Release Notes:
Measure Information Form
Version 2016B
**Test**Measure Information Form
Measure Set: Comprehensive Stroke(CSTK)
Set Measure ID: CSTK-04b
Performance Measure Name: Median Time to INR Reversal
Description: Median time from procoagulant reversal agent (i.e., fresh frozen plasma, recombinant factor VIIa, prothrombin complex concentrates) initiation at this hospital to first international normalized ratio (INR) value less than (<) 1.4 for patients with an admitting diagnosis of primary parenchymal ICH
Rationale: Intracerebral hemorrhage (ICH) is a life-threatening disorder. Patients receiving oral anticoagulants (OACs), as well as those with an acquired or congenital coagulopathy, are at increased risk for ICH and hemorrhagic expansion with warfarin-associated bleeds comprising 12% to 15% of all spontaneous hemorrhages. Prompt INR reversal with intravenous infusions of vitamin K and fresh-frozen plasma (FFP) has been historically recommended; however, normalization with prothrombin complex concentrates (PCCs) is increasingly recommended because several studies have shown that these agents can rapidly normalize the INR within minutes.
Type of Measure: Process
Improvement Noted As: Decrease in the median value
Continuous Variable Statement: Time (in minutes) from procoagulant reversal initiation at this hospital to first INR value < 1.4 in patients with an admitting diagnosis of primary parenchymal ICH
Included Populations:
- Discharges with ICD-9-CM Principal Diagnosis Code for hemorrhagic stroke as defined in Appendix A, Table 8.2.
AND
- Patients who have an Admitting Diagnosis of primary parenchymal ICH
AND
- INR < 1.4 following initiation of a procoagulant reversal agent
AND
- Procoagulant Reversal Agent Initiation performed at this hospital
Excluded Populations:
- Patients less than 18 years of age
- Patients who have a Length of Stay > 120 days
- Patients with Comfort Measures Only documented on day of or after hospital arrival
- Patients enrolled in clinical trials
Data Elements:
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: The median time to INR reversal should be analyzed in conjunction with the median time to treatment with a procoagulant reversal agent (CSTK-4a) and the rate for INR reversal achieved (CSTK-04). These measures, used together, will assist in understanding the median time to control intracerebral bleeding (CSTK-04a plus CSTK-04b) in patients with warfarin-related intracerebral hemorrhage and will identify potential opportunities for improvement.
Sampling: No.
Data Reported As: Aggregate measure of central tendency .
Selected References:
1. Ansell J, Hirsch J, Hylek E, Jacobson A, Crowther M, Palareti G; American College of Chest Physicians. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidleines (8th Edition). Chest. 3008;133(suppl):160S-198S.
2. Fredriksson K, Norrving B, Strömblad, LG. Emergency reversal of anticoagulation after intracerebral hemorrhage. Stroke. 1992;23:972-977.
3. Goldstein JN, Thomas SH, Frontiero V, Joseph A, Engel C, Snider R, Smith EE, Greenberg SM, Rosand J. Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related intracerebral hemorrhage. Stroke. 2006;37:151-155.
4. Hanley JP. Warfarin reversal. J Clin Pathol. 2004;57:1132-1139.
5. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:865-866.
6. Leissinger CA, Blatt PM, Hoots WK, Ewenstein B. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol. 2008;83:137-143.
7. Morgenstern LB, Hemphill JC III, Anderson C, Becker K, Broderick JP, Connolly ES Jr, Greenberg SM, Huang JN, Macdonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ; and on behalf of the American Heart Association Stroke council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2111-2114.
8. Nilsson OG, Lindgren A, Ståhl N, Brandt L, Säveland H. Incidence of intracerebral and subarachnoid hemorrhage in southern Sweded. J Neurol Neurosurg Psychiatry. 2000;69:601-607.
9. Pabinger I, Brenner B, Kalina U, Knaub S, Nagy A, Ostermann H; Beriplex P/N Reversal Study Group. Prothrombin complex concentrate (Beriplex P/N) for emergency anticoagulation reversal: a prospective multinational clinical trial. J Thromb Haemost. 2008;6:622-631.
10. Rådberg JA, Olsson JE, Rådberg CT. Prognostic parameters in spontaneous intracerebral hematomas with special reference to anticoagulant treatment. Stroke. 1991;22:571-576.
11. Reiss H, Meier-Hellman A, Motsch J, Elias M, Kusten FW, Dempfle CE. Prothrombin complex concentrate (Octaplex) in patients requiring immediate reversal of oral anticoagulation. Thromb Res. 2007;121:9-16.
12. Rosovsky RP, Crowther, MA. What is the evidence foro the off-label use of recombinant factor VII (rFVIIa) in the acute reversal of warfarin? Hematology Am Soc Hematol Educ Program. 2008:36-38.
13. Sjöblom L, Hårdemark HG, Lindgren A, Norrving B, Fahlén M, Samuelsson M, Stigendal L, Stockelberg D, Taghavi A, Wallrup L, Wallvik J. Mangement and prognostic features of intracerebral hemorrhage during anticoagulant therapy: a Swedish multicenter study. Stroke. 2001;32:2567-2574.
14. Watson HG, Baglin T, Laidlaw SL, Makris M, Preston FE. A comparison of the efficacy and rate of response to oral and intravenous vitamin K in reversal of over-anticoagulation with warfarin. Haematol. 2001;115:145-149.
Measure Algorithm:
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