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Release Notes:
Data Element
Version 2010A1

Data Element Name: Reason for No Lipid-Lowering Therapy
Collected For: AMI-T2, , (CMS Optional Test Measure)
Definition:Contraindications/reasons for not prescribing a lipid-lowering medication at discharge include: lipid-lowering medication allergy or other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist for not prescribing a lipid-lowering medication at discharge.

Suggested Data Collection Question:Is one or more of the following potential contraindications/reasons for not prescribing a lipid-lowering medication at discharge documented?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   Documentation that the patient has one or more of the following potential contraindications/reasons for not prescribing a lipid-lowering medication at discharge:

  • Lipid-lowering medication allergy
  • Other reasons documented by a physician/APN/PA or pharmacist for not prescribing a lipid-lowering medication at discharge

N   (No)   There is no documentation of potential contraindications/reasons for not prescribing a lipid-lowering medication at discharge, or unable to determine from medical record documentation.

Notes for Abstraction:
  • When there is documentation of a lipid-lowering medication “allergy” or “sensitivity,” regard this as documentation of a lipid-lowering medication allergy regardless of what type of reaction might be noted. Do not attempt to distinguish between true allergies/sensitivities and intolerances, side effects, etc. (e.g., “Allergies: Atorvastatin – Nausea” – select “Yes.”)
  • Documentation of an allergy/sensitivity to one particular lipid-lowering medication is acceptable to take as an allergy to the entire class of lipid-lowering medications (e.g., “Allergic to Lipitor”).
  • The abstractor should search every suggested data source listed for the collection of information. When conflicting information is documented in a medical record, a positive finding should take precedence over a negative finding (e.g., answer “Yes”), unless otherwise specified.
  • In determining whether there is a reason documented by physician/APN/PA or pharmacist for not prescribing a lipid-lowering medication at discharge:
    • Reasons must be explicitly documented (e.g., “Active PUD - Lipid lowering therapy contraindicated”) or clearly implied (e.g., “Hx muscle soreness to statins in past,” “Lipid lowering agents contraindicated,” “Intolerant of lipid lowering agents,” “Problems with lipid lowering agents in past,” “c/o severe diarrhea, will DC Lipitor,” “Pt. refusing all medications,” “Limited life expectancy, no further treatment,” “Supportive care only – no medication,” lipid-lowering medication on pre-printed order form is crossed out, “Lipid agents not indicated,” mid-stay order to “Hold Pravachol,” “DC simvastatin” or “No cholesterol medications” [no reason given]). If reasons are not mentioned in the context of lipid-lowering medications, do not make inferences (e.g., do not assume that a lipid-lowering medication is not being prescribed because of the patient’s history of alcoholism or severe liver disease alone).
    • Physician/APN/PA or pharmacist documentation of a hold on a lipid-lowering medication or discontinuation of a lipid-lowering medication that occurs during the hospitalization constitutes a “clearly implied” reason for not prescribing a lipid-lowering medication at discharge.
      EXCEPTIONS:
      -Discontinuation of a particular lipid-lowering medication in combination with documentation to start a different lipid-lowering medication (switch in type of lipid-lowering medication - e.g., “DC lovastatin” followed by “Start Zocor” in physician orders).
      -Lipid-lowering medication holds/discontinuations which are clearly labeled or identified as preop/pre-procedure.
      -Discontinuation of a lipid-lowering medication at a particular dosage in combination with documentation to start a different dosage of that lipid-lowering medication (increase/decrease in dosage - e.g., “DC Lofibra 67 mgs. po t.i.d.” followed by “Start Lofibra 67 mgs. po q a.m.” in physician orders).
      - Order for a one-time hold. One-time holds include the holding of just one dose of a medication or holding of a medication for a defined time period. The order of the one-time hold needs to be explicit and able to stand on its own (Do not cross-reference with other medical record documentation to determine one-time holds).
      Examples:
      ►“Hold Colestid in a.m.”
      ►“Hold Questran x 24-48 hours”
      ►“Hold Pravigard this evening. Resume dose in a.m.”
      ►“Hold Niacor until a.m.”
      ►“Hold atorvastatin today”
      ►“No Zetia today”
      -Documentation of a conditional hold or discontinuation of a lipid-lowering medication (e.g., “Hold Zocor if severe diarrhea persists,” “Stop atorvastatin if myalgias persist”).
    • If there is documentation of a plan to initiate/restart a lipid-lowering medication, and the reason/problem underlying the delay in starting/restarting the medication is also noted, this constitutes a “clearly implied” reason for not prescribing a lipid-lowering medication at discharge.
      Examples:
      -"Liver enzymes high. May start lovastatin as outpatient.” per discharge summary – select “Yes.”
      -“May add Zetia when pt. can tolerate” per consultation note – select “Yes.”
      -“Add statin if myalgias resolve” per admitting progress note – select “Yes.”
      -“Will restart lipid lowering therapy after diarrhea subsides” per discharge progress note – select “Yes.”
    • Reasons do NOT need to be documented at the time of discharge or otherwise associated specifically with discharge prescription: Documentation of contraindications anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating no lipid-lowering medications “due to abnormal liver enzymes” - select “Yes,” even if documentation indicates that the liver enzyme levels normalized by the time of discharge and the lipid-lowering medication was restarted).
    • Crossing out of a lipid-lowering medication order counts as an "other reason" for not prescribing lipid-lowering medication at discharge only if on a pre-printed order form.
    • Lipid-lowering medications may also be referred to as bile acid sequestrants, fibric acid derivatives, fibrates, HMG CoA? reductase inhibitors (statins), resin drugs, and nicotinic acid (e.g., “Problems with statins in past”).
  • In cases where there is a pre-arrival contraindication or physician/APN/PA or pharmacist documented reason for not prescribing a lipid-lowering medication, the following guidelines apply regardless of whether this documentation is included in a transfer record or outpatient record made part of the current record during hospitalization or whether it is re-noted by hospital staff during the current hospitalization:
    • Notation of a lipid-lowering medication allergy prior to arrival counts as a contraindication to lipid-lowering medication at discharge.
    • Pre-arrival hold or discontinuation of a lipid-lowering medication or notation such as "No lipid-lowering medications" counts as a reason for not prescribing a lipid- lowering medication at discharge ONLY if the underlying reason/problem is also noted (e.g., “Lipitor discontinued two weeks ago secondary to severe diarrhea”).
    • Pre-arrival "other reason" (other than a lipid-lowering medication hold/discontinuation or notation of "No lipid-lowering medications") counts as reason for not prescribing a lipid-lowering medication at discharge (e.g., "Intolerance to lipid agents", "Hx muscle soreness to statins in past").
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing notes
  • Progress notes
  • Physician orders
  • Discharge summary
  • Medication administration record (MAR)
Excluded Data Sources:
Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay)
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • Lipid-lowering medication allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Reason for No Lipid-Lowering Therapy
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)