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:

ICD-10-PCS Other Procedure Codes

ICD-10-PCS Principal Procedure Code

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:

Admission Date

Birthdate

Discharge Date

ICD-10-CM Principal Diagnosis Code

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:

Specifications Manual for Joint Commission National Quality Measures (v2023A1)
Discharges 01-01-23 (1Q23) through 06-30-23 (2Q23)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.