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  2. CQM-7483

CMS 996 suggestion for consideration

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    • Icon: OQR eCQMs - Outpatient Quality Reporting OQR eCQMs - Outpatient Quality Reporting
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      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We appreciate your suggestion to use ECG changes to capture the onset of STEMI during the ED encounter based on clinical guidelines.

      The STEMI measure does not take into account ECG timing or frequency, and instead uses the diagnosis of STEMI during the ED Encounter. This decision was based on clinical expert input and measure testing results indicating that ECG timing in EHR documentation was unreliable. In addition, the issue of capturing the time to intervention starting with STEMI onset as opposed to ED arrival has previously been brought to the measure developer. The measure developer will continue to evaluate feedback and recommendations during the annual update cycle and update the measure as needed to align with clinical guidelines and workflow.
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      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We appreciate your suggestion to use ECG changes to capture the onset of STEMI during the ED encounter based on clinical guidelines. The STEMI measure does not take into account ECG timing or frequency, and instead uses the diagnosis of STEMI during the ED Encounter. This decision was based on clinical expert input and measure testing results indicating that ECG timing in EHR documentation was unreliable. In addition, the issue of capturing the time to intervention starting with STEMI onset as opposed to ED arrival has previously been brought to the measure developer. The measure developer will continue to evaluate feedback and recommendations during the annual update cycle and update the measure as needed to align with clinical guidelines and workflow.
    • CMS0996v5
    • CMS0996v4
    • Metrics does not reflect true clinical quality of care

      Early presenting acute coronary syndrome (ACS) patients may arrive to the emergency department with ECG changes that do not meet STEMI criteria. The American College of Cardiology (ACC) recommends a serial ECG approach for patients with ongoing ACS symptoms, which involves obtaining an ECG every 15-30 minutes for the first hour after arrival for persistent symptoms. In that hour, ST segments may evolve and meet STEMI criteria, for which an alert is initiated. This is also the recommendation for every new onset of symptoms, in the event symptoms have resolved on arrival then resumed later. Given this change from the time of presentation, the ACC allows facilities to calculate time to reperfusion from the time of the ECG that meets STEMI criteria. 

      In review UF Health Shands’ CMS 996 Metric data for January through October 2024, 15% of the patients with a culprit lesion were activated based on an ECG in the emergency department subsequent to the initial ECG, many of which are obtained within the first hour of arrival. Despite clinically sound practice, these patients will fail on the current CMS STEMI-40 metric, since their ECGs did not meet alert criteria on arrival.

      We would suggest this metric to offer an exclusion for patients whose initial ECG did not meet STEMI criteria.

      For reference of ACC guidelines, please see attached document page e203 citing the following, "An initial normal ECG does not exclude ACS. Patients with an initial normal ECG should have a repeat ECG, if symptoms are ongoing, until other diagnostic testing rules out ACS." j.jacc.2021.07.053.pdf

        1. j.jacc.2021.07.053.pdf
          6.07 MB

            aweber Mathematica EH eCQM Team
            Satinej Jeff Satine
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