eCQM Title | Anticoagulation Therapy for Atrial Fibrillation/Flutter |
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eCQM Identifier (Measure Authoring Tool) | 71 | eCQM Version Number | 14.0.000 |
CBE Number | Not Applicable | GUID | 03876d69-085b-415c-ae9d-9924171040c2 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | The Joint Commission | ||
Measure Developer | The Joint Commission | ||
Endorsed By | None | ||
Description |
Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge |
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Copyright |
Measure specifications are in the Public Domain. LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved. |
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Disclaimer |
These performance measures are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications. The measures and specifications are provided without warranty. |
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Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification |
None |
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Risk Adjustment |
None |
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Rate Aggregation |
None |
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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. |
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Clinical Recommendation Statement |
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 |
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Improvement Notation |
Improvement noted as an increase in rate |
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Reference |
Reference Type: CITATION Reference Text: 'Berge, E., Abdelnoor, M., Nakstad, P. H., & Sandset, P.M. (2000). Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: A double-blind randomised study. Lancet (London, England), 355(9211), 1205-1210. https://doi.org/10.1016/s0140-6736(00)02085-7' |
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Reference |
Reference Type: CITATION Reference Text: 'Centers for Disease Control and Prevention (CDC) (2009). Prevalence and most common causes of disability among adults—United States, 2005. MMWR. Morbidity and mortality weekly report, 58(16), 421-426.' |
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Reference |
Reference Type: CITATION Reference Text: 'Connolly, S. J., Ezekowitz, M. D., Yusuf, S., Eikelboom, J., Oldgren, J., Parekh, A., . . . RE-LY Steering Committee and Investigators (2009). Dabigatran versus warfarin in patients with atrial fibrillation. The New England journal of medicine, 361(12), 1139-1151. https://doi.org/10.1056/NEJMoa0905561' |
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Reference |
Reference Type: CITATION Reference Text: 'Fuster, V., Ryden, L. E., Asinger, R. W., Cannom, D. S., Crijns, H. J., Frye, R. L., . . . American College of Cardiology/American Heart Association/European Society of Cardiology Board (2001). ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation). Journal of the American College of Cardiology, 38(4), 1231-1266. https://doi.org/10.1016/s0735-1097(01)01587-x' |
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Reference |
Reference Type: CITATION Reference Text: 'Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., . . . Heart Rhythm Society (2006). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). Circulation, 114(7), e257-354. https://doi.org/10.1161/CIRCULATIONAHA.106.177292' |
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Reference |
Reference Type: CITATION Reference Text: 'Goldstein, L. B., Adams, R., Alberts, M. J., Appel, L. J., Brass, L. M., Bushnell, C. D., . . . American Academy of Neurology (2006). 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, 37(6), 1583-1633. https://doi.org/10.1161/01.STR.0000223048.70103.F1' |
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Reference |
Reference Type: CITATION Reference Text: 'Gorelick, P. B., Sacco, R. L., Smith, D. B., Alberts, M., Mustone-Alexander, L., Rader, D., . . . Rhew, D. C. (1999). Prevention of a first stroke: A review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA, 281(12), 1112-1120. https://doi.org/10.1001/jama.281.12.1112' |
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Reference |
Reference Type: CITATION Reference Text: 'Hart, R. G., Benavente, O., McBride R., & Pearce, L. A. (1999). Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: A meta-analysis. Annals of Internal Medicine, 131(7), 492-501. https://doi.org/10.7326/0003-4819-131-7-199910050-00003' |
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Reference |
Reference Type: CITATION Reference Text: 'Jauch, E. C., Saver, J. L., Adams, H. P., Jr., Bruno, A., Connors, J. J., Demaerschalk, B. M., . . . Council on Clinical Cardiology (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 44(3), 870-947. https://doi.org/10.1161/STR.0b013e318284056a' |
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Reference |
Reference Type: CITATION Reference Text: 'Kernan, W. N., Ovbiagele, B., Black, H. R., Bravata, D. M., Chimowitz, M. I., Ezekowitz, M. D., . . . Council on Peripheral Vascular Disease (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 45(7), 2160-2236. https://doi.org/10.1161/STR.0000000000000024' |
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Reference |
