Specifications Manual for Joint Commission National Quality Measures (v2023A1)
Posted: 10/17/2022

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Release Notes:
Measure Information Form
Version 2023A1

Measure Information Form

Measure Set: Stroke Volume (STK-VOL)

Set Measure ID: STK-VOL-1

Performance Measure Name: Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy

Description: Percentage of eligible patients with ischemic stroke who receive mechanical endovascular reperfusion therapy

Rationale: Some Joint Commission-certified Primary Stroke Centers (PSC) perform mechanical thrombectomy (MT) procedures at their facility; however, all PSCs do not perform these procedures but rather transfer the ischemic stroke patient to a higher level stroke center for MT evaluation and intervention. This measure is intended to capture the volume of MTs procedures performed at PSCs that do offer this therapy for acute ischemic stroke. The measure is a simple count of the number of MT procedures performed at the PSC each month.. NOTE: Get With The Guidelines®-Stroke users may run reports to identify the number of patients with ischemic stroke due to a large vessel occlusion who receive mechanical endovascular reperfusion therapy at the facility.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients who receive mechanical endovascular reperfusion therapy
Included Populations: Patients with documented mechanical endovascular reperfusion therapy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes).

Excluded Populations: Not applicable

Data Elements:

Denominator Statement: Ischemic Stroke Patients
Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1.

Excluded Populations:
  • Patients less than 18 years of age
  • Patients who have a Length of Stay > 120 day

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-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: Data should be used to evaluate the quality of stroke care.

Sampling: No.

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

Selected References:
  • American Heart Association / American Stroke Association, Get With The Guidelines®-Stroke, Endovascular Therapy for Acute Ischemic Stroke, September 2020.

Measure Algorithm:

Measure Information Form STK-VOL-1
CPT® only copyright 2022 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2023A1)
Discharges 01-01-23 (1Q23) through 06-30-23 (2Q23)


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