, ECASS, and NINDS rt-PA Study Group Investigators. Association of Outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke Trials. Lancet 2004;363:768-774.

• The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. New England Journal of Medicine 1995;333:1581-1587.

Conditions Making the Administration of IV Thrombolytic Therapy Inadvisable Contraindications: • CT findings of intracranial hemorrhage, subarachnoid hemorrhage, or major

infarct signs • History of intracranial hemorrhage, brain aneurysm, vascular malformation, or

brain tumor • Internal bleeding (less than 22 days) • IV or IA t-PA given at a transferring hospital • No IV access • Patient/family refusal • Platelets less than 100,000, PTT greater than 40 sec after heparin use • PT greater than 15 or INR greater than 1.7, or unknown bleeding diathesis • Recent intracranial or spinal surgery, head trauma, or stroke (less than 3 months) • Recent surgery/trauma (less than15 days) • Seizure at onset • Suspicion of subarachnoid hemorrhage • Systolic blood pressure greater than 185 or diastolic blood pressure greater than

110 mm hg • Unable to determine eligibility Warnings/Conditions that might lead to increased risk of bleeding or unfavorable outcomes: • Acute pericarditis • Advanced age • Diabetic hemorrhagic retinopathy or other ophthalmic bleeding • Glucose less than 50 or greater than 400 mg/dl • Hemostatic defects including those secondary to severe renal or hepatic disease • Left heart thrombus • Life expectancy less than 1 year or severe co-morbid illness • Myocardial infarction (MI) within the past 3 months • Patient currently receiving oral anticoagulants (e.g. Warfarin sodium, Coumadin) • Pregnancy • Rapid improvement • Septic thrombophlebitis or occluded AV cannula at seriously infected site • Stroke severity – Too mild • Stroke severity – Too severe (e.g., NIHSS greater than 22) • Subacute bacterial endocarditis


STK - 4: Thrombolytic Therapy Numerator: Acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at this

hospital within 3 hours (≤ 180 minutes) of time last known well.Denominator: Acute ischemic stroke patients whose time of arrival is within 2 hours (≤ 120 minutes)

of time last known well.


START



On Table 8.1

Variable Key:Timing ITiming II

Arrival Date = UTD

Non-UTD

Missing

Arrival Time = UTDMissing

STK-4B

STK-4D

STK-4D

Non-UTD

STK-4X

STK-4X

Elective Carotid Intervention = Y

= N

MissingSTK-4

BSTK-4

X

STK-4H

Not on Table 8.1

Clinical Trial = Y

= N

MissingSTK-4

BSTK-4

X

Last Known Well = NMissingSTK-4

B

= Y

STK-4X

Date Last Known Well = UTD

Non-UTD

Missing STK-4

DSTK-4

X

ED Patient = NSTK-4

BMissingSTK-4

X

= Y


IV Thrombolytic Initiation = N

=Y

> 180

≥ 0 and ≤ 180

Stop





Timing II

STK-4B

STK-4H

Missing IV Thrombolytic Initiation Date = UTD

Non-UTD

IV Thrombolytic Initiation TimeMissing = UTD

Non-UTD

Timing II (in minutes) = IV Thrombolytic Initiation Date and IV Thrombolytic Initiation Time

- Date Last Known Well and Time Last Known Well

STK-4X

STK-4D

Timing I > 120

≥ 0 and ≤120

Reason For Not Initiating IV

Thrombolytic = Y

Missing

STK-4X

STK-4X

=N

Missing

Timing I (in minutes) = Arrival Date and Arrival Time -Date Last Known Well and Time Last Known Well

Time Last Known Well = UTD

Missing

Non-UTD

STK-4D

STK-4D


STK-4: Thrombolytic Therapy

Numerator: Acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of time last known well.

Denominator: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well.

Variable Key: Timing I, Timing II




b. If the ICD-9-CM Principal Diagnosis Code is on Table 8.1, continue processing and proceed to ED Patient.

