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  • Measure Summary
  • NQMC:010128
  • Oct 2015
  • NQF-Endorsed Measure

Stroke: percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Specifications manual for national hospital inpatient quality measures, version 4.3b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; 2014 Apr. various p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percent of patients 18 years of age and older hospitalized with ischemic stroke who are 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. In recent years, novel oral anticoagulants (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients.

Anticoagulantion therapy at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or transient ischemic attack (TIA).

Evidence for Rationale

Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

Primary Health Components

Stroke; antithrombotic therapy

Denominator Description

Ischemic stroke patients (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • Stroke ranks as the number five cause of death in the United States, following diseases of the heart, cancer, and chronic lung-related diseases. Each year, approximately 795,000 people experience a new or recurrent stroke. Approximately 610,000 of these are first attacks, and 185,000 are recurrent strokes. These numbers equate to one stroke victim every 40 seconds on average. According to 2010 mortality data, one of every 20 deaths in the United States is attributable to stroke. Women have a lifetime risk of stroke than men. Lifetime risk of stroke among those 55 to 75 years of age was 1 in 5 for women (20% to 21%) and approximately 1 in 6 for men (14% to 17%). Blacks have a risk of first-ever stroke that is almost twice that of whites (American Heart Association [AHA], 2015).
  • Stroke is also a leading cause of long-term disability (Centers for Disease Control and Prevention [CDC], 2009). Data from the National Heart, Lung and Blood Institute (NHLBI) revealed that 50% of ischemic stroke survivors age greater than 65 years had some hemiparesis; 35% experienced depressive symptoms; 30% were unable to ambulate without assistance; 26% were dependent in activities of daily living; 19% had aphasia; and 26% were institutionalized in a nursing home. The mean lifetime cost of ischemic stroke, including inpatient care, rehabilitation, and follow-up as necessary for residual deficits are estimated at $140,048 per person (AHA, 2015).
  • Antithrombotic agents significantly reduce the incidence of a recurrent vascular event after a stroke. The effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity and recurrence rates has been studied in several large clinical trials (Furie et al., 2011). 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.

Evidence for Additional Information Supporting Need for the Measure

American Heart Association (AHA). Heart disease and stroke statistics - 2015 update. Dallas (TX): American Heart Association (AHA); 2015. 22 p.

Centers for Disease Control and Prevention (CDC). Prevalence and most common causes of disability among adults--United States, 2005. MMWR Morb Mortal Wkly Rep. 2009 May 1;58(16):421-6. PubMed External Web Site Policy

Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, Halperin JL, Johnston SC, Katzan I, Kernan WN, Mitchell PH, Ovbiagele B, Palesch YY, Sacco RL, Schwamm LH, Wassertheil-Smoller S, Turan TN, Wentworth D, American Heart Association Stroke Council, Council on Cardiovascular Nursing. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Jan;42(1):227-76. PubMed External Web Site Policy

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Accreditation

Certification

Collaborative inter-organizational quality improvement

External oversight/Medicare

External oversight/Other national programs

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Safety

Case Finding Period

Discharges October 1 through June 30

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Discharges with an International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Principal Diagnosis Code for ischemic stroke (as defined in the appendices of the original measure documentation)

Exclusions

  • Patients less than 18 years of age
  • Patients who have a Length of Stay (LOS) greater than 120 days
  • Patients with Comfort Measures Only (as defined in the Data Dictionary) documented
  • Patients enrolled in clinical trials
  • Patients admitted for Elective Carotid Intervention (as defined in the Data Dictionary)
  • 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 (as defined in the Data Dictionary)

Exclusions/Exceptions

Medical factors addressed

Patient factors addressed

System factors addressed

Numerator Inclusions/Exclusions

Inclusions
Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge

Exclusions
None

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • STK Initial Patient Population Algorithm Flowchart
  • STK-2: Discharged on Antithrombotic Therapy Flowchart

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Unspecified

Original Title

STK-2: discharged on antithrombotic therapy.

Measure Collection Name

National Hospital Inpatient Quality Measures

Measure Set Name

Stroke

Submitter

The Joint Commission - Health Care Accreditation Organization

Developer

The Joint Commission - Health Care Accreditation Organization

Funding Source(s)

All external funding for measure development has been received and used in full compliance with The Joint Commission's Corporate Sponsorship policies, which are available upon written request to The Joint Commission.

Composition of the Group that Developed the Measure

The composition of the group that developed the measure is available at: http://www.jointcommission.org/assets/1/6/Roster_STK_Maintenance_TAP_web_posting_Jul2012.pdf External Web Site Policy.

Financial Disclosures/Other Potential Conflicts of Interest

Expert panel members have made full disclosure of relevant financial and conflict of interest information in accordance with the Joint Commission's Conflict of Interest policies, copies of which are available upon written request to The Joint Commission.

Endorser

National Quality Forum

NQF Number

0435

Date of Endorsement

2014 Dec 23

Measure Initiative(s)

Hospital Compare

Hospital Inpatient Quality Reporting Program

Quality Check®

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

This measure is reviewed and updated every 6 months.

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: Specifications manual for national hospital inpatient quality measures, version 4.3b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; 2014 Apr. various p.

Source(s)

Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

Measure Availability

Source available from The Joint Commission Web site External Web Site Policy. Information is also available from the QualityNet Web site External Web Site Policy. Check The Joint Commission Web site and QualityNet Web site regularly for the most recent version of the specifications manual and for the applicable dates of discharge.

NQMC Status

The Joint Commission originally submitted this NQMC measure summary to ECRI Institute on April 30, 2009. This NQMC summary was reviewed accordingly by ECRI Institute on September 9, 2009. The information was verified by the measure developer on November 9, 2009.

The Joint Commission informed NQMC that this measure was updated on April 28, 2010 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on September 3, 2010.

This NQMC summary was retrofitted into the new template on May 18, 2011.

The Joint Commission informed NQMC that this measure was updated on August 13, 2012 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on December 17, 2012.

The Joint Commission informed NQMC that this measure was updated again on August 28, 2013 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on January 30, 2014.

The Joint Commission informed NQMC that this measure was updated on March 23, 2015 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on April 10, 2015.

The Joint Commission informed NQMC that this measure was updated on July 22, 2015 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on August 4, 2015.

This NQMC summary was edited by ECRI Institute on November 16, 2015.

Copyright Statement

The Specifications Manual for National Hospital Inpatient Quality Measures [Version 5.0b, October, 2015] is the collaborative work of the Centers for Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is periodically updated by the Centers for Medicare & Medicaid Services and The Joint Commission. Users of the Specifications Manual for National Hospital Inpatient Quality Measures must update their software and associated documentation based on the published manual production timelines.

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