ecqm.measure

CMS71v8 - Anticoagulation Therapy for Atrial Fibrillation/Flutter (STK-03)

Rationale:

Anticoagulation Therapy for Atrial Fibrillation/Flutter (STK-03). 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.

Data Elements

AtrialFibrillationFlutterDiagnosis

Clinical Focus: This grouping value set contains diagnoses used to identify patients with a history of atrial fibrillation/flutter or a current finding of atrial fibrillation/flutter.

Data Element Scope: The intent of this data element is to identify patients with a diagnosis of atrial fibrillation or flutter. Using the Quality Data Model, this particular element would map to the Diagnosis category or the Diagnosis attribute for the Encounter category.

Inclusion Criteria: Include codes that identify patients with a history of atrial fibrillation/flutter or a current finding of atrial fibrillation/flutter. This is a grouping of ICD10CM, ICD9CM and SNOMEDCT codes.

Exclusion Criteria: None.

ResultValue constrained to codes in the Atrial Fibrillation/Flutter valueset (2.16.840.1.113883.3.117.1.7.1.202)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

AtrialFibrillationFlutterDiagnosis

0..*

AtrialFibrillationFlutterDiagnoses

Clinical Focus: This grouping value set contains diagnoses used to identify patients with a history of atrial fibrillation/flutter or a current finding of atrial fibrillation/flutter.

Data Element Scope: The intent of this data element is to identify patients with a diagnosis of atrial fibrillation or flutter. Using the Quality Data Model, this particular element would map to the Diagnosis category or the Diagnosis attribute for the Encounter category.

Inclusion Criteria: Include codes that identify patients with a history of atrial fibrillation/flutter or a current finding of atrial fibrillation/flutter. This is a grouping of ICD10CM, ICD9CM and SNOMEDCT codes.

Exclusion Criteria: None.

Diagnoses: Coded diagnoses/problems addressed during the encounter. The diagnoses attribute is intended to capture ALL diagnoses, including principal diagnosis. Use of the Encounter, Performed: diagnoses attribute and the Diagnosis datatype is redundant for relating the diagnosis to the Encounter, Performed. The Encounter, Performed: diagnoses syntax is preferred. Referencing the same diagnosis using Encounter, Performed (diagnoses attribute) and Diagnosis (datatype) should only occur if the measure must define a specified length of a prevalence period, e.g., The measure must assure that the diagnoseis have been present for at least some defined time period before the encounter, and were addressed during the Encounter

DataType

Cardinality

AtrialFibrillationFlutterDiagnoses

0..*

NonElectiveInpatientEncounterPerformed

Clinical Focus: This set of values contains procedures that represent non-elective inpatient encounters.

Data Element Scope: The intent of this data element is to identify non-elective inpatient encounters. Using the Quality Data Model, this particular element will map to the 'Encounter' category.

Inclusion Criteria: Only SNOMED CT codes representing non-elective inpatient encounter should be included.

Exclusion Criteria: None

Subject constrained to the Non-Elective Inpatient Encounter

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

NonElectiveInpatientEncounterPerformed

0..*

DischargedToHealthCareFacilityForHospiceCareDischargeDisposition

Clinical Focus: This set of values contains procedures used to represent the discharge of a patient to a health care facility for hospice care.

Data Element Scope: The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who where discharged to a health care facility for hospice care. Using the Quality Data Model, this particular value set is used with the Attribute of 'Discharge status' used with the 'Encounter' category.

Inclusion Criteria: Only SNOMED CT codes representing health care facilities for hospice care should be included.

Exclusion Criteria: None

DischargeDisposition: The disposition, or location to which the patient is transferred at the time of hospital discharge.

DataType

Cardinality

DischargedToHealthCareFacilityForHospiceCareDischargeDisposition

0..*

DischargedToHomeForHospiceCareDischargeDisposition

Clinical Focus: This set of values contains procedures used to represent the discharge of a patient to home for hospice care.

Data Element Scope: The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who where discharged to home for hospice care. Using the Quality Data Model, this particular value set is used with the Attribute of 'Discharge status' used with the 'Encounter' category.

Inclusion Criteria: Only SNOMED CT codes representing discharge to home for hospice care should be included.

Exclusion Criteria: None

DischargeDisposition: The disposition, or location to which the patient is transferred at the time of hospital discharge.

DataType

Cardinality

DischargedToHomeForHospiceCareDischargeDisposition

0..*

LeftAgainstMedicalAdviceDischargeDisposition

Clinical Focus: This set of values represents a patient leaving against medical advice.

Data Element Scope: The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who left against medical advice. Using the Quality Data Model, this particular value set is used with the Attribute of 'Discharge status' used with the 'Encounter' category.

Inclusion Criteria: Only SNOMED CT codes representing leaving against medical advice should be included.

Exclusion Criteria: None

DischargeDisposition: The disposition, or location to which the patient is transferred at the time of hospital discharge.

DataType

Cardinality

LeftAgainstMedicalAdviceDischargeDisposition

0..*

HemorrhagicStrokePrincipalDiagnosis

Clinical Focus: This grouping of value sets identifies patients who have had a hemorrhagic stroke, or stroke caused by hemorrhage.

Data Element Scope: The intent of this data element is to identify patients who have a diagnosis of hemorrhagic stroke, or stroke caused by a hemorrhage. Using the Quality Data Model, this particular element would map to the Principal Diagnosis attribute for the Encounter category.

Inclusion Criteria: Only use codes which represent a diagnosis of hemorrhagic stroke, or stroke caused by hemorrhage. This is a grouping of ICD10CM and SNOMED-CT codes.

