Performance Measurement Network

Question: Are patients that stroke while an inpatient included in the measure population?

If the patient is admitted to the hospital for a condition other than stroke and later suffers a stroke while an inpatient, will they be included or excluded in the stroke measure population?

Answer:

The stroke measure population is driven by the ICD-9-CM Principal Diagnosis Code assigned at discharge (See Appendix A, Table 8.1 Ischemic Stroke Codes and 8.2 Hemorrhagic Stroke Codes). If stroke is assigned as the principal diagnosis code, then the case is included in the denominator. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." See data element definition for ICD-9-CM Principal Diagnosis Code (Alphabetical Data Element Dictionary pdf).

The stroke measure set was developed for patients that present to the hospital for treatment of stroke. If the patient was admitted for another condition and suffered a stroke during the hospital stay, stroke most likely will be assigned as an ICD-9-CM Other Diagnosis Code(see data element defintion). However, if stroke is assigned as the principal diagnosis, the case will be in the measure population as stated above.

http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK,
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