Measure Information Form

Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-04

Performance Measure Name: Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )

Description: Intracerebral hemorrhage (ICH) stroke patients with an INR value greater than or equal to 1.4 at hospital arrival who are treated with a procoagulant reversal agent (i.e., fresh frozen plasma, recombinant factor VIIa, prothrombin complex concentrates)

Rationale: Intracerebral hemorrhage (ICH) is a life-threatening disorder. Oral anticoagulation poses significant risk. Despite newer direct oral anticoagulant (DOAC) medications, Vitamin K antagonists (VKA), i.e., warfarin, are most frequently prescribed (Zirlik, A., et al., 2016). Intraparenchymal hemorrhage accounts for 90% of all VKA-associated deaths. Death may result from larger hemorrhage volumes, increased risk of hemorrhagic expansion, and an increased number of comorbidities (Frontera, J.A., et al., 2016). Emergency anticoagulation reversal is needed to improve outcomes. In patients with VKA-associated ICH and an international normalized ratio (INR) above 1.3, anticoagulation should be discontinued and the INR normalized within 4 hours to lower in-hospital morbidity (Greenberg, S.M., et al., 2022). Four-Factor PCCs are preferred for rapid reversal followed by intravenous infusion of vitamin K, although fresh frozen plasma (FFP) is an alternative. Specific agents are available for DOAC reversal.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: ICH stroke patients treated with a procoagulant reversal agent

Included Populations: As above
Excluded Populations: None
Data Elements:

Procoagulant Reversal Agent Initiation

Reason for Not Administering a Procoagulant Reversal Agent

Denominator Statement: ICH stroke patients with INR value greater than or equal to 1.4 at hospital arrival.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for hemorrhagic stroke as defined in Appendix A, Table 8.2b for ICD-10 codes,
AND

Patients who have an Admitting Diagnosis of primary parenchymal ICH as defined in Appendix A, Table 8.2c for ICD-10 codes,
AND

INR greater than or equal to 1.4 performed closest to hospital arrival

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:

Admission Date

Admitting Diagnosis

Birthdate

Clinical Trial

Comfort Measures Only

Discharge Date

ICD-10-CM Principal Diagnosis Code

INR Value Greater Than or Equal to 1.4

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: 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:

Frontera, J. A., Lewin, J. J., 3rd, Rabinstein, A. A., Aisiku, I. P., Alexandrov, A. W., Cook, A. M., del Zoppo, G. J., Kumar, M. A., Peerschke, E. I., Stiefel, M. F., Teitelbaum, J. S., Wartenberg, K. E., & Zerfoss, C. L. (2016). Guideline for reversal of antithrombotics in intracranial hemorrhage: A statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocritical Care, 24 (1), 6–46.
Greenberg, S. M., Ziai, W. C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J. N., Hemphill, J. C., III, Johnson, R., Keigher, K. M., Mack, W. J., Mocco, J., Newton, E. J., Ruff, I. M., Sansing, L. H., Schulman, S., Selim, M. H., Sheth, K. N., Sprigg, N., & Sunnerhagen, K. S. (2022). 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke, 53 (7), e282–e361.
Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & 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. (2011). 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, 42, 853-54.
Zirlik, A., & Bode, C. (2017). Vitamin K antagonists: Relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. Journal of Thrombosis and Thrombolysis, 43 (3), 365–379. https://doi.org/10.1007/s11239-016-1446-0

Measure Algorithm:
Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step.

CSTK-04: Algorithm Narrative

CSTK-04: Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH)

Numerator Statement: ICH stroke patients treated with a procoagulant reversal agent.
Denominator Statement: ICH stroke patients with INR value greater than or equal to 1.4 at hospital arrival.

1. Start processing. Run cases, which are included in the Comprehensive Stroke Initial Patient Population and pass the edits defined in the Clinical Data Processing Flow, through this measure.

2. Check ICD-10 CM Principal Diagnosis Code

If all ICD-10 CM Principal Diagnosis codes are not on on Table 8.2b, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If at least one of the ICD-10 CM Principal Diagnosis codes is on Table 8.2b, continue processing and proceed to check Comfort Measures Only.

3. Check Comfort Measures Only.

If Comfort Measures Only is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Comfort Measures Only equals 1 the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If Comfort Measures Only equals 2, 3 or 4 continue processing and proceed to check Clinical Trial.

4. Check Clinical Trial.

If Clinical Trial is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Clinical Trial equals Y the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If Clinical Trial equals N continue processing and proceed to check INR Value Greater Than or Equal to 1.4.

5. Check INR Value Greater Than or Equal to 1.4.

If INR Value Greater Than or Equal to 1.4 is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If INR Value Greater Than or Equal to 1.4 equals N, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If INR Value Greater Than or Equal to 1.4 equals Y continue processing and proceed to check Admitting Diagnosis.

6. Check Admitting Diagnosis.

If Admitting Diagnosis is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If all Admitting Diagnosis codes are not on Table 8.2c, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
If at least one of the Admitting Diagnosis codes is on Table 8.2c, continue processing and proceed to check Procoagulant Reversal Agent Initiation.

7. Check Procoagulant Reversal Agent Initiation.

If Procoagulant Reversal Agent Initiation is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Procoagulant Reversal Agent Initiation equals Y continue processing and proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.
If Procoagulant Reversal Agent Initiation equals N, the case will proceed to check Reason for Not Administering a Procoagulant Reversal Agent.

8. Check Reason for Not Administering a Procoagulant Reversal Agent.

If Reason for Not Administering a Procoagulant Reversal Agent is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
If Reason for Not Administering a Procoagulant Reversal Agent equals Y, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop processing.
If Reason for Not Administering a Procoagulant Reversal Agent equals N, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

Specifications Manual for Joint Commission National Quality Measures (v2027A)
Discharges 01-01-2027 (1Q27) through 06-30-2027 (2Q27)

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