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  • Measure Summary
  • NQMC:009997
  • Mar 2015

Stroke: percentage of ischemic stroke patients with a post-treatment reperfusion grade of thrombolysis in cerebral infarction (TICI) 2B or higher in the vascular territory beyond the target arterial occlusion at the end of treatment with IA thrombolytic (t-PA) therapy and/or mechanical endovascular reperfusion therapy.

The Joint Commission. Disease-specific care certification program. Comprehensive stroke: performance measurement implementation guide. Oakbrook Terrace (IL): The Joint Commission; 2015 Mar. 278 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in April 2016.

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Primary Measure Domain

Clinical Quality Measures: Outcome

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of ischemic stroke patients with a post-treatment reperfusion grade of thrombolysis in cerebral infarction (TICI) 2B or higher in the vascular territory beyond the target arterial occlusion at the end of treatment with intra-arterial (IA) thrombolytic (t-PA) therapy and/or mechanical endovascular reperfusion therapy.

Rationale

The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral reperfusion. Four results are possible with this scoring system: 0 (no perfusion); 1 (perfusion past the initial occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch filling); and 3 (full perfusion with filling of all distal branches). Reperfusion past the target arterial occlusion and into the distal arterial bed and terminal branches, in conjunction with recanalization of the target arterial occlusion, demonstrates flow restoration or revascularization.

The Interventional Management of Stroke (IMS) I trial suggested that the combined use of reduced-dose intravenous (IV) thrombolytic (t-PA) therapy, followed by microcatheter delivered intra-arterial (IA) t-PA therapy, was safe and effective in selected ischemic stroke patients, as compared to patients treated with full dose IV t-PA in the National Institute of Neurologic Disease and Stroke (NINDS) rt-PA trial. In IMS I, a final TICI 2/3 reperfusion was achieved in 62% of ischemic stroke patients treated.

Evidence for Rationale

Adams HP Jr, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, Feinberg W, Mayberg M, Thies W. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a Special Writing Group of the Stroke Council. Circulation. 1996 Sep 1;94(5):1167-74. [102 references] PubMed External Web Site Policy

Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2004 Aug 3;110(5):588-636. PubMed External Web Site Policy

Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC Jr, Anbe DT, Kushner FG, Ornato JP, Pearle DL, Sloan MA, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW, Canadian Cardiovascular Society, American Academy of Family Physicians, American College of Cardiology, American Heart Association. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008 Jan 15;51(2):210-47. [90 references] PubMed External Web Site Policy

Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H, American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947. PubMed External Web Site Policy

Khatri P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA, IMS I and II Investigators. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009 Sep 29;73(13):1066-72. PubMed External Web Site Policy

Kole M, Amin B, Marin H, Russman A, Sanders W. Intracranial angioplasty and stent placement for direct cerebral revascularization of nonacute intracranial occlusions and near occlusions. Neurosurg Focus. 2009;26(3):E3. PubMed External Web Site Policy

Leifer D, Bravata DM, Connors JJ, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group, Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Mar;42(3):849-77. PubMed External Web Site Policy

Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DM, Peterson ED, Hernandez AF, Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012 Sep;43(9):2293-9. PubMed External Web Site Policy

Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007 Mar;38(3):967-73. PubMed External Web Site Policy

Sacks D, Black CM, Cognard C, Connors JJ III, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ, Ramee S, Rüfenacht DA, Stallmeyer MJB, Vorwerk D, American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, Society of Vascular and Interventional Neurology. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol. 2013 Feb;24(2):151-63. [142 references] PubMed External Web Site Policy

Sharma VK, Teoh HL, Wong LY, Su J, Ong BK, Chan BP. Recanalization therapies in acute ischemic stroke: pharmacological agents, devices, and combinations. Stroke Res Treat. 2010;2010 PubMed External Web Site Policy

Sims JR, Gharai LR, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009 Jun 16;72(24):2104-10. PubMed External Web Site Policy

The Joint Commission. Disease-specific care certification program. Comprehensive stroke: performance measurement implementation guide. Oakbrook Terrace (IL): The Joint Commission; 2015 Mar. 278 p.