Reference Type: CITATION Reference Text: 'Kleindorfer, D. O., Towfighi, A., Chaturvedi, S., Cockroft, K. M., Gutierrez, J., Lombardi-Hill, D., ... Williams, L. S. (2021). 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association. Stroke, 52(7), e364-e467. https://doi.org/10.1161/STR.0000000000000375' |
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Reference |
Reference Type: CITATION Reference Text: 'Lin, H. J., Wolf, P. A., Kelly-Hayes, M., Beiser, A. S., Kase, C. S., Benjamin, E. J., & D'Agostino, R. B. (1996). Stroke severity in atrial fibrillation: The Framingham Study. Stroke 27(10), 1760-1764. https://doi.org/10.1161/01.str.27.10.1760' |
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Reference |
Reference Type: CITATION Reference Text: 'Penado, S., Cano, M., Acha, O., Hernández, J. L., & Riancho, J. A. (2003). Atrial fibrillation as a risk factor for stroke recurrence. The American journal of medicine, 114(3), 206-210. https://doi.org/10.1016/s0002-9343(02)01479-1' |
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Reference |
Reference Type: CITATION Reference Text: 'Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., . . . American Heart Association Stroke Council (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for health care professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46-e110. https://doi.org/10.1161/STR.0000000000000158' |
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Reference |
Reference Type: CITATION Reference Text: 'Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E. J., Berry, J. D., Borden, W. B., . . . American Heart Association Statistics Committee and Stroke Statistics Subcommittee (2012). Heart disease and stroke statistics—2012 update: A report from the American Heart Association. Circulation, 125(1), e2-e220. https://doi.org/10.1161/CIR.0b013e31823ac046' |
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Reference |
Reference Type: CITATION Reference Text: 'Saxena, R., & Koudstaal, P. J. (2004). Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack (review). The Cochrane database of systematic reviews, (2), CD000185. https://doi.org/10.1002/14651858.CD000185.pub2' |
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Reference |
Reference Type: CITATION Reference Text: 'Saxena, R., Lewis, S., Berge, E., Sandercock, P. A., & Koudstaal, P. J. (2001). Risk of early death and recurrent stroke and effect of heparin in 3,169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke, 32(10), 2333-2337.' |
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Reference |
Reference Type: CITATION Reference Text: 'Van Walraven, C., Hart, R. G., Singer, D. E., Laupacis, A., Connolly, S., Petersen, P., . . . Hellemons, B. (2002).Oral anticoagulants vs. aspirin in nonvalvular atrial fibrillation: An individual patient meta-analysis. JAMA, 288(19), 2441-2448. https://doi.org/10.1001/jama.288.19.2441' |
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Reference |
Reference Type: CITATION Reference Text: 'Wann, L. S., Curtis, A. B., Ellenbogen, K. A., Estes, N. A., 3rd, Ezekowitz, M. D., Jackman, W. M., . . . Tracy, C. M. (2011). 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on dabigatran): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 57(11), 1330-1337. https://doi.org/10.1016/j.jacc.2011.01.010' |
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Definition |
None |
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Guidance |
The "Nonelective Inpatient Encounter" value set intends to capture all non-scheduled hospitalizations. This value set is a subset of the "Inpatient Encounter" value set, excluding concepts that specifically refer to elective hospital admissions. Non-elective Inpatient Encounters include emergency, urgent, and unplanned admissions. The "Medication, Discharge" datatype refers to the discharge medication list and is intended to express medications ordered for post-discharge use. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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Transmission Format |
TBD |
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Initial Population |
Inpatient hospitalizations (non-elective admissions) for patients age 18 and older, discharged from inpatient care with a principal diagnosis of ischemic stroke, ending during the measurement period |
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Denominator |
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke, and a history of atrial ablation, or current or history of atrial fibrillation/flutter |
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Denominator Exclusions |
- Inpatient hospitalizations for patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations. - Inpatient hospitalizations for patients discharged to another hospital - Inpatient hospitalizations for patients who left against medical advice - Inpatient hospitalizations for patients who expired - Inpatient hospitalizations for patients discharged to home for hospice care - Inpatient hospitalizations for patients discharged to a health care facility for hospice care - Inpatient hospitalizations for patients with comfort measures documented |
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Numerator |
Inpatient hospitalizations for patients prescribed or continuing to take anticoagulation therapy at hospital discharge |
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Numerator Exclusions |
Not Applicable |
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Denominator Exceptions |