3. Check ED Patient a. If ED Patient is missing, the case will proceed to a Measure Category

Assignment of X and will be rejected. Stop processing. b. If ED Patient equals No, the case will proceed to a Measure Category


c. If ED Patient equals Yes, continue processing and proceed to Clinical Trial.









c. If Elective Carotid Intervention equals No, continue processing and proceed to Arrival Date.

6. Check Arrival Date a. If the Arrival Date is missing, the case will proceed to a Measure Category

Assignment of X and will be rejected. Stop processing. b. If the Arrival Date equals Unable to Determine (UTD), the case will


c. If the Arrival Date equals a Non-Unable To Determine (non-UTD) Value, continue processing and proceed to Arrival Time.

7. Check Arrival Time a. If the Arrival Time is missing, the case will proceed to a Measure Category

Assignment of X and will be rejected. Stop processing. b. If the Arrival Time equals Unable to Determine (UTD), the case will


c. If the Arrival Time equals a Non-Unable To Determine (non-UTD) Value, continue processing and proceed to Last Known Well.

8. Check Last Known Well a. If Last Known Well is missing, the case will proceed to a Measure

Category Assignment of X and will be rejected. Stop processing. b. If Last Known Well equals No, the case will proceed to a Measure


c. If Last Known Well equals Yes, continue processing and proceed to Date Last Known Well.

9. Check Date Last Known Well a. If the Date Last Known Well is missing, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing. b. If the Date Last Known Well equals Unable to Determine (UTD), the case

will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If the Date Last Known Well equals a Non-Unable To Determine (non-UTD) Value, continue processing and proceed to Time Last Known Well.

10. Check Time Last Known Well a. If the Time Last Known Well is missing, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing.


b. If the Time Last Known Well equals Unable to Determine (UTD), the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If the Time Last Known Well equals a Non Unable To Determine (non-UTD) Value, continue processing and proceed to the Timing I calculation.

11. Calculate Timing I. Timing I, in minutes, is equal to the Arrival Date and the Arrival Time minus the Date Last Known Well and the Time Last Known Well. a. If the time in minutes is greater than 120, the case will proceed to a


b. If the time in minutes is greater than or equal to zero and less than or equal to 120, continue processing and proceed to IV Thrombolytic Initiation.

12. Check IV Thrombolytic Initiation a. If IV Thrombolytic Initiation is missing, the case will proceed to a Measure

Category Assignment of X and will be rejected. Stop processing. b. If IV Thrombolytic Initiation equals No, continue processing and proceed to

Reason for Not Initiating IV Thrombolytic. c. If IV Thrombolytic Initiation equals Yes, continue processing and proceed

to step 14 and check IV Thrombolytic Initiation Date.

13. Check Reason for Not Initiating IV Thrombolytic a. If Reason for Not Initiating IV Thrombolytic is missing, the case will


b. If Reason for Not Initiating IV Thrombolytic equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Reason for Not Initiating IV Thrombolytic equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

14. Check IV Thrombolytic Initiation Date a. If the IV Thrombolytic Initiation Date is missing, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing. b. If the IV Thrombolytic Initiation Date equals Unable to Determine (UTD),

the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If the IV Thrombolytic Initiation Date equals a Non Unable To Determine (non-UTD) Value, continue processing and proceed to IV Thrombolytic Initiation Time.


15. Check IV Thrombolytic Initiation Time a. If the IV Thrombolytic Initiation Time is missing, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing. b. If the IV Thrombolytic Initiation Time equals Unable to Determine (UTD),

the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If the IV Thrombolytic Initiation Time equals a Non Unable To Determine (non-UTD) Value, continue processing and proceed to the Timing II calculation.

16. Calculate Timing II. Timing II, in minutes, is equal to the IV Thrombolytic Initiation Date and the IV Thrombolytic Initiation Time minus the Date Last Known Well and the Time Last Known Well. a. If the time in minutes is greater than 180, the case will proceed to a


b. If the time in minutes is greater than or equal to zero and less than or equal to 180, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.




Measure Set: Stroke (STK) Set Measure ID #: STK-5 Performance Measure Name: Antithrombotic Therapy By End of Hospital Day 2 Description: Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2. 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 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. Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA. Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Ischemic stroke patients who had antithrombotic therapy administered by end of hospital day 2.