Tomsick T, Broderick J, Carrozella J, Khatri P, Hill M, Palesch Y, Khoury J, Interventional Management of Stroke II Investigators. Revascularization results in the Interventional Management of Stroke II trial. AJNR Am J Neuroradiol. 2008 Mar;29(3):582-7. PubMed External Web Site Policy

Primary Health Components

Ischemic stroke; thrombolysis in cerebral infarction (TICI) reperfusion grade; intra-arterial (IA) thrombolytic (t-PA) therapy; mechanical endovascular reperfusion therapy

Denominator Description

Ischemic stroke patients treated with intra-arterial (IA) thrombolytic (t-PA) therapy and/or mechanical endovascular reperfusion therapy (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Ischemic stroke patients with a post-treatment reperfusion grade of thrombolysis in cerebral infarction (TICI) 2B or higher

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

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Certification

Collaborative inter-organizational quality improvement

Internal quality improvement

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

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

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions

  • Discharges with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Principal Diagnosis Code for ischemic stroke as defined in the appendices of the original measure documentation

    AND

  • Patients with documented thrombolytic (intravenous [IV] thrombolytic or intra-arterial [IA] thrombolytic [t-PA]) therapy (ICD-9-CM Principal or Other Procedure Codes as defined in the appendices of the original measure documentation)

    OR

  • Patients with documented mechanical endovascular reperfusion therapy (ICD-9-CM Principal or Other Procedure Codes 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 greater than 120 days
  • Patients admitted for Elective Carotid Intervention (as defined in the Data Elements)

Exclusions/Exceptions

Medical factors addressed

Patient factors addressed

Numerator Inclusions/Exclusions

Inclusions
Ischemic stroke patients with a post-treatment reperfusion grade of thrombolysis in cerebral infarction (TICI) 2B or higher

Exclusions
None

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Paper medical record

Type of Health State

Physiologic Health State (Intermediate Outcome)

Instruments Used and/or Associated with the Measure

  • Comprehensive Stroke (CSTK) Initial Patient Population Algorithm Flowchart
  • CSTK-08: Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade Flowchart
  • Thrombosis in Cerebral Infarction (TICI) Reperfusion Grade

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

Risk adjustment devised specifically for this measure/condition

Description of Allowance for Patient or Population Factors

Risk adjustment for this measure is applied to the following data elements:

  • Admission Date
  • Birthdate
  • Hispanic Ethnicity
  • International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Other Diagnosis Codes
  • Intravenous (IV) Thrombolytic Therapy Prior to Intra-arterial (IA) or Mechanical Reperfusion Therapy
  • Initial Blood Glucose Value at Hospital Arrival
  • Initial Blood Pressure at Hospital Arrival
  • Initial National Institutes for Stroke Scale (NIHSS) Score at Hospital Arrival
  • Initial Platelet Count at Hospital Arrival
  • Proximal or Distal Occlusion
  • Race
  • Sex
  • Site of Primary Vessel Occlusion

Standard of Comparison

Internal time comparison

Original Title

CSTK-08: thrombolysis in cerebral infarction (TICI post-treatment reperfusion grade).

Measure Collection Name

Advanced Certification in Disease-specific Care Measures

Measure Set Name

Comprehensive Stroke Standardized Performance Measures

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

Unspecified

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 The Joint Commission.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Mar

Measure Maintenance

This measure is reviewed and updated by the developing organization every 6 months.

Date of Next Anticipated Revision

2015 Jul

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in April 2016.

Source(s)

The Joint Commission. Disease-specific care certification program. Comprehensive stroke: performance measurement implementation guide. Oakbrook Terrace (IL): The Joint Commission; 2015 Mar. 278 p.

Measure Availability

Source available from The Joint Commission Web site External Web Site Policy.

For more information, contact The Joint Commission at One Renaissance Blvd., Oakbrook Terrace, IL 60181; Phone: 630-792-5800; Fax: 630-792-5005; Web site: www.jointcommission.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 19, 2015. The information was verified by the measure developer on June 22, 2015.

The information was reaffirmed by the measure developer on April 6, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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