eMeasure Title Discharged on Statin Medication
eMeasure Identifier
(Measure Authoring Tool)
105 eMeasure Version number 2
NQF Number 0439 GUID 1f503318-bb8d-4b91-af63-223ae0a2328e
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward The Joint Commission
Measure Developer The Joint Commission
Endorsed By National Quality Forum
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.
Copyright
Measure specifications are in the Public Domain.

LOINC(R) is a registered trademark of the Regenstrief Institute.

This material contains SNOMED Clinical Terms (R) (SNOMED CT(c) ) copyright 2004-–2010 International Health Terminology Standards Development Organization. All rights reserved.
Disclaimer
None
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
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 Program’s 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).
Clinical Recommendation Statement
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).
Improvement Notation
An increase in rate
Reference
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).
Reference
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.
Reference
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.
Reference
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.
Reference
High-Dose Atorvastatin after Stroke or Transient Ischemic Attack. (New England Journal of Medicine. NEJM Vol. 355 2006:549-559.
Reference
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.
Reference
Pitt B, Loscalzo J, Ycas J, Raichlen JS. Lipid Levels After Acute Coronary Syndromes. J Am Coll Cardiol 2008;51;1440-1445.
Reference
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.
Reference
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.
Reference
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.
Reference
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.
Definition
None
Guidance
The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

The facility location arrival datetime and facility location departure datetime are coupled with the emergency department visit value set. They intend to represent arrival date/time at the emergency department and the discharge date/time from the emergency department, respectively.

Lipid-lowering medications are intended as active home meds that the patient may or may not continue to take during hospitalization.

The “Non-elective admissions” 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 admissions include emergency, urgent and unplanned admissions, including patients admitted for observation.
Transmission Format
None
Initial Patient Population
Patients admitted to the hospital for inpatient acute care with a principal diagnosis code for ischemic or hemorrhagic stroke with hospital stays <= 120 days during the measurement period for patients age 18 and older at the time of hospital admission.
Denominator
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.
Denominator Exclusions
Patients with comfort measures only documented 
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
Numerator
Ischemic stroke patients prescribed statin medication at hospital discharge.
Numerator Exclusions
Not Applicable
Denominator Exceptions
Patients with a reason for not prescribing statin medication at discharge
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
eMeasure Stroke (eSTK)