Included Populations: Not applicable Excluded Populations: None Data Elements: Antithrombotic Therapy Administered by End of Hospital Day 2

Denominator Statement: Ischemic stroke patients.

Included Populations: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1.

Excluded Populations: • Patients less than 18 years of age


• Patients who have a Duration of Stay less than 2 days • Patients who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented on day of or day after

arrival • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention • Patients discharged prior to the end of hospital day 2 • Patients with IV OR IA Thrombolytic (t-PA) Therapy Administered at This

Hospital or Within 24 Hours Prior to Arrival • Patients with a documented Reason For Not Administering Antithrombotic

Therapy By End Of Hospital Day 2

Data Elements: • Admission Date • Arrival Date • Birthdate • Clinical Trial • Comfort Measures Only • Discharge Date • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code • IV OR IA Thrombolytic (t-PA)Therapy Administered at This Hospital or

Within 24 Hours Prior to Arrival • Reason For Not Administering Antithrombotic Therapy By End Of Hospital

Day 2 Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion Selected References: • Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL,

Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. 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. 2007;38:1655-1711.

• Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the Early Management of Patients with Ischemic Stroke: Guidelines Update A Scientific Statement From the Stroke Council of the American Heart Association/American Stroke Association. Stroke. Vol. 36, 2005: 916:923.


• Brott TG, Clark WM, Grotta JC, et al. Stroke the first hours. Guidelines for acute treatment. Consensus Statement. National Stroke Association. 2000.

• Chen ZM, Sandercock P, Pan HC, et al. 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 2000;31:1240-1249.


• Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in Primary Care, Centre for Health Services Research University of Newcastle upon Tyne, & Centre for Health Economics of York, 1998.



STK - 5: Antithrombotic Therapy By End of Hospital Day 2Numerator: Ischemic stroke patients who had antithrombotic therapy administered by end of hospital day 2.Denominator: Ischemic stroke patients.


START



Not on Table 8.1

Variable Key:Duration of Stay

Arrival Date = UTD

Non-UTD

Missing

STK-5B

STK-5D

STK-5X

Elective Carotid Intervention = Y

= N

MissingSTK-5

BSTK-5

X

STK-5H

Duration of Stay (in days) = Discharge Date – Arrival Date

Duration of Stay

≥ 2

≥ 0 and < 2STK-5

B

Comfort Measures Only = 1

= 2, 3, 4

STK-5B

On Table 8.1

Clinical Trial = Y

=N

MissingSTK-5

XSTK-5

B

MissingSTK-5

X


Antithrombotic Therapy Administered By End of

Hospital Day 2 = Y

= N

= N

Stop



STK-5H

Missing

=Y

STK-5X

STK-5D

Reason For Not Administering Antithrombotic

Therapy By End Of Hospital Day 2

Missing

IV OR IA Thrombolytic (t-PA)Therapy Administered at This

Hospital or Within 24 Hours Prior to Arrival

=N

=Y



STK-5B

STK-5 B

STK-5 B

Missing


STK-5: Antithrombotic Therapy By End of Hospital Day 2

Numerator: Ischemic stroke patients who had antithrombotic therapy administered by end of hospital day 2.

Denominator: Ischemic stroke patients.

Variable Key: Duration of Stay




b. If the ICD-9-CM Principal Diagnosis Code is on Table 8.1, continue processing and proceed to Comfort Measures Only.


Category Assignment of X and will be rejected. Stop processing. b. If Comfort Measures Only equals 1, the case will proceed to a Measure


c. If Comfort Measures Only equals 2, 3, or 4, continue processing and proceed to Clinical Trial.








c. If Elective Carotid Intervention equals No, continue processing and proceed to Arrival Date.


6. Check Arrival Date a. If the Arrival Date is missing, the case will proceed to a Measure Category

Assignment of X and will be rejected. Stop processing. b. If the Arrival Date equals Unable to Determine (UTD), the case will proceed

to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If the Arrival Date equals a Non-Unable To Determine (non-UTD) Value, continue processing and proceed to Duration of Stay calculation.