Inpatient hospitalizations for patients with a documented reason for not prescribing anticoagulation therapy at discharge |
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Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
TJC."Ischemic Stroke Encounter"
"Encounter with a History of Atrial Ablation" union "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Flutter"
( "Denominator" Encounter where Encounter.dischargeDisposition in "Discharge To Acute Care Facility" or Encounter.dischargeDisposition in "Left Against Medical Advice" or Encounter.dischargeDisposition in "Patient Expired" or Encounter.dischargeDisposition in "Discharged to Home for Hospice Care" or Encounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care" ) union "Encounter with Comfort Measures during Hospitalization for Patients with Documented Atrial Fibrillation or Flutter"
"Denominator" Encounter with ["Medication, Discharge": "Anticoagulant Therapy"] DischargeAnticoagulant such that DischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod
None
"Denominator" Encounter with "Documented Reason for Not Giving Anticoagulant at Discharge" NoDischargeAnticoagulant such that NoDischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod
None
"Encounter with a History of Atrial Ablation" union "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Flutter"
"Denominator" Encounter with "Documented Reason for Not Giving Anticoagulant at Discharge" NoDischargeAnticoagulant such that NoDischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod
( "Denominator" Encounter where Encounter.dischargeDisposition in "Discharge To Acute Care Facility" or Encounter.dischargeDisposition in "Left Against Medical Advice" or Encounter.dischargeDisposition in "Patient Expired" or Encounter.dischargeDisposition in "Discharged to Home for Hospice Care" or Encounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care" ) union "Encounter with Comfort Measures during Hospitalization for Patients with Documented Atrial Fibrillation or Flutter"
["Medication, Not Discharged": "Anticoagulant Therapy"] NoAnticoagulant where NoAnticoagulant.negationRationale in "Medical Reason For Not Providing Treatment" or NoAnticoagulant.negationRationale in "Patient Refusal"
( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["Procedure, Performed": "Atrial Ablation"] AtrialAblationProcedure such that Global."NormalizeInterval" ( AtrialAblationProcedure.relevantDatetime, AtrialAblationProcedure.relevantPeriod ) starts before start of IschemicStrokeEncounter.relevantPeriod ) union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["Diagnosis": "History of Atrial Ablation"] AtrialAblationDiagnosis such that AtrialAblationDiagnosis.prevalencePeriod starts before start of IschemicStrokeEncounter.relevantPeriod ) union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["Assessment, Performed": "History of Atrial Ablation"] AtrialAblationAssessment such that Global."EarliestOf" ( AtrialAblationAssessment.relevantDatetime, AtrialAblationAssessment.relevantPeriod ) on or before end of IschemicStrokeEncounter.relevantPeriod )
"Denominator" Encounter with TJC."Intervention Comfort Measures" ComfortMeasure such that Coalesce(start of Global."NormalizeInterval"(ComfortMeasure.relevantDatetime, ComfortMeasure.relevantPeriod), ComfortMeasure.authorDatetime) during Global."HospitalizationWithObservation" ( Encounter )
( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["Diagnosis": "Atrial Fibrillation or Flutter"] AtrialFibrillationFlutter such that AtrialFibrillationFlutter.prevalencePeriod starts on or before end of IschemicStrokeEncounter.relevantPeriod ) union ( TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter where exists ( IschemicStrokeEncounter.diagnoses Diagnosis where Diagnosis.code in "Atrial Fibrillation or Flutter" ) )
TJC."Ischemic Stroke Encounter"
"Denominator" Encounter with ["Medication, Discharge": "Anticoagulant Therapy"] DischargeAnticoagulant such that DischargeAnticoagulant.authorDatetime during Encounter.relevantPeriod
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
["Intervention, Order": "Comfort Measures"] union ["Intervention, Performed": "Comfort Measures"]
"Non Elective Encounter with Age" NonElectiveEncounterWithAge where exists ( NonElectiveEncounterWithAge.diagnoses Diagnosis where Diagnosis.code in "Ischemic Stroke" and Diagnosis.rank = 1 )
["Encounter, Performed": "Nonelective Inpatient Encounter"] NonElectiveEncounter where AgeInYearsAt(date from start of NonElectiveEncounter.relevantPeriod) >= 18 and NonElectiveEncounter.relevantPeriod ends during day of "Measurement Period"
if ( HasStart(period)) then start of period else end of period
Earliest(NormalizeInterval(pointInTime, period))
not ( start of period is null or start of period = minimum DateTime )
Encounter Visit let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod sort by end of relevantPeriod ), VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod), EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED where LastED.relevantPeriod ends 1 hour or less on or before VisitStart sort by end of relevantPeriod ) return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), end of Visit.relevantPeriod]
if pointInTime is not null then Interval[pointInTime, pointInTime] else if period is not null then period else null as Interval<DateTime>
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |
eMeasure Stroke (eSTK) |
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