Specifications Manual for National Hospital Inpatient Quality Measures STK-6-1

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

Release Notes:

New Measure Information Form

Version 3.0b

**NQF ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Collected For: The Joint Commission Only

CMS Informational Only

Measure Set: Stroke (STK)

Set Measure ID #: STK-6

Performance Measure Name: Discharged on Statin Medication

Description: Ischemic stroke patients with LDL > 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.

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 > 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 > 100 mg/dl (or with LDL <>

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

Specifications Manual for National Hospital Inpatient Quality Measures STK-6-2

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

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 ≥ 100 mg/dl (or with LDL <>

Type of Measure: Process

Improvement Noted As: An increase in rate

Numerator Statement: Ischemic stroke patients prescribed statin medication at hospital discharge

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Statin Medication Prescribed at Discharge

Denominator Statement: Ischemic stroke patients with an LDL ≥ 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival

Included Populations:

• Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1

• Patients who were on a lipid-lowering medication prior to hospital arrival as defined in Appendix C, Table 1.6

• Patients with LDL-c not measured

• Patients with LDL-c Greater Than or Equal to 100 mg/dL

Excluded Populations:

• Patients less than 18 years of age

• Patients who have a Length of Stay >120 days

• Patients with Comfort Measures Only documented

• Patients enrolled in clinical trials

• Patients admitted for Elective Carotid Intervention

• Patients without Evidence of Atherosclerosis

• Patients discharged/transferred to another hospital for inpatient care

• Patients who left against medical advice or discontinued care

• Patients who expired

Specifications Manual for National Hospital Inpatient Quality Measures STK-6-3

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

• Patients discharged/transferred to a federal health care facility

• Patients discharged/transferred to hospice

• Patients with a Reason For Not Prescribing Statin Medication at Discharge

Data Elements:

• Admission Date

• Birthdate.

• Clinical Trial

• Comfort Measures Only

• Discharge Date

• Discharge Status

• Elective Carotid Intervention

• Evidence of Atherosclerosis

• ICD-9-CM Principal Diagnosis Code

• LDL-c Greater Than or Equal to 100 mg/dL

• LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival

• Pre-Arrival Lipid-Lowering Agent

• Reason For Not Prescribing Statin Medication at Discharge

Risk Adjustment: No

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes, for additional information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion

Selected References:

• 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).

• 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

• 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 if the American Heart Association. 1994. .

Specifications Manual for National Hospital Inpatient Quality Measures STK-6-4

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

• 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.

• High-Dose Atorvastatin after Stroke or Transient Ischemic Attack. (New England Journal of Medicine. NEJM Vol. 355 2006:549-559.

• 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.

• Pitt B, Loscalzo J, Ycas J, Raichlen JS. Lipid Levels After Acute Coronary Syndromes. J Am Coll Cardiol 2008;51;1440-1445.

• 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.

• 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

• 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.

• 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

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Specifications Manual for National Hospital Inpatient Quality Measures STK-6-5

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

STK - 6: Discharged on Statin MedicationNumerator:Ischemic stroke patients prescribed statin medication at hospital dischargeDenominator:Ischemic stroke patients with an LDL ≥ 100 mg/dL, OR LDL not measured, OR who were on a lipid-lowering medication prior to hospital arrival ICD-9-CM Principal Diagnosis CodeSTARTRun cases that are included in the Stroke Initial Patient Population and pass the edits defined in the Data Processing Flow through this measure. On Table 8.1Not on Table 8.1Comfort Measures Only = 1, 2, 3= 4Discharge Status= 01, 03, 04, 05, 06, 21, 61, 62, 63, 64, 65, 70Evidence of Atherosclerosis = NMissing=Y = 02, 07, 20, 43, 50, 51, 66MissingSTK-6HSTK-6XSTK-6XSTK-6BSTK-6BSTK-6BSTK-6B Missing Clinical Trial=Y=NSTK-6BSTK-6X Missing Elective Carotid Intervention=Y=NSTK-6BSTK-6X

Specifications Manual for National Hospital Inpatient Quality Measures STK-6-6

Discharges 10-01-09 (4Q09) through 03-31-10 (1Q10)

StopXCase WillBe RejectedSTK-6HMissingSTK-6X = N = YPre-Arrival Lipid-Lowering Agent LDL-c Measured Within The First 48 Hours or 30 Days Prior to Hospital Arrival=N = YMissingSTK-6XLDL-c Greater Than or Equal To 100 mg/dLMissingSTK-6X= NStatin Medication Prescribed At DischargeMissing = N = YReason for Not Prescribing Statin Medication At DischargeSTK-6B = N = Y=YSTK-6XEIn Numerator PopulationDIn Measure PopulationBNot In Measure PopulationSTK-6BSTK-6BMissing