7. Calculate the Duration of Stay. The Duration of Stay, in days, is equal to the Discharge Date minus the Arrival Date.

8. Check Duration of Stay a. If the Duration of Stay is greater than or equal to zero and less than 2, the

case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

b. If the Duration of Stay is greater than or equal to 2, continue processing and proceed to IV or IA Thrombolytic (t-PA) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival.

9. Check IV or IA Thrombolytic (t-PA) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival a. If IV or IA Thrombolytic (t-PA) Therapy Administered at This Hospital or

Within 24 Hours Prior to Arrival is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If IV or IA Thrombolytic (t-PA) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If IV or IA Thrombolytic (t-PA) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival equals No, continue processing and proceed to Antithrombotic Therapy Administered By End of Hospital Day 2.

10. Check Antithrombotic Therapy Administered By End of Hospital Day 2 a. If Antithrombotic Therapy Administered By End of Hospital Day 2 is


b. If Antithrombotic Therapy Administered By End of Hospital Day 2 equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.

c. If Antithrombotic Therapy Administered By End of Hospital Day 2 equals No, continue processing and check Reason for Not Administering Antithrombotic Therapy By End of Hospital Day 2.


11. Check Reason for Not Administering Antithrombotic Therapy By End of Hospital Day 2 a. If Reason for Not Administering Antithrombotic Therapy By End of Hospital

Day 2 is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Reason for Not Administering Antithrombotic Therapy By End of Hospital Day 2 equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Reason for Not Administering Antithrombotic Therapy By End of Hospital Day 2 equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.



Measure Information Form Measure Set: Stroke (STK) Set Measure ID #: STK-6 Performance Measure Name: Discharged on Statin Medication Description: 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. Rationale: 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 Programʼs 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). Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Ischemic stroke patients prescribed statin medication at hospital discharge.

Included Populations: Not applicable Excluded Populations: None Data Elements: Statin Medication Prescribed at Discharge

Denominator Statement: Ischemic stroke patients with 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.

Included Populations: • Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic

stroke as defined in Appendix A, Table 8.1 • Patients who were on a lipid-lowering medication prior to hospital arrival

as defined in Appendix C, Table 1.6 • Patients with LDL-c not measured • Patients with LDL-c Greater Than or Equal to 100 mg/dL

Excluded Populations: • Patients less than 18 years of age • Patients who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention • 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


• Patients with a Reason For Not Prescribing Statin Medication at Discharge Data Elements: • Admission Date • Birthdate • Clinical Trial • Comfort Measures Only • Discharge Date • Discharge Disposition • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code • LDL-c Greater Than or Equal to 100 mg/dL • LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital

Arrival • Pre-Arrival Lipid-Lowering Agent • Reason For Not Prescribing Statin Medication at Discharge

Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion Selected References: • Adams RJ, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick

P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Sacco RL, Schwamm LH. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39(5).

• Craig SR, Amin RV, Russell DW, Paradise NF. Blood cholesterol screening influence of fasting state on cholesterol results and management decisions. J Gen Intern Med. 2000 Jun;15(6):395-9.

• Feinberg WM, Albers GW, Barnett HJM, et al. Guidelines for the Management of Transient Ischemic Attacks. From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association. 1994.


• Gore JM, Goldberg RJ, Matsumoto AS, et al. Validity of serum total cholesterol level obtained within 24 hours of acute myocardial infarction. Am J Cardiol. 1984;54:722-725.

• High-Dose Atorvastatin after Stroke or Transient Ischemic Attack. (New England Journal of Medicine. NEJM Vol. 355 2006:549-559.

• National Institutes of Health. 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. National Cholesterol Education Program National Heart, Lung, and Blood Institute National Institutes of Health. NIH Publication No. 12-5215. 2002.

• Pitt B, Loscalzo J, Ycas J, Raichlen JS. Lipid Levels After Acute Coronary Syndromes. J Am Coll Cardiol 2008;51;1440-1445.


• 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 Circulation Vol. 106 2002: 3143-3421.

