Specifications Manual for Joint Commission National Quality Measures (v2021B2)
Posted: 9/29/2021

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Measure Information Form
Version 2021B2

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

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-3

Performance Measure Name: Anticoagulation Therapy for Atrial Fibrillation/Flutter

Description: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.

Rationale: 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. In recent years, novel oral anticoagulant agents (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients. 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.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients prescribed anticoagulation therapy at hospital discharge.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Ischemic stroke patients with documented atrial fibrillation/flutter.
Included Populations:
  • Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1
  • Patients with documented Atrial Fibrillation/Flutter

Excluded Populations:
  • Patients less than 18 years of age
  • Patients who have a Length of Stay greater than 120 days
  • Patients with Comfort Measures Only documented
  • Patients enrolled in clinical trials
  • 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
  • Patients with a documented Reason For Not Prescribing Anticoagulation Therapy

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and 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:
  • Berge, E., M. Abdelnoor, P. H. Nakstad, and P. M. Sandset. "Low Molecular-Weight Heparin Versus Aspirin in Patients with Acute Ischaemic Stroke and Atrial Fibrillation: A Double-Blind Randomised Study. Haest Study Group. Heparin in Acute Embolic Stroke Trial." [In eng]. Lancet 355, no. 9211 (Apr 8 2000): 1205-10.
  • Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009): 421-6.
  • Connolly, S. J., M. D. Ezekowitz, S. Yusuf, J. Eikelboom, J. Oldgren, A. Parekh, J. Pogue, et al. "Dabigatran Versus Warfarin in Patients with Atrial Fibrillation." [In eng]. N Engl J Med 361, no. 12 (Sep 17 2009): 1139-51.
  • Fuster, V., L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, et al. "Acc/Aha/Esc Guidelines for the Management of Patients with Atrial Fibrillation: Executive Summary. A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation): Developed in Collaboration with the North American Society of Pacing and Electrophysiology." [In eng]. J Am Coll Cardiol 38, no. 4 (Oct 2001): 1231-66.
  • Fuster, V., L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, et al. "Acc/Aha/Esc 2006 Guidelines for the Management of Patients with Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): Developed in Collaboration with the European Heart Rhythm Association and the Heart Rhythm Society." [In eng]. Circulation 114, no. 7 (Aug 15 2006): e257-354.
  • Goldstein, L. B., R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, et al. "Primary Prevention of Ischemic Stroke: A Guideline from the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology Affirms the Value of This Guideline." [In eng]. Stroke 37, no. 6 (Jun 2006): 1583-633.
  • Gorelick, P. B., R. L. Sacco, D. B. Smith, M. Alberts, L. Mustone-Alexander, D. Rader, J. L. Ross, et al. "Prevention of a First Stroke: A Review of Guidelines and a Multidisciplinary Consensus Statement from the National Stroke Association." [In eng]. JAMA 281, no. 12 (Mar 24-31 1999): 1112-20.
  • Hart, R. G., O. Benavente, R. McBride, and L. A. Pearce. "Antithrombotic Therapy to Prevent Stroke in Patients with Atrial Fibrillation: A Meta-Analysis." [In eng]. Ann Intern Med 131, no. 7 (Oct 5 1999): 492-501.
  • January, C.T., Wann, S., Calkins, H., Chen, L.Y., Cigarroa, J.E., Cleveland, J.C., Ellinor, P.T., et al. "Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society…2019 AHA/ACC/HRS Focused Update of the 2014 AHA/...A Report of the American College of Cardiology/American Heart Association." [In eng.]. Circulation 140, no. 2 (Jan 28 2019):e125–e151.
  • Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al. "Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association." [In Eng]. Stroke (Jan 31 2013).
  • Kernan, W.N., B. Ovbiagele, H. R. Black, D. M. Bravata, M. I. Chimowitz, M. D. Ezekowitz, M. C. Fang, M. Fisher, K. L. Furie, D. V. Heck, S. C. Johnston, S. E. Kasner, S. J. Kittner, P. H. Mitchell, M. W. Rich, D. Richardson, L. H. Schwamm, J. A. Wilson. “Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association.” [in eng.] Stroke 45, no. 7 (May 2014): 2160-223.
  • Lin, H. J., P. A. Wolf, M. Kelly-Hayes, A. S. Beiser, C. S. Kase, E. J. Benjamin, and R. B. D'Agostino. "Stroke Severity in Atrial Fibrillation. The Framingham Study." [In eng]. Stroke 27, no. 10 (Oct 1996): 1760-4.
  • Penado, S., M. Cano, O. Acha, J. L. Hernandez, and J. A. Riancho. "Atrial Fibrillation as a Risk Factor for Stroke Recurrence." [In eng]. Am J Med 114, no. 3 (Feb 15 2003): 206-10.
  • Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e31-e32.
  • Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
  • Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al. "Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
  • Saxena, R., and P. J. Koudstaal. "Anticoagulants for Preventing Stroke in Patients with Nonrheumatic Atrial Fibrillation and a History of Stroke or Transient Ischemic Attack (Review). ." Cochrane Database Syst Rev, no. 4 (2011): CD000185.
  • Saxena, R., S. Lewis, E. Berge, P. A. Sandercock, and P. J. Koudstaal. "Risk of Early Death and Recurrent Stroke and Effect of Heparin in 3169 Patients with Acute Ischemic Stroke and Atrial Fibrillation in the International Stroke Trial." [In eng]. Stroke 32, no. 10 (Oct 2001): 2333-7.
  • van Walraven, C., R. G. Hart, D. E. Singer, A. Laupacis, S. Connolly, P. Petersen, P. J. Koudstaal, Y. Chang, and B. Hellemons. "Oral Anticoagulants Vs Aspirin in Nonvalvular Atrial Fibrillation: An Individual Patient Meta-Analysis." [In eng]. JAMA 288, no. 19 (Nov 20 2002): 2441-8.
  • Wann, L. S., A. B. Curtis, K. A. Ellenbogen, N. A. Estes, 3rd, M. D. Ezekowitz, W. M. Jackman, C. T. January, et al. "2011 Accf/Aha/Hrs Focused Update on the Management of Patients with Atrial Fibrillation (Update on Dabigatran): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines." [In eng]. J Am Coll Cardiol 57, no. 11 (Mar 15 2011): 1330-7.

Measure Algorithm:

Measure Information Form STK-3
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Specifications Manual for Joint Commission National Quality Measures (v2021B2)
Discharges 10-1-21 through 12-31-21 (4Q21)

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