Exclusion Criteria: None.

PrincipalDiagnosis: The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

DataType

Cardinality

HemorrhagicStrokePrincipalDiagnosis

0..*

IschemicStrokePrincipalDiagnosis

Clinical Focus: This grouping of value sets identifies patients who have had a stroke caused by ischemia, where the blood supply is restricted to an area of the brain by something like thrombosis or an embolism.

Data Element Scope: The intent of this data element is to identify patients who have a diagnosis of ischemic stroke, or stroke caused by ischemia. Using the Quality Data Model, this particular element would map to the Principal Diagnosis attribute for the Encounter category or to the Diagnosis Category.

Inclusion Criteria: Only use codes which represent a diagnosis of ischemic stroke, or stroke caused by ischemia. This is a grouping of ICD10CM and SNOMED-CT codes and concepts.

Exclusion Criteria: None.

PrincipalDiagnosis: The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

DataType

Cardinality

IschemicStrokePrincipalDiagnosis

0..*

EmergencyDepartmentVisitPerformed

Clinical Focus: This set of values identifies procedures representing an emergency department encounter.

Data Element Scope: The intent of this data element is to identify patients who have had an emergency department encounter. Using the Quality Data Model, this particular element will map to the 'Encounter' category.

Inclusion Criteria: Include codes representing an emergency department visit encounter utilizing the SNOMED CT code system.

Exclusion Criteria: None

Subject constrained to the Emergency Department Visit

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

EmergencyDepartmentVisitPerformed

0..*

ComfortMeasuresOrder

Clinical Focus: This set of values contains care regimes used to define comfort measure care.

Data Element Scope: The intent of this data element is to identify patients receiving comfort measures care. Using the Quality Data Model, this particular element would map to the Intervention category.

Inclusion Criteria: Include SNOMEDCT regime and therapy codes for comfort measures, terminal care, dying care, and hospice care.

Exclusion Criteria: None.

Subject constrained to the Comfort Measures

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

ComfortMeasuresOrder

0..*

ComfortMeasuresPerformed

Clinical Focus: This set of values contains care regimes used to define comfort measure care.

Data Element Scope: The intent of this data element is to identify patients receiving comfort measures care. Using the Quality Data Model, this particular element would map to the Intervention category.

Inclusion Criteria: Include SNOMEDCT regime and therapy codes for comfort measures, terminal care, dying care, and hospice care.

Exclusion Criteria: None.

Subject constrained to the Comfort Measures

InterventionPerformed: Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The time the intervention begins stopTime – The time the intervention ends NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

DataType

Cardinality

ComfortMeasuresPerformed

0..*

AnticoagulantTherapyDischarge

Clinical Focus: This set of values contains medications that are prescribed for anticoagulant therapy at hospital discharge for patients following acute ischemic stroke.

Data Element Scope: The intent of this data element is to identify patients who are prescribed anticoagulant therapy at discharge following acute ischemic stroke. Using the Quality Data Model, this particular element would map to the Medication category.

Inclusion Criteria: Include oral and injectable drug forms. Include Warfarin, heparins and direct thrombin inhibitors.

Exclusion Criteria: Exclude enoxaparin and heparin codes generally given for VTE prophylaxis.

Subject constrained to the Anticoagulant Therapy

MedicationDischarge: Data elements that meet criteria using this datatype should document that the medications indicated by the QDM category and its corresponding value set should be taken by or given to the patient after being discharged from an inpatient encounter. Timing: The time the discharge medication list on the discharge instruction form is authored.

DataType

Cardinality

AnticoagulantTherapyDischarge

0..*

EthnicityPatientCharacteristicEthnicity

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Ethnicity valueset (2.16.840.1.114222.4.11.837)

PatientCharacteristicEthnicity: Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set. Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

DataType

Cardinality

EthnicityPatientCharacteristicEthnicity

0..*

OncAdministrativeSexPatientCharacteristicGender

Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.

Data Element Scope: Gender

Inclusion Criteria: Male and Female only.

Exclusion Criteria: Any gender identity that is not male or female.

ResultValue constrained to codes in the ONC Administrative Sex valueset (2.16.840.1.113762.1.4.1)

PatientCharacteristicGender: Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set. Timing: Birth (administrative) sex does not have a specific timing.

DataType

Cardinality

OncAdministrativeSexPatientCharacteristicGender

0..*

PayerPatientCharacteristicPayer

Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC

Inclusion Criteria: All codes in the code system

Exclusion Criteria: none

ResultValue constrained to codes in the Payer valueset (2.16.840.1.114222.4.11.3591)

PatientCharacteristicPayer: Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The first day of insurance coverage with the referenced payer stopTime – The last day of insurance coverage with the referenced payer

DataType

Cardinality

PayerPatientCharacteristicPayer

0..*

RacePatientCharacteristicRace

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Race valueset (2.16.840.1.114222.4.11.836)

PatientCharacteristicRace: Data elements that meet criteria using this datatype should document the patient’s race. Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

DataType

Cardinality

RacePatientCharacteristicRace

0..*

AtrialAblationPerformed

Clinical Focus: This grouping value set represents atrial ablation procedures.

Data Element Scope: The intent of this data element is to identify patients with a history of atrial ablation procedure. Using the Quality Data Model, this particular element would map to the Procedure category.

Inclusion Criteria: Include codes that identify patients with a history of atrial ablation procedure. This is a grouping of ICD10CM and SNOMEDCT codes.

Exclusion Criteria: Exclude codes that do not meet the inclusion criteria.

Subject constrained to the Atrial Ablation

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

AtrialAblationPerformed

0..*