• Van Dis FJ, Keilson LM, Rundell CA, et al. Direct measurement of serum low-density lipoprotein cholesterol in patients with acute myocardial infarction on admission to the emergency room. Am J Cardiol. 1996;77:1232-1234.

• Weiss R, Harder M, Rowe J. The relationship between nonfasting and fasting lipid measurements in patients with or without type 2 diabetes mellitus receiving treatment with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors. Clin Ther. 2003 May;25(5):1490-7.


STK - 6: Discharged on Statin MedicationNumerator: Ischemic stroke patients prescribed statin medication at hospital discharge.Denominator: Ischemic stroke patients with an LDL ≥ 100 mg/dL, OR LDL not measured, OR who

were on a lipid-lowering medication prior to hospital arrival.


START



On Table 8.1

Not on Table 8.1


= 4


= 1, 5, 8

= 2, 3, 4, 6, 7

Missing

STK-6H

STK-6X

STK-6B

STK-6B

STK-6B

Missing Clinical Trial =Y

=N

STK-6B

STK-6X

Missing Elective Carotid Intervention =Y

=N

STK-6B

STK-6X

MissingSTK-6

X


Stop


STK-6H

Missing

STK-6X

= N

= Y

Pre-Arrival Lipid-Lowering Agent

LDL-c Measured Within The First 48 Hours or 30 Days Prior to

Hospital Arrival

=N

= Y

Missing

STK-6X

LDL-c Greater Than or Equal To

100 mg/dL

Missing

STK-6X

= N

Statin Medication Prescribed At Discharge

Missing

= N

= Y

Reason for Not Prescribing Statin

Medication At Discharge

STK-6B

= N

= Y

=Y

STK-6X




STK-6B

STK-6B

Missing


STK-6: Discharged on Statin Medication

Numerator: Ischemic stroke patients prescribed statin medication at hospital discharge.

Denominator: 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.





3. Check Discharge Disposition a. If Discharge Disposition equals 2, 3, 4, 6 or 7 the case will proceed to a















c. If Elective Carotid Intervention equals No, continue processing and proceed to Pre-Arrival Lipid-Lowering Agent.

7. Check Pre-Arrival Lipid-Lowering Agent a. If Pre-Arrival Lipid-Lowering Agent is missing, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing. b. If Pre-Arrival Lipid-Lowering Agent equals No, continue processing and

check LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival.

c. If Pre-Arrival Lipid-Lowering Agent equals Yes, continue processing and proceed to step 10 and check Statin Medication Prescribed at Discharge.

8. Check LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival a. If LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital

Arrival is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival equals Yes, continue processing and check LDL-c Greater Than or Equal to 100 mg/dL.

c. If LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival equals No, continue processing and proceed to step 10 and check Statin Medication Prescribed at Discharge.

9. Check LDL-c Greater Than or Equal to 100 mg/dL a. If LDL-c Greater Than or Equal to 100 mg/dL is missing, the case will


b. If LDL-c Greater Than or Equal to 100 mg/dL equals No, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If LDL-c Greater Than or Equal to 100 mg/dL equals Yes, continue processing and check Statin Medication Prescribed at Discharge.


10. Check Statin Medication Prescribed at Discharge a. If Statin Medication Prescribed at Discharge is missing, the case will


b. If Statin Medication Prescribed at Discharge equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.

c. If Statin Medication Prescribed at Discharge equals No, continue processing and check Reason for Not Prescribing Statin Medication at Discharge.

11. Check Reason for Not Prescribing Statin Medication at Discharge a. If Reason for Not Prescribing Statin Medication at Discharge is missing,

the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Reason for Not Prescribing Statin Medication at Discharge equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.

c. If Reason for Not Prescribing Statin Medication at Discharge equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.



Measure Information Form Measure Set: Stroke (STK) Set Measure ID #: STK-8 Performance Measure Name: Stroke Education Description: Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke. Rationale: There are many examples of how patient education programs for specific chronic conditions have increased healthful behaviors, improved health status, and/or decreased health care costs of their participants. Clinical practice guidelines include recommendations for patient and family education during hospitalization as well as information about resources for social support services. Some clinical trials have shown measurable benefits in patient and caregiver outcomes with the application of education and support strategies. The type of stroke experienced and the resulting outcomes will play a large role in determining not only the course of treatment but also what education will be required. Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patientʼs prognosis and potential for rehabilitation. Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Ischemic or hemorrhagic stroke patients with documentation that they or their caregivers were given educational material addressing all of the following:

1. Activation of emergency medical system 2. Follow-up after discharge 3. Medications prescribed at discharge 4. Risk factors for stroke 5. Warning signs and symptoms of stroke

Included Populations: Not applicable Excluded Populations: None


Data Elements: • Education Addresses Activation of Emergency Medical System • Education Addresses Follow-up After Discharge • Education Addresses Medications Prescribed at Discharge • Education Addresses Risk Factors for Stroke • Education Addresses Warning Signs and Symptoms of Stroke

Denominator Statement: Ischemic stroke or hemorrhagic stroke patients discharged home.

Included Populations: • Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic or

hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2. • A discharge to home, home care or court/law enforcement

Excluded Populations: • Patients less than 18 years of age • Patients who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention

Data Elements: • Admission Date • Birthdate • Clinical Trial • Comfort Measures Only • Discharge Date • Discharge Disposition • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code

Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion


Selected References: • Duncan et al, Stroke Rehabilitation Clinical Practice Guidelines Stroke.

2005;36:e100-e143. • Evans RL, Matlock AL, Bishop DS, Stranahan S, Pederson C. Family

intervention after stroke: Does counseling or education help?, Stroke 1988;19:1243-1249.

• Kaiser Permanente Clinical Practice Guidelines for Acute Stroke, Kaiser Permanente Medical Group, 1998.

• Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Medical Care 1999;37:5-14.

• Post Stroke Rehabilitation, Clinical Practice Guideline No.16, Agency for Health Care Policy and Research (now known as Agency for Healthcare Research and Quality), 1995.


STK - 8: Stroke EducationNumerator: Ischemic or hemorrhagic stroke patients with documentation that they or their caregivers were given

educational material addressing all of the following:1. Activation of emergency medical system2. Follow-up after discharge3. Medications prescribed at discharge4. Risk factors for stroke5. Warning signs and symptoms of stroke

Denominator: Ischemic stroke or hemorrhagic stroke patients discharged home.

START




= 4


= 1, 8

Missing

= 2, 3, 4, 5, 6, 7

MissingSTK-8

X

STK-8B

STK-8B

Variable Key: Missing Counter

Education Counter

Initialize Missing Counter = 0Initialize Education Counter = 0

Add 1 to Missing Counter

STK-8H

= Y

= N

Add 1 to Education Counter Education Addresses Activation of Emergency Medical System

Missing Clinical Trial =Y

=N

STK-8B

STK-8X

Missing Elective Carotid Intervention =Y

=N

STK-8B

STK-8X

MissingSTK-8

X


STK-8H

MissingAdd 1 to Missing Counter Education Addresses Follow-up After Discharge = Y

=N

Add 1 to Education Counter

MissingAdd 1 to Missing Counter = Y

=N

Add 1 to Education Counter Education Addresses

Medications Prescribed At Discharge

MissingAdd 1 to Missing Counter = Y

=N

Add 1 to Education Counter Education Addresses Risk Factors for Stroke

= Y Add 1 to Education Counter Education Addresses Warning Signs and Symptoms of Stroke

=N

Education Counter < 5

Missing Counter

= 0

= 5

XCase Will Be Rejected > 0



STK-8X


STK-8B

Stop

MissingAdd 1 to Missing Counter


STK-8: Stroke Education

Numerator: Ischemic or hemorrhagic stroke patients with documentation that they or their caregivers were given educational material addressing all of the following: 1. Activation of emergency medical system 2. Follow-up after discharge 3. Medications prescribed at discharge 4. Risk factors for stroke 5. Warning signs and symptoms of stroke

Denominator: Ischemic stroke or hemorrhagic stroke patients discharged home.

Variable Key: Missing Counter, Education Counter


2. Check Discharge Disposition a. If Discharge Disposition equals 2, 3, 4, 5, 6 or 7, the case will proceed to a


b. If Discharge Disposition equals 1 or 8 continue processing and proceed to Comfort Measures Only.










5. Check Elective Carotid Intervention a. If Elective Carotid Intervention is missing, the case will proceed to a



c. If Elective Carotid Intervention equals No, continue processing and initialize missing and education counters.

6. Initialize Missing Counter and Education Counter. Set both counters equal to zero. Continue processing and proceed to Education Addresses Activation of Emergency Medical System.

7. Check Education Addresses Activation of Emergency Medical System a. If Education Addresses Activation of Emergency Medical System is

missing, add one to the Missing Counter. Continue processing and proceed to Education Addresses Follow-up After Discharge.

b. If Education Addresses Activation of Emergency Medical System equals Yes, add one to the Education Counter. Continue processing and proceed to Education Addresses Follow-up After Discharge.

c. If Education Addresses Activation of Emergency Medical System equals No, continue processing and proceed to Education Addresses Follow-up After Discharge.

8. Check Education Addresses Follow-up After Discharge a. If Education Addresses Follow-up After Discharge is missing, add one to

the Missing Counter. Continue processing and proceed to Education Addresses Medications Prescribed At Discharge.

b. If Education Addresses Follow-up After Discharge equals Yes, add one to the Education Counter. Continue processing and proceed to Education Addresses Medications Prescribed At Discharge.

c. If Education Addresses Follow-up After Discharge equals No, continue processing and proceed to Education Addresses Medications Prescribed At Discharge.

9. Check Education Addresses Medications Prescribed At Discharge a. If Education Addresses Medications Prescribed At Discharge is missing,

add one to the Missing Counter. Continue processing and proceed to Education Addresses Risk Factors for Stroke.

b. If Education Addresses Medications Prescribed At Discharge equals Yes, add one to the Education Counter. Continue processing and proceed to Education Addresses Risk Factors for Stroke.


c. If Education Addresses Medications Prescribed At Discharge equals No, continue processing and proceed to Education Addresses Risk Factors for Stroke.

10. Check Education Addresses Risk Factors for Stroke a. If Education Addresses Risk Factors for Stroke is missing, add one to the

Missing Counter. Continue processing and proceed to Education Addresses Warning Signs and Symptoms of Stroke.

b. If Education Addresses Risk Factors for Stroke equals Yes, add one to the Education Counter. Continue processing and proceed to Education Addresses Warning Signs and Symptoms of Stroke.

c. If Education Addresses Risk Factors for Stroke equals No, continue processing and proceed to Education Addresses Warning Signs and Symptoms of Stroke.

11. Check Education Addresses Warning Signs and Symptoms of Stroke a. If Education Addresses Warning Signs and Symptoms of Stroke is

missing, add one to the Missing Counter. Continue processing and proceed to the Missing Counter.

b. If Education Addresses Warning Signs and Symptoms of Stroke equals Yes, add one to the Education Counter. Continue processing and proceed to the Missing Counter.

c. If Education Addresses Warning Signs and Symptoms of Stroke equals No, continue processing and proceed to the Missing Counter.

12. Check Missing Counter a. If the Missing Counter is greater than zero, the case will proceed to a

Measure Category Assignment of X and will be rejected. Stop processing. b. If the Missing Counter equals zero, continue processing and proceed to

Education Counter.

13. Check Education Counter a. If the Education Counter is less than five, the case will proceed to a


b. If the Education Counter equals five, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.




Measure Set: Stroke (STK) Set Measure ID #: STK-10 Performance Measure Name: Assessed for Rehabilitation Description: Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. Rationale: Each year about 700,000 people experience a new or recurrent stroke, which is the nation's third leading cause of death. Approximately two thirds of these individuals survive and require rehabilitation. Stroke is a leading cause of serious, long-term disability in the United States, with about 4.4 million stroke survivors alive today. Forty percent of stroke patients are left with moderate functional impairment and 15 to 30 percent with severe disability. More than 60% of those who have experienced stroke, serious injury, or a disabling disease have never received rehabilitation. Stroke rehabilitation should begin as soon as the diagnosis of stroke is established and life-threatening problems are under control. Among the high priorities for stroke are to mobilize the patient and encourage resumption of self-care activities as soon as possible. A considerable body of evidence indicates better clinical outcomes when patients with stroke are treated in a setting that provides coordinated, multidisciplinary stroke-related evaluation and services. Effective rehabilitation interventions initiated early following stroke can enhance the recovery process and minimize functional disability. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. Type of Measure: Process Improvement Noted As: An increase in rate Numerator Statement: Ischemic or hemorrhagic stroke patients assessed for or who received rehabilitation services.

Included Populations: Not applicable Excluded Populations: None Data Elements: Assessed for Rehabilitation Services

Denominator Statement: Ischemic or hemorrhagic stroke patients.


Included Populations: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2. Excluded Populations: • Patients less than 18 years of age • Patients who have a Length of Stay greater than 120 days • Patients with Comfort Measures Only documented • Patients enrolled in clinical trials • Patients admitted for Elective Carotid Intervention • 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 Data Elements: • Admission Date • Birthdate • Clinical Trial • Comfort Measures Only • Discharge Date • Discharge Disposition • Elective Carotid Intervention • ICD-9-CM Principal Diagnosis Code

Risk Adjustment: No Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion. Selected References: • American Academy of Physical Medicine and Rehabilitation. Rehabilitation Helps

Stroke Patients Recover Skills. AAPM&R Chicago, IL Office: Author. • American Academy of Physical Medicine and Rehabilitation. Urgency Key But

Perseverance Pays Off. AAPM&R Chicago, IL Office: Author.


• Bates B, Choi JY, Duncan PW, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Recker D, Zorowitz R. American Heart Association/American Stroke Association-endorsed practice guideline. Veterans Affairs/Department of Defense clinical practice guideline for the management of adult stroke rehabilitation care. Stroke. 2005;36:2049. Retrieved August 2, 2007 from World Wide Web. http://stroke.ahajournals.org/cgi/content/full/36/9/2049.

• Management of patients with stroke. Rehabilitation, prevention and management of complications, and discharge planning, Scottish Intercollegiate network Guidelines Network (SIGN), 2002.

• National Institute of Neurological Disorders. Post-Stroke Rehabilitation Fact Sheet. National Institute of Neurological Disorders Bethesda, MD Office: Author.

• Post Stroke Rehabilitation, Clinical Practice Guideline No.16, Agency for Health Care Policy and Research (now known as Agency for Healthcare Research and Quality), 1995.

• VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation in the Primary Care Setting, 2003.

• Zorowitz RD, et al, the Post-Stroke Rehabilitation Outcomes Project (PSROP), Top Stroke Rehabil. 2005 Fall;12(4).


STK - 10: Assessed for RehabilitationNumerator: Ischemic or hemorrhagic stroke patients assessed for or who received rehabilitation services.Denominator: Ischemic or hemorrhagic stroke patients.

START



= 1, 2, 3

= 4


=1, 5, 8

= 2, 3, 4, 6, 7 Missing

Clinical Trial =Y

=N

Missing


Assessed For Rehabilitation

Services = N

= Y

Missing


Stop


Comfort Measures Only

Elective Carotid Intervention =Y

Missing

=N

Missing



STK-10: Assessed for Rehabilitation

Numerator: Ischemic or hemorrhagic stroke patients assessed for or who received rehabilitation services.

Denominator: Ischemic or hemorrhagic stroke patients.













5. Check Elective Carotid Intervention a. If Elective Carotid Intervention is missing, the case will proceed to a



c. If Elective Carotid Intervention equals No, continue processing and proceed to Assessed for Rehabilitation Services.


6. Check Assessed for Rehabilitation Services a. If Assessed for Rehabilitation Services is missing, the case will proceed to

a Measure Category Assignment of X and will be rejected. Stop processing.

b. If Assessed for Rehabilitation Services equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

c. If Assessed for Rehabilitation Services equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing

preview of “stroke list - measuredesc strokecm.pdf” stroke measures... · s p e c ific a tio n...

Documents